A 25-year-old pregnant woman with abdominal pain

[cleo_md]

 25-year-old pregnant female with complaints of abdominal pain? ?

A 25-year-old pregnant woman presented to the emergency department with abdominal pain that had begun about 2 hours before admission. She was at 28 weeks of gestation and denied contractions. She also denied trauma or drug use and claimed the pregnancy had been normal to date. She had insulin-dependent diabetes (present since late childhood) that was controlled with insulin, and she had no other medical problems.

On examination, she was anxious and was having mild pain. She was having vaginal bleeding that appeared to be light, and she was mildly tender over the lower abdomen. Her blood pressure was 125/62 mm Hg, and her heart rate was 89 beats per minute. Fetal monitoring showed no current fetal distress.


What problems are associated with these symptoms?


What is the next step in evaluating this patient?

[cleo_md]

No OB/GYN enthusiasts???

Causes of abdominal pain in a pregnant woman include appendicitis, ovarian cysts or torsion, an ectopic pregnancy, pyelonephritis, gastroenteritis, hepatitis, pelvic inflammatory disease, diabetic ketoacidosis, uterine leiomyoma (rupture, necrosis, bleeding), pancreatitis, bowel obstruction, acute cholecystitis, nephrolithiasis, diverticulitis, and malignancy.

Most of these are unlikely in this patient, as most would not involve vaginal bleeding in addition to the pain. Possible diagnoses that could be associated with bleeding include placental abruption (abruptio placentae), placenta previa with premature labor, uterine rupture, and malignancy of the lower reproductive tract


What is the next step in evaluating this patient?

[dr_b.e.s.m]

I think next step will be U/S

also lab investigations like CBC, Bl. group (as she's bleeding) , PT, PTT, Platlets (for DIC !).

[cleo_md]

 Excellent Dr Bahaa 

If a a patient presents with the classic triad of vaginal bleeding, contractions, and abdominal pain, she should be taken immediately to surgery to deliver the baby and control bleeding, which can be catastrophic.

In cases that do not have the classic presentation, further evaluation may need to be done to determine the diagnosis. Ultrasonography is a sensitive way to diagnose placenta previa, but it is not as sensitive at detecting placental abruption because images of small amounts of fresh blood can be mistaken for the placenta. Only about 50% of cases can be detected by ultrasonography. Electronic fetal heart monitoring may help to make the diagnosis by detecting the indirect effects of vascular compromise on the fetus. A case-control study by Matsuda failed to demonstrate any typical ultrasonographic or fetal monitoring patterns that could predict adverse outcomes. The clinical impression remains the most important part of the evaluation, and a high index of suspicion is warranted.

If a hematoma is identified on ultrasonography, the size and location can be useful in predicting fetal survival. Retroplacental hematomas have a worse fetal prognosis than subchorionic hematomas, and hematomas larger than 60 mL are associated with a fetal mortality rate of at least 50%.

Blood testing should be done to detect reduced fibrinogen levels and other coagulation abnormalities.


What symptoms and signs are typical of placental abruption?

What causes placental abruption?

What is the treatment for placental abruption?

[dr_b.e.s.m]

Thanks Dr Cleo for the interesting info? specially the hint about predicting fetal prognosis depending on the site and amount of haematoma.


Wanna ask about something.

If a a patient presents with the classic triad of vaginal bleeding, contractions, and abdominal pain, she should be taken immediately to surgery to deliver the baby and control bleeding, which can be catastrophic.

So we can deliver based only on clinical data (the triad) ? Also where is the role of expectant management? For example if bleeding is mild and no fetal distress and the patient is away from term, shall we deliver or we can observe till closer to term ?

[cleo_md]

Dr Bahaa...This question is more of a question to leave an imprint" classic triad of vaginal bleeding, contractions, and abdominal pain, she should be taken immediately to surgery"

Ofcourse in the right setting with the right gyn/ob specialist mild presentations can be managed as clinically warranted . Expectant management is definitely used if the abruption is mild and fetal status is reassuring.

[3abeer]

SALAM CLEO, I MISS U 
PLACENTAL ABRUPTIO:

causes bleeding in the 3rd trimester,
abdominal pain that is continous( not as labour) , vaginal bleeding if revealed abruptio, & none if concealed


on exam :
vitals: according to the lost amount of blood
board rigid abdomen

im not that good in obe/gyne

[dr_b.e.s.m]

This is from Current Ob&Gyn talking about bleeding in third trimester


There are 2 principles that must be followed in investigation of third-trimester hemorrhage:

VERY IMPORTANT

(1) Any woman experiencing vaginal bleeding in late pregnancy must be evaluated in a hospital capable of dealing with maternal hemorrhage and a compromised perinate.

