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Baby Rose - Dominique Jones

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Dominique Jones

on 10 June 2014

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Transcript of Baby Rose - Dominique Jones

Dominique C. Jones

Baby Rose
Our Patient
A 32 y.o. Caucasian female G1P0 at 34 weeks and 4 days gestation presents to the emergency room complaining of significant painless bright red vaginal bleeding over the past hour. She had been feeling well until this afternoon when she noticed blood running down her leg. She reports some contractions, but has not timed them. Her pregnancy has been uncomplicated to date and she has no significant past medical history. She takes no medications other than PNV. She does have a history of tobacco use, 2 ppd x 14 years, and has been smoking in this pregnancy but denies EtOH or illicit drug use. Patient denies abdominal pain, nausea, fever, chills, syncope, recent trauma, recent sexual intercourse, and any similar episodes in the past.

Allergies: NKDA

ROS and Physical Exam
ROS: Negative
Physical Exam
General: Well-nourished Caucasian female in mild distress
Vitals: T- 98.7, HR- 115, RR- 16, BP- 109/56 (sitting)
Lungs: clear to auscultation
Heart: Rapid regular rhythm, no murmurs
Abdomen: Distended abdomen consistent with late 3rd trimester pregnancy. Soft, NT, (+) BS
Extremities: No edema
Uterine Height: 34cm
Fetal Lie: Longitudinal
NST: baseline FHR of 137, accelerations with no decelerations

Other Info:
Denies surgeries, injuries, hospitalizations, or other illnesses
Menarches: 14 y/o
Menses: Regular 28 day cycles with 4 day duration menses; moderate flow first two days and becomes gradually lighter towards end of menses
2002 & 2012: Chlamydia, treatment completed
Contraception Hx: Denies use of barrier or hormonal methods
Social Hx:
Smoking 2 ppd x 14 years

Differential Diagnosis:
Placenta Previa
Placental Abruption
Uterine Rupture
Vasa Previa
Bloody Show
Coagulation Disorder
Vaginal Lesion/Injury
Cervical Lesion/Injury
Placenta Previa:
Definition & Types
Placenta Previa: Incidence
Placenta Previa:
Risk Factors
Placenta Previa: Clinical Manifestations
Placental Previa:
Diagnostic Evaluation
A. Marginal
B. Partial
C. Complete

Definition: Abnormal implantation of the placenta over the internal cervical os
Occurs in approximately 0.5% of pregnancies (1:200 births) and accounts for nearly 20% of all antepartum hemorrhage.

More than 90% of placenta previas diagnosed in the second trimester resolve as pregnancy advances.

Previous C/S
Surgery on the uterus (i.e.D&C)
Advanced Maternal Age
Multiple gestation
Prior Placenta Previa
Minority race
Uterine fibroids

A. Transabdominal

B. Transvaginal
Sudden and profuse onset of PAINLESS vaginal bleeding in the second or third trimester.
Uterine contractions without uterine tetany.
On average, a patient's first episode of bleeding will occur at 34 weeks, with delivery at 36 weeks.

Placental Previa: Treatment
For little or no bleeding:
Bed rest at home is recommended
For heavy bleeding:
Hospitalization with hemodynamic stabilization
Blood transfusion is given if necessary
Enforced bed rest
Restrictions of activity
Constant FHR monitoring
Medications that prevent premature labor (i.e. tocolytics)
> 36 weeks = C-section
< 36 weeks = given steroids to speed babys lung development
For bleeding that won’t stop:
Emergency C-section – even if the baby is premature
Placental Abruption: Incidence
Placental Abruption:
Risk Factors
Placental Abruption:
Clinical Manifestations
PAINFUL vaginal bleeding
Tetanic uterine activity (i.e. contraction)
Abdominal or back pain and uterine tenderness
Fetal distress
Non-reassuring fetal heart rate
Placental abruption may cause preterm labor
DIC may result from the release of thromboplastin into the maternal circulation with placental separation

Grade 1
Small amount of vaginal bleeding, uterine tenderness, no fetal heart abnormalities, and no evidence of shock or coagulopathy.
Grade 2
Mild to moderate vaginal bleeding. Uterine activity maybe tetanic or with frequent palpable and painful contractions. Fetal Heart tones may be absent and when present often show evidence of fetal distress.
Maternal tachycardia, narrowed pulse pressure, and orthostatic hypotension may be present.
Grade 3
External bleeding may be moderate or excessive but may be concealed
The uterus is tetanic and tender to palpation
Fetal death has occurred
Maternal hemodynamic status is unstable, showing signs of hypotension and tachycardia
Most common cause of third trimester bleeding

