A 27-year-old woman, gravida 2 para 1, at 32 weeks gestation comes to the emergency department due to abdominal pain. A few hours ago, the patient developed a sudden onset of constant abdominal pain that has not resolved with rest. For the last 30 minutes, the pain has increased and become unbearable. She has had light vaginal bleeding but no passage of clots or fluid. The patient has no chronic medical conditions, and her only surgery is a cesarean delivery in her last pregnancy due to preterm labor and fetal malpresentation. She smokes a pack of cigarettes daily but does not use alcohol or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 100/min, and respirations are 18/min. Fetal heart tracing shows a baseline of 170/min and occasional late decelerations. The uterus is tender to palpation and has frequent palpable, painful contractions. Speculum examination shows a closed cervix with minimal bleeding. Ultrasound reveals a fundal placenta, a singleton fetus in transverse presentation, and a normal amniotic fluid index. There is a 5-cm (1.97-in) pedunculated uterine fibroid and bilateral normal adnexae. Which of the following factors in this patient's history most likely increased the risk for this clinical presentation?

Question

A 27-year-old woman, gravida 2 para 1, at 32 weeks gestation comes to the emergency department due to abdominal pain.  A few hours ago, the patient developed a sudden onset of constant abdominal pain that has not resolved with rest.  For the last 30 minutes, the pain has increased and become unbearable.  She has had light vaginal bleeding but no passage of clots or fluid.  The patient has no chronic medical conditions, and her only surgery is a cesarean delivery in her last pregnancy due to preterm labor and fetal malpresentation.  She smokes a pack of cigarettes daily but does not use alcohol or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 100/min, and respirations are 18/min.  Fetal heart tracing shows a baseline of 170/min and occasional late decelerations.  The uterus is tender to palpation and has frequent palpable, painful contractions.  Speculum examination shows a closed cervix with minimal bleeding.  Ultrasound reveals a fundal placenta, a singleton fetus in transverse presentation, and a normal amniotic fluid index.  There is a 5-cm (1.97-in) pedunculated uterine fibroid and bilateral normal adnexae.  Which of the following factors in this patient's history most likely increased the risk for this clinical presentation?

Quizplus · Accepted Answer

11ec25c8_da1c_0991_bc81_fde45741552b_MD0003_00 This patient has sudden-onset, severe abdominal pain; vaginal bleeding; and a tender uterus with frequent contractions consistent with abruptio placentae. Placental abruption is the premature separation of the placenta from the uterine wall prior to fetal delivery. Placental abruption A common risk factor is tobacco use, which causes both structural and functional placental changes, such as thickened villous membranes and nicotine-induced vasospasm that is proportional to packs per day smoked. These placental changes can cause ischemia, necrosis, and hemorrhage of maternal vessels at the uteroplacental interface that result in placental detachment, increased intrauterine pressure (causing uterine tenderness), and uterine irritability (eg, high-frequency contractions). As the degree of placental separation increases, the risk of fetal compromise and mortality from hypoxia (eg, recurrent late decelerations) also increases. Other risk factors for abruptio placentae include cocaine use, hypertension (eg, preeclampsia), and abdominal trauma. (Choice A) Transverse fetal presentation is common at earlier gestational ages due to small fetal size in comparison to greater amniotic fluid volume. Fetal presentation does not increase the risk of abruptio placentae. Transverse fetal presentation (Choice B) A pedunculated fibroid may become ischemic and painful during pregnancy because uterine blood flow typically shifts centrally toward the placenta and fetus. However, this does not increase the risk of premature placental separation. pedunculated fibroid (Choice C) Patients with an anterior, low-lying placenta are at increased risk of placenta previa, the implantation of the placenta over the cervix. In contrast to this patient, those with placenta previa typically have painless vaginal bleeding. placenta previa (Choice D) A previous cesarean delivery (ie, weakened myometrium) increases the risk for uterine rupture, a full-thickness uterine wall defect. Uterine rupture can cause severe abdominal pain, vaginal bleeding, and fetal heart rate abnormalities; however, patients typically have increasingly irregular contractions that decrease in intensity because ruptured myometrial fibers cannot contract in unison. uterine rupture (Choice E) Prior preterm labor increases the risk for subsequent preterm labor but not abruptio placentae. This patient's cervix is closed, making preterm labor unlikely. Educational objective: Abruptio placentae, the premature detachment of the placenta from the uterine wall, presents with painful vaginal bleeding, uterine tenderness, contractions, and fetal heart rate tracing abnormalities. Risk factors include tobacco or cocaine use, hypertension, and abdominal trauma. References: Placental abruption: epidemiology, risk factors and consequences. (http://www.ncbi.nlm.nih.gov/pubmed/21241259)

A 27-Year-Old Woman, Gravida 2 Para 1, at 32 Weeks