(2) A vaginal or rectal examination must not be performed until placenta previa has been ruled out and until preparations are complete for management of massive hemorrhage and maternal or perinatal complications. (Vaginal or rectal examination is extremely hazardous because of the possibility of provoking an uncontrollable, catastrophic hemorrhage.)




Then we see if it's life threatening bleeding or not, each has a different management. We look for signs of hypovolemic shock.

Nonemergency Bleeding

A. HISTORY AND ABDOMINAL EXAMINATION

Once the patient is evaluated and found to be hemodynamically stable, the cause of bleeding must be quickly identifed. After a brief history is obtained, the patient's abdomen should be examined and a bedside ultrasound performed to evaluate the location of the placenta and the fetal status.
If ultrasound is not immediately available, fetal heart tones should be obtained and the fundal height marked on the abdomen with a ballpoint or other indelible pen. This aids in determining gestational age, and later in ascertaining if the uterus is rapidly expanding from concealed hemorrhage due to abruptio placentae. Leopold's maneuvers assist in determination of fetal size, presentation, position, and engagement. It is crucial to determine whether the presenting part is well engaged in the pelvis. When there is engagement, total placenta previa is unlikely. Palpation for uterine contractions, tone, and tenderness should be conducted. Hemodynamic status can change after initial assessment and therefore should be continuously reevaluated.

B. LABORATORY EVALUATION

Laboratory evaluation should include: blood type and cross-match (give 2?6 units, depending on the hemodynamic status) as well as a complete blood count with platelets and baseline coagulation status (prothrombin time and partial thromboplastin time). D-Dimer or fibrin split products are useful when abruptio placentae is suspected. These are the most sensitive tests to confirm coagulopathy; however, they are qualitative studies and give little information about the severity of abruption. Recent literature has demonstrated a correlation between elevated CA-125 levels and abruption. This assay has little clinical utility, as it usually requires a long turnaround time. A Kleihauer-Betke test may be useful in the Rh-negative patient. The results are useful in calculating the appropriate dose of Rh immune globulin.

C. VAGINAL EXAMINATION

Neither a vaginal examination nor a rectal examination should be performed until placenta previa has been excluded. Once this has been achieved, both a speculum and a manual vaginal examination should be performed to evaluate for the presence of either a nonobstetric etiology or labor. When other causes have been excluded, placental abruption (including marginal sinus bleed) becomes the assumed diagnosis.

D. ULTRASOUND EXAMINATION

The most accurate way to confirm a diagnosis of placenta previa is by ultrasound. A translabial study may better assess the placental location for a posterior placenta than a transabdominal scan. Transvaginal ultrasound is the most accurate means to evaluate for placenta previa. It has been demonstrated to be safe in experienced hands. Finally, the addition of color flow Doppler to real-time ultrasound increases the sensitivity. It has limited sensitivity in diagnosing a retroplacental clot (caused by abruption), even in experienced hands. However, ultrasound may be useful for diagnosis of a concealed hemorrhage when a combination of abnormal findings coexist sonographically.
Ultrasound evaluation should be performed in the labor and delivery suite if possible. Fetal heart rate monitoring should continue at regular intervals throughout the study. Assessment of amniotic fluid volume and confirmation of fetal age should be obtained at time of ultrasound. In addition, an amniocentesis for fetal lung maturity should be performed if indicated.

E. MANAGEMENT OF BLEEDING

At this point, findings regarding the status of the mother, fetus, and placenta and evaluation of labor should be combined to provide a diagnosis and to plan the course of management. The 3 general management options are immediate delivery, continued labor, or expectant management, depending on the diagnosis.
If the fetus is immature, the patient should be treated expectantly unless additional complications appear (eg, continuing bleeding, fetal distress, labor, or spontaneous rupture of the membranes). In about 90% of cases, third-trimester bleeding will subside within 24 hours. If placental studies signify a high placental implantation and bleeding stops, vaginal examination is indicated prior to discharge of the patient to exclude nonobstetric causes of bleeding.
In the past, a ?double setup examination? was frequently employed for diagnosis of third-trimester bleeding. All preparations were made for cesarean section, except for administering the anesthetic. A careful vaginal examination with a speculum was then conducted. If the placenta was not visualized, it was thought that placenta previa could be ruled out. This proved to be a highly inaccurate, dangerous method of diagnosis as compared with ultrasonic localization of the placenta and cesarean delivery without vaginal examination for placenta previa. Therefore, the double setup examination has largely been abandoned.
Nonobstetric causes of bleeding in late pregnancy usually result only in spotting that does not increase with activity. There are no uterine contractions, and the definitive diagnosis is usually made by speculum examination, Papanicolaou smear, culture, or colposcopy. Only in advanced cancer is there a poor maternal prognosis. Vaginal lacerations and varices may require repair but have a good prognosis. Most infections causing bleeding clear readily when treated with appropriate agents. Benign neoplasias and eversions require simple treatment and have a good prognosis.