S1E54 Placenta Previa & Placenta Abruption

<v Speaker 1>All right, so in today's podcast, we're going to be
<v Speaker 1>going over a couple high old complications related to pregnancy.
<v Speaker 1>This is going to be the first of a few
<v Speaker 1>podcasts I plan on making on pregnancy related complications. Thank
<v Speaker 1>you everybody for the support, the really nice comments, the
<v Speaker 1>five star reviews on Apple Podcasts and Spotify. I truly
<v Speaker 1>do appreciate it. Thank you so much. And let's go
<v Speaker 1>ahead and get started. So let's start with placental abruption
<v Speaker 1>aka abruptio plucente. What is this, Well, it's a partial
<v Speaker 1>or complete separation of the placenta at or after twenty
<v Speaker 1>weeks of gestation. So we have this premature separation of
<v Speaker 1>the placenta from the uterus. We'll talk about why this
<v Speaker 1>happens in a moment, but first let's talk about timing.
<v Speaker 1>So why is timing so important? Why is it generally
<v Speaker 1>only considered a placental abruption if it occurs after twenty weeks. Well,
<v Speaker 1>if this happens prior to twenty weeks, in that case,
<v Speaker 1>it's usually considered to be part of a spontaneous abortion
<v Speaker 1>rather than an abruption, except for some rare cases, and
<v Speaker 1>then it also has to be prior to fetal expulsion,
<v Speaker 1>and this part is pretty obvious. After the fetus is delivered,
<v Speaker 1>the placenta naturally separates from the world the uterus, and
<v Speaker 1>so this is no longer an abnormal finding. So again
<v Speaker 1>timing it's after twenty weeks and prior to delivery of
<v Speaker 1>the fetus. All right, So we have this placental abruption,
<v Speaker 1>this separation of the placenta. Why is this happening, Well,
<v Speaker 1>it's due to a rupture of maternal vessels in something
<v Speaker 1>called the decidua basalus. So this is the main area
<v Speaker 1>to focus on for patho thrumb and also plays a
<v Speaker 1>role with the clinical consequences seen contractions, tissue brick down,
<v Speaker 1>et cetera. But rupture of the maternal vessels in the
<v Speaker 1>decidua basalus is what you need to know so quick
<v Speaker 1>anatomy review. The placenta is where the nutrient and gas
<v Speaker 1>exchange occurs between the mother and the fetus. It has
<v Speaker 1>two sides, the baby side called the coreon and the
<v Speaker 1>mother's side the decidua basalice, which is attached to the
<v Speaker 1>uterine wall. The deciduo basalus contains the maternal blood vessels,
<v Speaker 1>arteries and veins that supply oxygen rich blood to the fetus.
<v Speaker 1>In a placental abruption, the vessels in the deciduoa basalus
<v Speaker 1>mom's side become damaged or weakened, which causes them to rupture,
<v Speaker 1>which obviously leads to significant bleeding causing hematoma. And all
<v Speaker 1>of this just pushes the uterine wall in placenta apart
<v Speaker 1>and the separation it can be partial or complete, depending
<v Speaker 1>on the severity of the bleed. So basically to recap
<v Speaker 1>in a placental abruption, vessels in the decidu of basalus rupture.
<v Speaker 1>These ruptured vessels bleed and accumulate, which eventually causes the
<v Speaker 1>placenta to separate and peel away. So then the next
<v Speaker 1>question becomes why did these vessels rupture in the first place,
<v Speaker 1>And that takes us to our risk factors. So think,
<v Speaker 1>what are some things that damage and weaken blood vessels
<v Speaker 1>that disrupt vascular integrity. Let's start with an easy one,
<v Speaker 1>and that is smoking. So this is one of the
<v Speaker 1>few modifiable risk factors. It's also associated with a fourfold
<v Speaker 1>increased risk and it's thought to be related to its
<v Speaker 1>phasoconstrictive effects which cause placental hypoperfusion necrosis et cetera. Another
<v Speaker 1>one is cocaine again vasoconstriction, eschemia, et cetera. Up to
<v Speaker 1>ten percent of pregnant women using cocaine to the third
<v Speaker 1>trimester will develop an abruption hypertension. This one's really important,
<v Speaker 1>five fold increased risk compared to normal intensive Obviously, anytime
<v Speaker 1>the blood pressure is increased, you can have arterial wall damage.
