• A 30-year-old, G1P0, female at 36 weeks gestation presents to the emergency room with sudden onset of severe back pain which has lasted for 2 hours. Thirty minutes prior to presentation she noted bright red vaginal bleeding. She has had no prenatal care. On physical exam she is afebrile; her blood pressure is 30/80 mmHg, pulse is 106/min, and respirations are 18/min. Abdominal palpation reveals a gravid hypertonic uterus and palpable uterine contractions. You observe blood in the vaginal vault. Results of transabdominal ultrasound are shown.
  • Clinical definition
    • premature separation of a normally implanted placenta
      • placenta abruptio and placenta previa are the two most common causes of third trimester bleeding
  • Epidemiology
    • incidence
      • 1% of all pregnancies
    • demographics
      • more common in African-American women
    • risk factors  
      • trauma (e.g., motor vehicle accident)
      • prior placental abruption
      • maternal smoking
      • cocaine use
      • hypertensive disorders of pregnancy such as
        • eclampsia
        • preeclampsia
      • premature rupture of membrane
      • hyperhomocystinemia
  • Pathophysiology
    • rupture of maternal vessels results in
      • bleeding into the decidual-placental interface that leads to
        • placental separation from the uterine wall
  • Associated conditions
    •  may be associated with cardiovascular disease
  • Prognosis
    • mother
      • prompt intervention decreases the incidence of maternal mortality
    • fetus
      • increased mortality rate
  • Symptoms 
    • abrupt third trimester vaginal bleeding
    • abdominal and/or back pain 
    • uterine contractions
  • Physical exam
    • gravid hypertonic uterus
    • blood/clots may be observed in the vaginal vault
    • fetal distress is present
  • Ultrasound 
    • indications
      • used to rule out placenta previa
      • to find a retroplacental hematoma which is
        • classic for placental abruption
  • Diagnostic criteria
    • a clinical diagnosis that can be confirmed with pathologic placental evaluation
  • Placenta previa
    • presents as painless vaginal bleeding
  • Uterine rupture
  • Normal or pre-term labor
  • Conservative
    • expectant management with continuous fetal monitoring
      • indications
        • when both the mother and fetus are stable and the fetus is < 34 weeks gestation
    • vaginal delivery
      • indications
        • in cases where the fetus is 36 weeks gestation, vaginal delivery is preferrable if there are no indications to cesarean delivery
          • if the patient is not in active labor then
            • amniotomy and oxytocin administration can be used
  • Operative
    • immediate delivery
      • indications
        • in cases of non-reassuring fetal status
        • in cases of hemodynamic instability in the mother
        • when the fetus is 34-36 weeks gestation; however, this is dependent on
          • patient specific factors
          • balancing risk and benefit
  • Complications
    • disseminated intravascular coagulation (DIC)
    • hemorrhagic shock
    • recurrence risk in future pregnancies
      • 3-15% have a recurrence
    • fetal anemia

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