A 32-year-old woman, gravida 2 para 1, with dichorionic-diamniotic twins at 34 weeks gestation is brought to the emergency department after developing leakage of fluid an hour ago. While in the emergency department, the patient has a sudden large gush of fluid that is followed by heavy vaginal bleeding and constant lower abdominal pain. Her pregnancy has been complicated by gestational hypertension, but the patient has not required any antihypertensive therapy. The patient's last pregnancy ended in a cesarean delivery for breech presentation. Her prior prenatal ultrasounds showed 2 fundal placentas. Blood pressure is 160/100 mm Hg and pulse is 118/min. Fetal heart rate tracing shows both fetuses with baselines of 110/min and no variability. The uterus is firm, tender, and has a fundal height of 38 cm. Speculum examination shows approximately 75 mL of red blood in the vagina. After evacuation of the blood, a moderate amount of continued bleeding is observed coming from the cervical os that is 3 cm dilated. Which of the following is the most likely cause of this patient's presentation?

Question

A 32-year-old woman, gravida 2 para 1, with dichorionic-diamniotic twins at 34 weeks gestation is brought to the emergency department after developing leakage of fluid an hour ago.  While in the emergency department, the patient has a sudden large gush of fluid that is followed by heavy vaginal bleeding and constant lower abdominal pain.  Her pregnancy has been complicated by gestational hypertension, but the patient has not required any antihypertensive therapy.  The patient's last pregnancy ended in a cesarean delivery for breech presentation.  Her prior prenatal ultrasounds showed 2 fundal placentas.  Blood pressure is 160/100 mm Hg and pulse is 118/min.  Fetal heart rate tracing shows both fetuses with baselines of 110/min and no variability.  The uterus is firm, tender, and has a fundal height of 38 cm.  Speculum examination shows approximately 75 mL of red blood in the vagina.  After evacuation of the blood, a moderate amount of continued bleeding is observed coming from the cervical os that is 3 cm dilated.  Which of the following is the most likely cause of this patient's presentation?

Quizplus · Accepted Answer

11ec25c8_da13_f336_bc81_aded42c9aca4_MD0003_00 This patient with vaginal bleeding and a tender, firm uterus after rupture of membranes most likely has abruptio placentae. Placental abruption is the premature placental separation from the uterine wall prior to fetal delivery. It can occur following an uncontrolled gush of amniotic fluid, particularly in patients with uterine overdistension (eg, twin gestation, polyhydramnios) because the sudden loss of volume leads to rapid uterine decompression. The rapid decompression causes shearing of maternal decidual vessels and bleeding at the decidual-placental interface, which leads to increased intrauterine pressure (ie, tender, firm uterus), abdominal pain, and vaginal bleeding. Other risk factors include maternal hypertension, abdominal trauma, and tobacco use. Placental abruption Some cases of abruptio placentae are self-limited and clinically insignificant; however, a large abruption can impair fetal perfusion (ie, fetal hypoxia) and increase the risk of demise, as evidenced by fetal heart rate tracing abnormalities (eg, bradycardia, minimal variability). Potential maternal complications include hemorrhage and disseminated intravascular coagulation. Therefore, acute abruption with active bleeding and evidence of fetal hypoxia requires emergent delivery. (Choice A) Placenta accreta, the attachment of placental villi directly to the myometrium, can occur in patients with prior cesarean delivery due to implantation of an anterior placenta over the uterine scar. However, patients typically have postpartum hemorrhage. In addition, this patient's placentas are fundal, making this diagnosis less likely. Placenta accreta (Choice B) Uterine rupture, a full-thickness disruption of the uterine wall, may present in laboring patients with prior cesarean delivery and cause abdominal pain, vaginal bleeding, and fetal heart rate tracing abnormalities. However, patients classically have palpable fetal parts on abdominal examination and a uterus with decreasing rigidity and contractions due to decreased intrauterine pressure. Uterine rupture (Choice C) Vasa previa, fetal placental vessels overlying the cervix, can cause bleeding due to injury of fetal vessels with rupture of membranes; however, bleeding is typically painless. Vasa previa (Choice D) Laceration of cervical blood vessels can occur with birth trauma or surgical complications (eg, cesarean delivery, cerclage placement). It is not associated with uterine tenderness or fetal heart rate tracing abnormalities. Educational objective: Abruptio placentae is premature placental separation from the uterine wall that can lead to fetal hypoxia and maternal hemorrhage. Patients typically have abdominal pain, vaginal bleeding, and a firm, tender uterus. Risk factors include uterine overdistension, hypertension, abdominal trauma, and tobacco use. References: Placental abruption: epidemiology, risk factors and consequences. (http://www.ncbi.nlm.nih.gov/pubmed/21241259)

A 32-Year-Old Woman, Gravida 2 Para 1, with Dichorionic-Diamniotic Twins