Occurs in approximately 1 in 100 deliveries

Increased risk of maternal/fetal death

10-30% neonatal mortality associated

Chronic hypertension
Advanced Maternal Age
Previous abruption
Cigarette smoking
Cocaine use
Excessive alcohol consumption

Placental Abruption: Diagnostic Evaluation
History and Physical

Labs (Hgb/Hct, PT/PTT, fibrinogen)

More than 50% of patients with confirmed abruption will have evidence of hemorrhage on ultrasound
Shows retroplacental hematoma or placental thickening only part of the time

Diagnosis is based on clinical picture once other causes have been excluded
Placental Abruption: Treatment
Correct shock (IV fluids, packed RBCs, fresh frozen plasma, cryoprecipitate, platelets)

Maternal oxygenation administration

Expectant management or induction of labor; Close observation of mother and fetus

Constant fetal heart monitoring

If there is fetal distress, perform C-section

An emergent C-section may be necessary at any point during labor

Objective and Methods
Literature Search: A pub-med literature search was conducted on 06/03/14, with the search terms: transvaginal ultrasound, OR transabdominal
ultrasound in diagnosing placenta previa. This
yielded 16 articles. The following article (below) was selected based
on its relevance to the desired

Transvaginal and transabdominal ultrasound for the diagnosis of placenta previa

P: Patients with placenta previa
I: Use of Transvaginal (TVS) ultrasound
C: Use of Transabdominal (TAS) ultrasound
O: Provide a more accurate diagnosis
Strengths/Weaknesses & Recommendations
Update on Patient
The study sought to evaluate the use of TVS and TAS ultrasound in the diagnosis of placenta previa and its effect on length of stay in the hospital
Looked at 131 patients with an equivocal diagnosis of placenta previa:
58 patients underwent an ultrasound exam because of an antepartum hemorrhage.
72 patients underwent an ultrasound exam because of malpresentation and or unstable lie.

Prospective, Randomized study

Gestational age was between 29 and 38 weeks

All patients had both TVS and TAS ultrasound exams

TVS ultrasound exam appeared to be a safe technique in the diagnosis of placenta previa.

None of the patients experienced any secondary vaginal bleeding following the TVS

The sensitivity and specificity of both techniques appeared to be reasonably good and the positive predictive value of TVS is better than TAS in the detection of placenta previa
All exams were performed by the same authors
All patients had both TVS and TAS ultrasound exams

Study was limited to a small geographical region/population
Ultrasound exams for patients with bladder over distention and myometrial focal contractions should have been repeated to prevent a high false positive in TAS ultrasound exams
Article did not list their own strengths and limitations

Recommendations from authors
TVS should be complementary to the TAS approach
TVS ultrasound exam should be performed by experienced personnel and the TVS probe should only be inserted 3cm into the vagina so that there is no risk of provoking

Based on the patients clinical presentation, placenta previa was suspected and further confirmed by transvaginal ultrasound.

A vaginal exam was deferred because of the risk of provoking life threatening hemorrhage. A digital examination is absolutely contraindicated until placenta previa is excluded.

Our patient was clinically stable but her bleeding could not be appropriately controlled. Since her fetus was reasonably mature, the decision was made to do an emergency c-section.

At the end…there was a delivery of a healthy baby girl!!!


Callahan T., Caughey A. Blueprints Obstetrics and Gynecology. 6th ed. (2013) Lippincott Williams and Wilkins.

Decherney A. Current Diagnosis and Treatment in Obstetrics and Gynecology. 11th ed. (2013) McGraw Hill Medical.

Sunna E., Ziadeh S. Transvaginal and Transabdominal Ultrasound for the Diagnosis of Placenta Praevia.
J of Ob. and Gyn
. 1999; 19(2): 152-154
Placental Abruption: Definition & Classifications
Definition: Premature separation of the normally implanted placenta from the uterine wall after 20 weeks of gestation but prior to the delivery of the infant.
Concealed form
External form

History & Physical
Baseline admission labs
Sterile Speculum Exam

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