Obgyn · Year 3 · from Obgyn
Case 2: Placenta Previa with Third Trimester Bleeding
Patient Demographics
- Age: 36 years
- Sex: Female
- Occupation: Restaurant manager
Chief Complaint
"I woke up to bright red bleeding. I'm soaking through pads."
History of Present Illness
The patient is G4P2012 at 32 weeks gestation. She woke from sleep with sudden painless bright red vaginal bleeding. She has soaked through 3 pads in the past 2 hours. She denies abdominal pain, contractions, or trauma. She was told at her 20-week ultrasound that she had a "low-lying placenta" and was scheduled for a repeat ultrasound next week.
Past Medical History
- Two prior cesarean deliveries (low transverse incisions)
- One first-trimester miscarriage
Risk Factors for Placenta Previa
- Prior cesarean deliveries (strongest risk factor)
- Multiparity
- Advanced maternal age
Physical Examination Findings
- Vital Signs: BP 105/68 mmHg, HR 102 bpm, Temperature 98.2F
- General: Anxious, pale
- Abdomen: Soft, non-tender, uterus non-tender, no contractions palpated
- EXTERNAL exam only: Active bright red bleeding from vaginal introitus
- NO speculum or digital exam (contraindicated until placenta previa ruled out)
Initial Management
- Two large-bore IVs placed
- Type and crossmatch for 4 units PRBCs
- IV fluid resuscitation initiated
- Continuous fetal monitoring
Fetal Assessment
- Fetal Heart Rate: Baseline 150 bpm, moderate variability, no decelerations
- Fetus tolerating bleeding episode
Diagnostic Workup
- Hemoglobin: 9.8 g/dL (was 11.2 at last prenatal visit)
- Platelets: 210,000
- Type and Screen: B positive, antibody negative
- Coagulation studies: Normal
- Transvaginal Ultrasound (safe in previa - does not touch cervix):
- Complete placenta previa - placenta completely covering internal cervical os
- Placenta appears to be invading into lower uterine segment (concern for accreta)
- No evidence of abruption
- AFI normal, EFW 1,950 grams
Diagnosis
Complete Placenta Previa with:
- Third trimester hemorrhage
- Possible placenta accreta spectrum (given prior cesareans)
Management Plan
Immediate Stabilization:
- Continued IV fluids
- Blood available at bedside
- Transfused 2 units PRBCs (Hgb was 9.8 and actively bleeding)
- Anesthesia notified
- OR on standby
Bleeding Management:
- Bleeding slowed spontaneously over 2 hours
- Total estimated blood loss ~800 mL
Expectant Management Protocol (if stable):
- Inpatient observation until delivery
- Bed rest with bathroom privileges
- Serial hemoglobin monitoring
- Antenatal corticosteroids (betamethasone x 2 doses given)
- No pelvic rest (already maintained)
- Type and screen always current
MRI for Accreta Evaluation:
- Performed on hospital day 3
- Demonstrated loss of retroplacental clear zone
- Bladder wall irregularity
- Findings concerning for placenta accreta
Delivery Planning
Multidisciplinary Team:
- Maternal-fetal medicine
- Gynecologic oncology (accreta expertise)
- Urology (bladder involvement possible)
- Blood bank (massive transfusion protocol prepared)
Planned Cesarean Hysterectomy:
- Scheduled at 34 weeks if stable (balances prematurity vs. hemorrhage risk)
- If recurrent significant bleeding: emergent delivery regardless of gestational age
Hospital Course
- Remained stable with no further bleeding episodes
- Repeat betamethasone at 34 weeks not indicated (single course)
- Delivered by cesarean hysterectomy at 34 weeks 2 days
- Placenta accreta confirmed at surgery
- EBL 2,500 mL, received 4 units PRBCs
- No bladder injury
- Infant: 2,180 grams, Apgar 8/9, NICU for prematurity
Clinical Image
Image Description: Transvaginal ultrasound image demonstrating complete placenta previa with the placenta completely covering the internal cervical os. The lower image shows normal placental position for comparison.
Attribution: Image from Radiopaedia. Case courtesy of Dr. Ian Bickle. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/placenta-praevia