Snapshot A 33-year-old G4P3 presents to the obstetrician at 29 weeks gestation with painless vaginal bleeding. The bleeding began 2 hours ago and she has delivered a substantial amount of blood with clots. She is having no uterine contractions and the fetal pulse is 150/min. Her last pregnancy was delivered by emergency cesarean at 37 weeks due to double-footing breech presentation during labor. Findings on transvaginal ultrasound show the placenta extending over the internal cervical os. Epidemiology Incidence occurs in approximately 1 per 250 births location most common tricuspid valve Risk factors previous placenta previa previous cesarean delivery multiple gestations Etiology Overview placenta previa is a condition characterized placental tissue extending over or < 2 cm from the internal cervical os and is associated with painless third trimester bleeding Associated conditions placenta previa-accreta spectrum placenta previa is present along with placenta accreta, placenta increta, or placenta percreta Presentation Symptoms asymptomatic finding on routine ultrasound painless vaginal bleeding up to 90% of cases uterine contractions, pain, and bleeding 10-20% of cases Physical exam digital vaginal examination is contraindicated until placenta previa is excluded (may result in severe hemorrhage) findings may include the following hemorrhage usually spontaneously ceases after 1-2 hours hypotension tachycardia usually no fetal distress (in contrast with vasa previa) Imaging Ultrasound transvaginal ultrasound gold standard for diagnosis of placenta previa identification of placental tissue extending over the internal cervical os on 2nd or 3rd trimester imaging transabdominal ultrasound can be used as a screening test or in conjunction with transvaginal ultrasound if distance between edge of placenta and cervical os is ≤ 2 cm on transabdominal ultrasound, perform transvaginal ultrasound to better visualize placental position Studies Serum labs Rh compatability test Complete blood cell (CBC) count Prothrombin time (PT) and activated partial thromboplastin time (aPTT) Blood type and cross Levels of fibrin split products (FSP) and fibrinogen Differential Abruptio placentae key distinguishing factors placenta prematurely separates from the uterine wall presents with painful bleeding that does not spontaneously cease Placenta accreta key distinguishing factors placenta invades the uterine wall placenta does not separate after delivery, which may lead to postpartum bleeding Vasa previa key distinguishing factors fetal vessels extend over the internal cervical os presents with fetal heart decelerations due to compression of umbilical vessels Treatment Medical monitoring in the case of asymptomatic placenta previa monitor placental position determine whether placenta accreta is also present if persistent placenta previa, plan for cesarean delivery hemostasis in the case of actively bleeding placenta previa admit for maternal and fetal monitoring achieve and maintain maternal hemodynamic stability Surgical cesarean delivery cesarean delivery should be performed in these cases: active labor fetal distress (category III fetal heart rate tracing that does not respond to in utero resuscitation) inability to achieve maternal hemodynamic stability significant vaginal bleeding after 34 weeks of gestation Complications Congenital malformations associated with 2-fold increase Fetal malpresentation Vasa previa rupture of fetal vessels that cross the membranes covering the cervix cesarean delivery indicated Postpartum hemorrhage
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.OB.17.4867) A 39-year-old G4P3 woman 38 weeks pregnant presents to the emergency department with bright red vaginal bleeding that started one hour ago following sexual intercourse with her partner. She denies any abdominal pain. Her medical history is notable for three prior cesarean sections. She has not seen an obstetrician because she felt similar to her previous pregnancies. Her temperature is 98.6°F (37°C), blood pressure is 100/70 mmHg, pulse is 95/min, and respirations are 20/min. The fetal pulse is 130/min; its tracing is shown in Figure A. The patient's physical exam is unremarkable. Inspection of the vagina reveals no active bleeding. The transvaginal ultrasound machine is being prepared. What is the most likely diagnosis? QID: 109556 FIGURES: A Type & Select Correct Answer 1 Vasa previa 0% (0/8) 2 Uterine rupture 0% (0/8) 3 Placenta previa 100% (8/8) 4 Placental abruption 0% (0/8) 5 Cord prolapse 0% (0/8) M 6 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.OB.14.16) A 28-year-old G2P1 woman at 29 weeks gestation presents to the obstetrician after noticing red spots on her undergarments over the past week. Her vaginal bleeding has not been painful; however, she is concerned that it has persisted. Her previous child was born by cesarean section and she is currently taking folate and a multivitamin. She endorses feeling fetal movements. Her temperature is 98.9°F (37.2°C), blood pressure is 120/84 mmHg, pulse is 88/min, respirations are 17/min, and oxygen saturation is 99% on room air. Physical exam is notable for a gravid uterus and non-tender abdomen. Speculum exam reveals a closed cervical os and a small amount of blood. Which of the following is the most likely diagnosis? QID: 105186 Type & Select Correct Answer 1 Placenta percreta 0% (0/10) 2 Placenta previa 60% (6/10) 3 Placental abruption 30% (3/10) 4 Uterine rupture 0% (0/10) 5 Vasa previa 10% (1/10) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic