A 39-year-old woman, gravida 3 para 2, comes to the emergency department at 37 weeks gestation due to leakage of fluid for the last 2 hours. She has also had some vaginal bleeding and contractions for the last hour. Fetal movement is normal. The patient immigrated to the United States 6 months ago and has had no prenatal care this pregnancy. Her previous pregnancies were uncomplicated and delivered vaginally at term. Blood pressure is 100/60 mm Hg, pulse is 102/min, and respirations are 16/min. On speculum examination, rupture of membranes is confirmed and the patient has some small blood clots at the cervical os. An ultrasound reveals an active fetus in cephalic presentation whose growth is consistent with gestational age and placental tissue covering the cervix. Fetal heart rate baseline is 150/min with accelerations and no decelerations. Tocodynamometry shows contractions every 3 minutes. Which of the following is the most appropriate next step in management of this patient?

Question

A 39-year-old woman, gravida 3 para 2, comes to the emergency department at 37 weeks gestation due to leakage of fluid for the last 2 hours.  She has also had some vaginal bleeding and contractions for the last hour.  Fetal movement is normal.  The patient immigrated to the United States 6 months ago and has had no prenatal care this pregnancy.  Her previous pregnancies were uncomplicated and delivered vaginally at term.  Blood pressure is 100/60 mm Hg, pulse is 102/min, and respirations are 16/min.  On speculum examination, rupture of membranes is confirmed and the patient has some small blood clots at the cervical os.  An ultrasound reveals an active fetus in cephalic presentation whose growth is consistent with gestational age and placental tissue covering the cervix.  Fetal heart rate baseline is 150/min with accelerations and no decelerations.  Tocodynamometry shows contractions every 3 minutes.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da12_e1c4_bc81_1f60cee0b2ad_MD0003_00 This patient's ultrasound is consistent with placenta previa, which occurs when the placenta covers the cervix. Risk factors include multiparity and advanced maternal age (≥35), as in this patient; additional risk factors are prior cesarean delivery and prior previa. Patients are at risk for severe antepartum hemorrhage, which typically presents as painless vaginal bleeding and occurs with or without contractions. Placenta previa is usually diagnosed during a routine ultrasound; however, in patients without prenatal care, it may be found incidentally at term with vaginal bleeding (as seen in this patient). During labor, contractions or cervical manipulation can shear the placenta off the cervix (ie, partial detachment), resulting in massive maternal hemorrhage. Therefore, even in patients with minimal bleeding, stable vital signs, and reassuring fetal heart rate tracings, cesarean delivery is indicated after 36-37 weeks gestation (Choices D and E). (Choice A) Anti-D immunoglobulin is administered in pregnancy to prevent Rh-isoimmunization in an Rh-negative mother. Prior to delivery, the fetal Rh status is typically unknown but presumed to be Rh positive. This patient requires urgent cesarean delivery to prevent hemorrhage. Because anti-D immunoglobulin is protective when given up to 72 hours after delivery, it can be administered postpartum if indicated (ie, Rh-negative mother and Rh-positive infant). If the patient is Rh-positive or the infant Rh-negative, anti-D immunoglobulin has no benefit. (Choice C) Digital cervical examination is contraindicated in patients with placenta previa as digital examination enters the cervical canal, disrupting the previa and leading to severe hemorrhage. In contrast, speculum examination can be used in patients with known or suspected placenta previa to verify and quantify vaginal bleeding as it does not enter the cervical canal. Digital cervical examination Educational objective: Placenta previa occurs when the placenta covers the cervix, creating the potential for massive antepartum hemorrhage from cervical dilation. Labor and vaginal delivery are contraindicated in these patients; therefore, cesarean delivery is typically performed at 36-37 weeks gestation. References: Abnormal placentation: placenta previa, vasa previa, and placenta accreta. (http://www.ncbi.nlm.nih.gov/pubmed/26244528)

A 39-Year-Old Woman, Gravida 3 Para 2, Comes to the Emergency