Emergency Medicine · Year 3 · from Emergency Medicine
Case 2: Placental Abruption - Third Trimester Bleeding
Patient Demographics
- Age: 32 years
- Sex: Female
- Occupation: Nurse
Chief Complaint
"I'm 34 weeks pregnant and having severe abdominal pain with bleeding."
History of Present Illness
A 32-year-old G2P1 at 34 weeks gestation presents with sudden onset of severe constant abdominal pain and vaginal bleeding that began 1 hour ago. She describes the pain as "the worst ever" - different from contractions she experienced in her first pregnancy. She reports decreased fetal movement since the pain started. Her pregnancy has been uncomplicated until now.
Initial Assessment
ESI Level: 1 - Obstetric emergency
First Impression:
- Appearance: Distressed, clutching abdomen
- Work of breathing: Tachypneic
- Circulation: Pale
Vital Signs:
- Heart rate: 118 bpm
- Blood pressure: 100/62 mmHg
- Respiratory rate: 24 breaths/min
- SpO2: 97% on room air
- Temperature: 37.1C
Fetal Heart Tones: 168 bpm with decreased variability (continuous monitoring initiated)
Primary Survey
Airway: Patent Breathing: Tachypneic, clear lungs Circulation: Tachycardic, borderline hypotensive, pale Disability: Alert, GCS 15, severe pain Exposure: Vaginal bleeding (moderate), rigid abdomen
Resuscitation
Immediate Interventions:
- Left lateral decubitus positioning (avoid IVC compression)
- Two large-bore IVs
- Crystalloid bolus initiated
- Type and crossmatch 4 units PRBCs
- OB/GYN STAT consultation
- Continuous fetal monitoring
- Neonatology notification
Third Trimester Bleeding - Differential Diagnosis
| Condition | Pain | Bleeding | Uterine Tone | Fetal Status |
|---|---|---|---|---|
| Placental Abruption | Severe, constant | Variable (may be concealed) | Rigid, tetanic | Often compromised |
| Placenta Previa | Painless | Bright red, profuse | Soft | Usually stable initially |
| Vasa Previa | Minimal | With ROM, dark blood | Soft | Rapidly compromised |
| Uterine Rupture | Severe | Variable | May lose contour | Compromised |
This presentation is most consistent with placental abruption
Secondary Survey
SAMPLE History:
- Symptoms: Sudden severe abdominal pain, vaginal bleeding, decreased fetal movement
- Allergies: None
- Medications: Prenatal vitamins
- PMH: G2P1, prior SVD at term, no complications
- LMP: N/A (34 weeks pregnant)
- Events: Sudden onset while at work
Risk Factors for Abruption:
- Hypertension/preeclampsia: Blood pressure has been normal
- Trauma: Denies
- Cocaine use: Denies
- Prior abruption: No
- Advanced maternal age: No
- Smoking: No
Physical Examination:
Abdominal/Uterine:
- Uterus rigid, "board-like"
- Severe tenderness diffusely
- Fundal height >dates (may indicate concealed hemorrhage)
- Unable to palpate fetal parts (uterine tension)
Pelvic Exam (NO DIGITAL EXAM until placenta previa ruled out):
- Sterile speculum: Dark blood in vaginal vault
- Cervix visualized: Closed, no placenta visible
- Digital exam (after US): 2cm/50%/−2 station
Diagnostic Testing
Labs:
- CBC: Hgb 9.8 (baseline 11.2), Plt 142
- Type and screen: A positive
- Fibrinogen: 180 mg/dL (low - DIC concern)
- PT/INR: 14.2/1.3
- PTT: 38
- BMP: Normal except K 5.1
Bedside Ultrasound:
- Retroplacental clot visualized
- Fetal heart rate present but with minimal variability
- Biophysical profile: 4/10
Fetal Monitoring:
- Fetal heart rate: 170 bpm baseline
- Minimal variability
- Recurrent late decelerations
- Sinusoidal pattern emerging - OMINOUS
Diagnosis
Severe placental abruption with:
- Fetal compromise (non-reassuring tracing)
- Maternal hemorrhage
- Early DIC
Management
Emergency Cesarean Section Decision:
- Non-reassuring fetal status with late decelerations
- Maternal hemorrhage with DIC
- Decision-to-incision time goal: <30 minutes
Pre-operative Interventions:
- 2 units PRBCs transfusing
- FFP ordered for coagulopathy
- Anesthesia at bedside
- Neonatology in OR
Cesarean Section Findings:
- 40% placental abruption with 500mL retroplacental clot
- Couvelaire uterus (blood infiltrating myometrium)
- Live female infant delivered - vigorous after brief resuscitation
- Apgars: 5, 7, 9
- EBL: 1.5L
Disposition
Mother:
- ICU admission for monitoring
- Total transfusion: 4 units PRBCs, 2 units FFP
- Fibrinogen improved with transfusion
- Stable, transferred to postpartum floor POD 1
- Discharged POD 4
Neonate:
- Birth weight: 2.1 kg (appropriate for 34 weeks)
- Brief respiratory support, weaned to room air
- NICU admission for prematurity
- Discharged at 2 weeks of life
Teaching Points
- Painful third trimester bleeding = abruption until proven otherwise
- Concealed hemorrhage: Amount of visible bleeding doesn't correlate with severity; 20% of abruptions have no external bleeding
- DIC risk: Abruption releases thromboplastin; monitor coagulation closely
- Fetal monitoring is critical: Non-reassuring tracing mandates urgent delivery
- No digital exam until previa ruled out: Risk of catastrophic hemorrhage with previa
- Ultrasound sensitivity is limited: May not visualize all abruptions; clinical diagnosis
- Rhogam: Give to Rh-negative mothers after any significant bleeding
Clinical Image
Image Description: Obstetric ultrasound demonstrating a retroplacental hematoma (arrow) separating the placenta from the uterine wall, consistent with placental abruption.
Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Hani Salam. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/placental-abruption-2