Case of the Month
November 2007

33-year-old female – light vaginal bleeding

Dispatch
"Aid 2, aid response, 33-year-old female – vaginal bleeding”

While en route the dispatcher updates you…your patient is a 33-year-old female with a small amount of vaginal bleeding who feels nauseated. She is 31 weeks pregnant.

En route your crew discusses the following considerations:

• Reasons for bleeding during pregnancy (especially in the 3rd trimester)
• Transport destination considerations
• Viability of a 31 week pregnancy

Scene Size-up
You arrive at the scene and are met at the front door by the patient’s husband. He leads you through the house to his wife who is lying on a bed. She appears very anxious and pale; you notice she is slightly diaphoretic. Nothing strikes you as unusual about the patient’s surroundings.

Initial Assessment
You approach the patient and check her radial pulse which is 124/min and thready; her wrist feels cool. Your partner palpates a blood pressure and finds it to be 94/P. Her respirations are 24 without labor. 

Initial Treatment
Because of her skin signs, heart rate and a high index of suspicion, you decide the patient is SICK and request a medic unit. Your team members start oxygen at 10 L/min via NRM. The decision to rapidly transport the patient is made. 

Vital Signs

• Respirations                         24
• Pulse rate                            Radial at 124, thready
• Mental status                       Alert and oriented to person, place and time
• Skin signs                            Pale, sweaty
• Blood pressure                      94/palp
• Pulse oximetry                      98% on mask

Further Evaluation and Treatment
While moving the patient to the stretcher you collect her medical and pregnancy history. She has had a normal pregnancy up to this point with good prenatal care and no reports of abnormalities. This is her fifth pregnancy and all of the previous births were normal with the exception of her last delivery which went fine, however there was evidence of a subtle placental abruption that had no effect on the baby. The rest of her medical history is unremarkable other than borderline hypertension.

About 12 hours ago she had minor back discomfort and cramping. The back pain went away, but the cramping returned. She became concerned when she saw dark red spotting and passed a small blood clot. She felt nauseated and lightheaded when she stood up to go to the bathroom.

Your team begins BLS transport. En route to the rendezvous point it is decided that you can make it to the hospital before the ALS unit arrives. You call the ED and medic unit to let them know you are inbound. An ED physician meets you at the ED doors and quickly evaluates the patient. She has alerted the labor and delivery unit and she immediately directs you there.

An ultrasound reveals a partial abruption of her placenta. Fetal heart tones find the baby is moderately distressed. Due to the mother’s poor vital signs and the fetal distress it is decided that an emergency C-section is needed.  The surgery is performed and the mother and infant do well long term.

Placental Abruption
Placental abruption (abruptio placentae) is a condition where the placenta prematurely separates from the uterine wall most often in the third trimester. Depending on how much of the placenta peels away, the results can range from inconsequential to fatal for both mother and child. As the placenta detaches from the uterus, bleeding occurs. In severe cases it can cause shock and death in the mother. Even if the mother is not affected, the ability of the placenta to function properly can also be impaired causing grave problems for the fetus.

Risk factors for placental abruption include:

• Maternal hypertension - most common cause of abruption, occurring in approximately 44% of all cases
• Maternal trauma (motor vehicle accidents, assaults, falls)
• Cigarette smoking
• Alcohol consumption
• Cocaine use
• Short umbilical cord
• Sudden decompression of the uterus (premature rupture of membranes, delivery of first twin)
• Advanced maternal age

Signs and symptoms of placental abruption can include:

• Abdominal cramping, back pain or uterine tenderness (often an abruption is painless)
• Cramping or contractions
• Vaginal spotting or bleeding of dark or bright red blood (frequently there is no vaginal bleeding)
• Maternal signs of shock
• Decreased fetal activity
• Fetal distress

Treatment in the field should focus on the treatment of the mother and rapid transport to a facility that can properly care for the patient. High flow oxygen, proper patient position and rapid transport are key to patient and fetus survival. Remember the impact of the third trimester fetus on the major vessels that pass through the abdomen (supine hypotension syndrome). When lying down, place the mother at a moderate angle to her left or right side to relieve pressure on the vena cava and aorta. Because the signs and symptoms of this issue can be so subtle, you must respect your index of suspicion (IOS) and anticipate the worst case scenario. 

Placental Abruption
WebMD (external link)