A 34-year-old woman, gravida 4 para 2 aborta 1, comes to the emergency department at 24 weeks gestation with vaginal bleeding that started after intercourse. The patient woke up in a pool of bright red blood and continues to soak through a pad every hour. She has not had routine prenatal care during this pregnancy but had a sonogram at 8 weeks gestation that showed a singleton intrauterine pregnancy. The patient has had 2 cesarean deliveries at term and a cervical conization earlier this year. She smokes a pack of cigarettes daily but does not use alcohol or illicit drugs. Blood pressure is 124/78 mm Hg and pulse is 92/min. Fetal monitoring shows a baseline of 140/min, accelerations, absent decelerations, and moderate variability. Irregular contractions are seen on tocodynamometry. Abdominal examination reveals a gravid, nontender uterus. On speculum examination, there are large clots in the vaginal vault, a closed cervix, and active bleeding from the os. Which of the following is the most likely diagnosis in this patient?

Question

A 34-year-old woman, gravida 4 para 2 aborta 1, comes to the emergency department at 24 weeks gestation with vaginal bleeding that started after intercourse.  The patient woke up in a pool of bright red blood and continues to soak through a pad every hour.  She has not had routine prenatal care during this pregnancy but had a sonogram at 8 weeks gestation that showed a singleton intrauterine pregnancy.  The patient has had 2 cesarean deliveries at term and a cervical conization earlier this year.  She smokes a pack of cigarettes daily but does not use alcohol or illicit drugs.  Blood pressure is 124/78 mm Hg and pulse is 92/min.  Fetal monitoring shows a baseline of 140/min, accelerations, absent decelerations, and moderate variability.  Irregular contractions are seen on tocodynamometry.  Abdominal examination reveals a gravid, nontender uterus.  On speculum examination, there are large clots in the vaginal vault, a closed cervix, and active bleeding from the os.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_da16_643a_bc81_2f6b499d7116_MD0003_00 This patient's vaginal bleeding after 20 weeks gestation is due to placenta previa, a condition in which the placenta covers the cervix. This patient's risk factors for placenta previa include prior cesarean delivery, multiparity, and smoking; additional risk factors include prior placenta previa and multiple gestation. Placenta previa has the potential for massive antepartum hemorrhage because cervical manipulation (even minimal manipulation from intercourse) causes partial placental detachment and painless vaginal bleeding (eg, nontender uterus, painless irregular contractions) from the intervillous space. This bleeding is primarily of maternal origin; therefore, many patients have reassuring fetal monitoring initially (eg, accelerations, no decelerations). Placenta previa Treatment depends on maternal hemodynamic stability and fetal status. Stable patients are managed expectantly, as most previas resolve by the third trimester. Patients with persistent previa undergo cesarean delivery at 36-37 weeks gestation (prior to the onset of labor). (Choice A) Cervical insufficiency causes second trimester pregnancy loss due to intrinsic cervical instability or from a reduced cervical length (eg, prior cervical conization). Most patients have an incidental shortened or dilated cervix on ultrasound. There is typically no vaginal bleeding. Symptomatic patients typically have pelvic pressure and painless cervical dilation; this patient's cervix is closed. (Choice B) Complete hydatidiform mole usually causes first trimester vaginal bleeding. This diagnosis is unlikely because complete hydatidiform moles have a snowstorm appearance due to hydropic villi and an absent fetus on ultrasound. (Choice C) Inevitable abortion presents at <20 weeks gestation with vaginal bleeding, pelvic pain, and a dilated cervix. (Choice E) Placental abruption, the separation of the placenta from the uterus prior to fetal delivery, causes vaginal bleeding and uterine contractions. Abruptio placentae is more common in smokers (as in this patient), but patients typically have constant abdominal pain (ie, tender uterus) and fetal decelerations. Placental abruption (Choice F) Preterm labor is cervical dilation ≥3 cm or effacement (eg, length <2 cm) with regular painful uterine contractions at <37 weeks gestation. Light bleeding due to cervical vascularity may be seen; however, frank hemorrhage (as in this patient) is not consistent with labor. In addition, this patient's contractions are irregular and her cervix is closed. Educational objective: Placenta previa occurs when the placenta covers the cervix and presents with painless vaginal bleeding after 20 weeks gestation. Blood loss is primarily maternal; therefore, initial fetal monitoring is typically reassuring. References: Risk factors and pregnancy outcomes: complete versus incomplete placenta previa in mid-pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/30128867) Effect of site of placentation on pregnancy outcomes in patients with placenta previa. (http://www.ncbi.nlm.nih.gov/pubmed/30016336)

A 34-Year-Old Woman, Gravida 4 Para 2 Aborta 1, Comes