APGO Educational Objectives:

The student will be able to demonstrate a knowledge of:

1. an approach to the patient who presents with third trimester bleeding
2. the symptoms, physical findings, and diagnostic methods that differentiate patients with placenta previa and abruptio placentae, and other causes of third trimester bleeding
3. complications of placenta previa and abruptio placentae
4. the immediate management of shock secondary to third trimester bleeding     

Recommended Reading Assignment:

1. Third Trimester Bleeding, Chapter 20 in Obstetrics and Gynecology, 3rd Edition, Beckmann, et al, pp. 260-268, 1998
2. Chapter 34 in Maternal Fetal Medicine: Principles and Practice, Creasy and Resnik, pp 592-612.

Questions: 

1. Given the above history, what is your differential diagnosis for this patient?
2. What historical/medical factors are of importance to you in making a differential diagnosis between a placenta previa and an abruptio placenta?
3. What laboratory studies would you order and/or what examination would you perform as part of the work up/evaluation of this patient?
4. What are the limitations of the testing procedures that you have either performed or ordered to substantiate a diagnosis.

General physical examination of the patient is unremarkable. Her blood pressure is 120/84. Pulse rate is 88 beats per minute. Her fundal height is 30 cm. Fetal heart tones are present and in normal range. The infant is in a breech presentation. There is no abdominal pain or tenderness or vaginal bleeding. Her CBC is normal and coagulation studies are negative. Sterile speculum examination demonstrates a normal appearing cervix. There is no evidence of a polyp. Pap smear is reported as negative. The ultrasound examination performed signed out as "There is no evidence of an abruptio placenta. Fetal measurements are consistent with the patients' 30 weeks gestational age. The fetus is noted to be a breech presentation. The placenta is posterior and low lying. A placenta previa can not be excluded".

5. Given this clinical situation, what would be your management of this patient?
6. How would this management plan differ had the radiologist confirmed the presence of total placenta previa?
7. How would this management plan change were the patient at 38 weeks gestation at the time of her initial presentation with painless vaginal bleeding?

Five days later you, as the House Officer are paged "STAT" by the nurse on the Post Partum Unit who has just been summoned to this patient's room. The patient has a large 12 inch in diameter area, bright red, vaginal bleeding noted by you at the time when you examine her. She does not have any uterine tenderness. Pulse rate is 114 beats per minute. the fetal heart tones which had previously been 150 beats per minute are now 170 beats per minute. The patient appears pale and is apprehensive.

8. What would be your management of this patient now?

At the time of surgery, performing an emergency cesarean section delivery, a 1200 gram male infant with APGARs of 6, 8 and 9 is delivered and given to the neonatologist in attendance. A posterior placenta previa is noted. The placenta is removed and there continues to be a large amount of bleeding in the lower uterine segment where the placenta had been located. The anesthesiologist advises you that he has initiated transfusions of the patient and that her pulse rate is 140 and also administers volume expanders, intraoperatively.

9. What measures can be taken at the time of surgery for this massive acute bleeding?
10. What are the potential complications in the immediate post operative period from hypovolemic shock?
11. Outline management plans for the management of this patient in the immediate post operative period?
12. Define vasa previa.
13. What is the classic presentation of a vasa previa?
14. What are the various techniques of prenatal diagnosis of evasive previa?