<v Speaker 1>And then the next one is trauma, so blunt trauma,
<v Speaker 1>a motor vehicle accident, fall, et cetera. Even though this
<v Speaker 1>isn't the most common risk factor, it's definitely popular on
<v Speaker 1>exam questions and I have this one in school. So
<v Speaker 1>in trauma like a motor vehicle accident, for instance, you
<v Speaker 1>have this rapid acceleration deceleration of the uterus where the
<v Speaker 1>uterine wall stretches with the sudden movement. As the uterus
<v Speaker 1>is pretty flexible, but the placenta it's not so stretchy,
<v Speaker 1>so it stays in place. So you have this shearing
<v Speaker 1>force that just rips the two apart. And then we
<v Speaker 1>have our last risk factor, which is previous abruption. Like
<v Speaker 1>so many things in medicine, if you had it before,
<v Speaker 1>good chance you'll hap it again. And in the case
<v Speaker 1>of a placental abruption, very good chance. So there are
<v Speaker 1>some other risk factors, but those are the five to
<v Speaker 1>focus on, smoking, cocaine, hypertension, trauma, and previous abruption. All right,
<v Speaker 1>let's talk about something super high yield next, and that
<v Speaker 1>is your clinical manifestations. So for clinical manifestations, there's really
<v Speaker 1>two things that you need to know, pain and bleeding.
<v Speaker 1>Neither as one hundred percent in real life, but in
<v Speaker 1>preparation for an exam, you need to assume you'll be
<v Speaker 1>given the most common clinical presentation, which is abrupt onset
<v Speaker 1>of vaginal bleeding and mild to moderate abdominal pain. So
<v Speaker 1>let's talk about that vaginal bleeding. This is usually going
<v Speaker 1>to be abrupted onset, and this is a key component,
<v Speaker 1>but it's not very specific because there's obviously other causes
<v Speaker 1>of third trimester bleeding, like with placenta previa, which will
<v Speaker 1>go over next, and there is something called a concealed
<v Speaker 1>abruption where most of the blood is actually trapped behind
<v Speaker 1>the placenta, and in these cases, even in a very
<v Speaker 1>severe abruption, there may be little to no vaginal bleeding.
<v Speaker 1>So that's clinical knowledge, but for an exam, always be
<v Speaker 1>thinking classic presentation, which is abrupt onset of vaginal bleeding,
<v Speaker 1>as this will be how the vast majority of patients
<v Speaker 1>present around eighty percent of individuals with a placental abruption. Next,
<v Speaker 1>abdominal pain, so pain. This is associated with the uterine contractions,
<v Speaker 1>which are often high frequency in low amplitude, So the
<v Speaker 1>abdominal pain. It's important because on an exam, in some cases,
<v Speaker 1>the only thing to differentiate an abruption from placenta previa
<v Speaker 1>is the mention of some type of abdominal pain. So
<v Speaker 1>classic presentation mild to moderate abdominal pain is going to
<v Speaker 1>be typical. Back pain is also a possibility when the
<v Speaker 1>placenta is on the posterior wall of the uterus. In
<v Speaker 1>some cases the abdominal pain can be very severe, so
<v Speaker 1>abdominal pain very important to remember. So clinical manifestations. Nothing's
<v Speaker 1>one hundred percent in medicine, but for the exam, associate
<v Speaker 1>placental abruption with painful vaginal bleeding at or after twenty
<v Speaker 1>weeks gestation. Next is our physical exam, so really just
<v Speaker 1>one thing to focus on, and this is really important
<v Speaker 1>because it's another key to help you on your exam question,
<v Speaker 1>and that is the uterus it's going to be tender
<v Speaker 1>and rigid. On exam. You also may hear it being
<v Speaker 1>described as hypertonic, which just means high muscle tone, which
<v Speaker 1>is from those frequent contractions. So really important to remember rigid,
<v Speaker 1>tender or hypertonic uterus. Okay, diagnosis next, So in acute
<v Speaker 1>placental abruption, it's mainly a clinical diagnosis and you should
<v Speaker 1>suspect this in any pregnant patient that has abrupt onset
<v Speaker 1>of vaginal blas, abdominal pain contractions, especially in the presence
<v Speaker 1>of uterine tenderness and increase uterintone. As we talked about before,
<v Speaker 1>there are some other things that help support the diagnosis
<v Speaker 1>feudal heart rate, abnormalities, disseminated intravascular coagulation which can be
<v Speaker 1>associated with abruption. So remember again this is mainly a
<v Speaker 1>clinical diagnosis and you should suspect it in any pregnant
<v Speaker 1>patient with sudden onset vaginal bleeding, abdominal pain, contractions, tender
<v Speaker 1>and rigid uterus. With that being said, you should also
<v Speaker 1>know ultrasound can be helpful and what you should know
<v Speaker 1>for your ultrasound finding is something that's known as a
<v Speaker 1>retro placental hematoma. So a clot behind the placenta. If
<v Speaker 1>this is present, this strongly supports the diagnosis and on
<v Speaker 1>an exam question, if you see this mentioned, slam dunk,
<v Speaker 1>it's a placental abruption. In real life it can be
<v Speaker 1>absent and a good deal of patience, So it's great
<v Speaker 1>if it's present, but not so helpful when it's not.
<v Speaker 1>Ultrasound is also helpful to rule out your differentials such
<v Speaker 1>as placenta previa, which will go over next. So again,
<v Speaker 1>diagnosis mainly clinical, but the ultrasound what you're looking for.
<v Speaker 1>The classic finding is going to be a retro placental hematoma,
<v Speaker 1>all right, So treatment it depends on a lot of factors,
<v Speaker 1>including hemodynamic stability of the mother, the status of the fetus,
<v Speaker 1>and I don't think the questions you'll get will be
<v Speaker 1>about treatment, but just so you have an idea. Part
<v Speaker 1>of the treatment is focused on hemodynamic support for the mother,
<v Speaker 1>so things like blood transfusion, IV fluids, et cetera. Of
<v Speaker 1>course continuous fetal heart rate monitoring, and then depending on
<v Speaker 1>a number of factors, often emergent delivery is indicated, whether
<v Speaker 1>by vaginal or cesarean birth. Okay, so quick recap placental abruption.
<v Speaker 1>Placenta is peeling away from the uterus prematurely. This is
<v Speaker 1>at or after twenty weeks of gestation and prior to birth.
<v Speaker 1>Those maternal vessels, whether diseased from hypertension, smoking, or damaged
<v Speaker 1>from car accident fall, have ruptured and are filling that
<v Speaker 1>separated space with blood. Most often will see bleeding on
<v Speaker 1>physical exam. In some cases the bleeding can be hidden.
<v Speaker 1>One thing I want you to remember is this patient
<v Speaker 1>will likely be in pain, very likely contractions, et cetera.
<v Speaker 1>Uterus is going to be tender and rigid. Diagnosis is
<v Speaker 1>made clinically ultrasound. If it shows a retro placental hematoma,
<v Speaker 1>slam dunk, But it doesn't always For things you need
<v Speaker 1>to remember that always come up in the description on
<v Speaker 1>an exam question. That's pain, bleeding, the rigid uterus, and contractions.
<v Speaker 1>This is how I remembered it and hopefully it will
<v Speaker 1>help you too. Instead of placental abruption, I used to
<v Speaker 1>remember it as placental crab eruption. Think of a crab
<v Speaker 1>with its little claws literally snipping the placenta away from
<v Speaker 1>the uterine wall and crab and placental crab eruption stands
<v Speaker 1>for four super important things you need to remember that
<v Speaker 1>will be on an exam question. So C and crab
<v Speaker 1>is for contractions, R is for rigid, as in a
<v Speaker 1>rigid or hypertonic uterus, A is for abdominal pain, which
<v Speaker 1>is so important, and then B is for bleeding. So again,
<v Speaker 1>placental crab eruption, crab contractions, rigid, abdominal pain, bleeding. All right,
<v Speaker 1>let's talk about the next condition which will be very
<v Speaker 1>similar in many ways to placental abruption, and that is
<v Speaker 1>going to be placenta previa. And this is the presence
<v Speaker 1>of placental tissue that extends over or near the internal
<v Speaker 1>cervical os. So really straightforward. In a normal pregnancy, the
<v Speaker 1>placenta is usually right around the top of the uterus.
<v Speaker 1>In placenta previa, the placenta is at the bottom of
<v Speaker 1>the uterus, sometimes covering the entire cervical oss. This can
<v Speaker 1>cause a number of problems which will go over but
<v Speaker 1>again placenta previa. The placenta is in the wrong spot,
<v Speaker 1>plugging up the internal cervical oss and varying degrees. Now
<v Speaker 1>why this happens, we're not really sure, which is good news.
<v Speaker 1>From an exam standpoint. As one less thing to remember.
