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Emergency Medicine

Answer 4
  1.  Placental abruption. This patient has signs and symptoms of a placental abruption, a premature separation of a normally implanted placenta. Placental abruption occurs in approximately 1% to 2% of all pregnancies.5,6 The presentation of placental abruption varies depending on the degree and location of the placental separation. Some patients present with minor bleeding and are hemodynamically stable, whereas others have major bleeding, hemorrhagic shock, and fetal demise. Approximately 20% of placental abruptions are “concealed” with little or no visible vaginal bleeding.5 In cases of concealed placental abruption, maternal shock may not coincide with the amount of visible blood loss, and the emergency physician should suspect a concealed placental abruption in a pregnant patient with undifferentiated shock. Placental abruption is categorized using a grading system of 1 through 3 based on clinical presentation and laboratory findings. Grade 1 occurs in 40% of cases; these patients are asymptomatic or have vaginal spotting, are hemodynamically stable, and have no evidence of disseminated intravascular coagulation (DIC), and the fetal heart rate is normal. Grade 2 placental abruption occurs in 45% of cases and is characterized by moderate vaginal bleeding or hematoma, uterine tenderness with contractions, maternal tachycardia, a nonreassuring fetal heart rate, and decreased maternal fibrinogen levels. Grade 3 placental abruption occurs in 15% of cases and is characterized by severe vaginal bleeding, extreme blood loss, uterine tenderness and contractions, maternal hypovolemic shock, fetal distress or fetal death, and a high risk of DIC. Based on the patient’s symptoms, she has a grade 3 placental abruption, and the risk of DIC and associated fetal death is 10% to 20%.

    5. Hladky K, Yankowitz J, Hansen WF. Placental abruption. Obstet Gynecol Surv 2002;57:299–305.

    6. Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol 2006;108:1005–16.

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