A 27-year-old woman, gravida 3 para 1 aborta 1, at 36 weeks gestation comes to the emergency department due to abdominal pain and heavy vaginal bleeding that began acutely an hour ago. She reports no leakage of fluid. The patient's 11-week and 18-week ultrasounds revealed a singleton intrauterine pregnancy with a posterior placenta. She was previously evaluated in the emergency department at 27 weeks gestation for preterm contractions after she fell on her abdomen. Her examination at that time was normal and she was discharged without intervention. The patient has no chronic medical conditions. Her pregnancy history includes an 8-week spontaneous abortion and a cesarean delivery after a failed labor induction. The patient smokes ½ pack of cigarettes a day, but does not drink alcohol or use illicit drugs. She takes a daily prenatal vitamin and iron supplementation. Temperature is 36.7 C (98 F), blood pressure is 110/60 mm Hg, and pulse is 94/min. The fetal heart rate tracing shows a baseline of 150/min, moderate variability, no accelerations, and occasional late decelerations. Tocometer shows contractions every 2 minutes. Abdominal examination demonstrates a firm, tender, gravid abdomen. Speculum examination shows 50 mL of clotted blood in the vagina and continued heavy bleeding. The cervix is 4 cm dilated and 80% effaced, with the fetal head at 0 station. Which of the following is the most likely cause of this patient's presentation?

Question

A 27-year-old woman, gravida 3 para 1 aborta 1, at 36 weeks gestation comes to the emergency department due to abdominal pain and heavy vaginal bleeding that began acutely an hour ago.  She reports no leakage of fluid.  The patient's 11-week and 18-week ultrasounds revealed a singleton intrauterine pregnancy with a posterior placenta.  She was previously evaluated in the emergency department at 27 weeks gestation for preterm contractions after she fell on her abdomen.  Her examination at that time was normal and she was discharged without intervention.  The patient has no chronic medical conditions.  Her pregnancy history includes an 8-week spontaneous abortion and a cesarean delivery after a failed labor induction.  The patient smokes ½ pack of cigarettes a day, but does not drink alcohol or use illicit drugs.  She takes a daily prenatal vitamin and iron supplementation.  Temperature is 36.7 C (98 F), blood pressure is 110/60 mm Hg, and pulse is 94/min.  The fetal heart rate tracing shows a baseline of 150/min, moderate variability, no accelerations, and occasional late decelerations.  Tocometer shows contractions every 2 minutes.  Abdominal examination demonstrates a firm, tender, gravid abdomen.  Speculum examination shows 50 mL of clotted blood in the vagina and continued heavy bleeding.  The cervix is 4 cm dilated and 80% effaced, with the fetal head at 0 station.  Which of the following is the most likely cause of this patient's presentation?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c01e_b186_8f63_25a6ac5d66c7_MD0005_00 This patient presents in the third trimester with painful vaginal bleeding; a tender, rigid uterus; and a fetal heart rate tracing with late decelerations-a presentation consistent with abruptio placentae. Abruptio placentae, the partial or complete separation of the placenta from the uterus prior to fetal delivery, is associated with maternal trauma, hypertension, tobacco or cocaine use, and a history of prior abruptio placentae. late decelerations Abruptio placentae Abruptio placentae occurs when maternal vessel rupture at the uteroplacental interface causes intrauterine bleeding. This bleeding causes the detachment of the placenta from the uterus, an increase in the intrauterine pressure (eg, tender, distended uterus), and uterine irritability (eg, high-frequency, low-intensity contractions). Some abruptio placentae are self-limiting and contained whereas others progress as the bleeding and placental separation continue. As the degree of placental separation increases, the risk of fetal compromise and mortality from hypoxia (eg, late decelerations in the fetal heart rate tracing) also increases. Maternal complications include hemorrhage and disseminated intravascular coagulation. An acute abruptio placentae with active bleeding is an indication for delivery; the mode of delivery is dependent on both maternal and fetal stability. (Choice B) Bloody show refers to a normal bloody mucoid cervical discharge that commonly occurs during labor due to cervical dilation and effacement. Bloody show is not associated with fetal heart rate abnormalities or a tender, rigid uterus. (Choice C) Placenta accreta, direct attachment of the placenta to the myometrium, typically presents with a postpartum hemorrhage and inability to remove the placenta. Placenta accreta typically occurs in patients with an anterior placenta that implants over the uterine scar from a previous cesarean delivery. Placenta accreta (Choice D) Placenta previa occurs when the placenta implants over the cervix and is associated with painless vaginal bleeding. Placenta previa (Choice E) Uterine rupture, the full thickness disruption of the uterine wall, is associated with severe lower abdominal pain, vaginal bleeding, fetal heart rate tracing abnormalities, and loss of fetal station. Fetal parts are often palpable through the abdominal wall. This patient's abdominal exam demonstrates a firm, tender uterus. Uterine rupture fetal station Educational objective: Abruptio placentae, the detachment of the placenta from the uterus prior to fetal delivery, presents with painful vaginal bleeding and fetal heart rate abnormalities. Risk factors include abdominal trauma, hypertension, and tobacco or cocaine use. References: Placental abruption: epidemiology, risk factors and consequences. (http://www.ncbi.nlm.nih.gov/pubmed/21241259) Severe placental abruption: clinical definition and associations with maternal complications. (http://www.ncbi.nlm.nih.gov/pubmed/26393335)

A 27-Year-Old Woman, Gravida 3 Para 1 Aborta 1, at 36