<v Speaker 1>But one hypothesis is that the upper uterine cavity where
<v Speaker 1>the placenta normally in plants, is not well vascularized, whether
<v Speaker 1>this is due to previous surgery, multi parity, or other issues.
<v Speaker 1>So I do have a quick knuomonic placenta abruption which
<v Speaker 1>we just went over. The placenta was moving away from
<v Speaker 1>the uterus. Remember it is kind of being ripped apart
<v Speaker 1>and placenta previa. The placenta is plugging up the uterus.
<v Speaker 1>So placenta abruption placenta away. Placenta previa placenta plug essentially,
<v Speaker 1>so placenta abruption has an a. Remember the placenta is
<v Speaker 1>moving away from the uterus. Placenta previa has a p
<v Speaker 1>so remember the placenta is plugging up the uterus. Just
<v Speaker 1>another way to help you remember the differences between the two.
<v Speaker 1>All right, So with placenta previa, what are some risk
<v Speaker 1>factories you should know? There's three main ones to focus on.
<v Speaker 1>Starting with a previous placenta previa. Again, like so many
<v Speaker 1>things in medicine, if you had it before, higher risk
<v Speaker 1>of having it again. Previous cesarean birth and then finally,
<v Speaker 1>multiple gestation, so carrying more than one baby at a time, twins,
<v Speaker 1>et cetera. One study found placenta previa was forty percent
<v Speaker 1>higher among twin berths than among singleton berths. There's other
<v Speaker 1>risk factors, increasing maternal age, smoking, cocaine use, male fetus,
<v Speaker 1>but focus on the three we went over above, if
<v Speaker 1>you're even going to bother them memorizing risk factors at all,
<v Speaker 1>because to be honest, they're not the highest deeled thing
<v Speaker 1>to know. With that being said, though, let's talk about
<v Speaker 1>something that is very high yield, and that's the clinical manifestations.
<v Speaker 1>So let's start with the fact that this may be
<v Speaker 1>an asymptomatic finding on routine ultrasound at approximately eighteen to
<v Speaker 1>twenty weeks of gestation. So the majority of placenta previus
<v Speaker 1>will be an asymptomatic finding on mid trimester ultrasound examination,
<v Speaker 1>and luckily about ninety percent identified on ultrasound at eighteen
<v Speaker 1>to twenty weeks will resolve before delivery, So many women
<v Speaker 1>may be asymptomatic. But this isn't what you should remember
<v Speaker 1>for the exam. On the exam, they're not going to
<v Speaker 1>give you an asymptomatic patient what they're going to give
<v Speaker 1>you is a patient with painless vaginal bleeding. Painless I'll
<v Speaker 1>repeat it again, painless vaginal bleeding. In the second half
<v Speaker 1>of pregnancy, the most common symptom of placenta previa is
<v Speaker 1>painless vaginal bleeding, which occurs in up to ninety percent
<v Speaker 1>of cases. Compared this to placental abruption, which again, remember
<v Speaker 1>more often than not had painful bleeding. So placenta previa
<v Speaker 1>painless bleeding. Now in real life, ten to twenty percent
<v Speaker 1>of patients with placenta previa may have some pain from
<v Speaker 1>uterine contractions, et cetera. But we're preparing for an exam,
<v Speaker 1>and for an exam, remember the most common which is
<v Speaker 1>painless vaginal bleeding. So how do you remember that? While
<v Speaker 1>instead of placenta previa, remember it as placenta stevia. Placenta
<v Speaker 1>previa is now placenta stevia. Stevia as we know, is
<v Speaker 1>that sugar free or a sugarless sweetener, and placenta previa
<v Speaker 1>is the pain free or painless vaginal bleeding. It works
<v Speaker 1>for me. I know it's a little weird, but hopefully
<v Speaker 1>it helps you too. Placenta stevia sugar free sweetener pain
<v Speaker 1>free vaginal bleeding. Okay, diagnosis, Let's first talk about what
<v Speaker 1>you do not want to do, and this will often
<v Speaker 1>be tested on. So you don't want to perform a
<v Speaker 1>digital vaginal exam anytime there is any vaginal bleeding in
<v Speaker 1>the second or third trimester. A digital examination is absolutely
<v Speaker 1>contraindicated until you perform ultrasound and rule out a placenta previa.
<v Speaker 1>If you perform a digital vaginal exam on a patient
<v Speaker 1>with placenta previa, remember the placenta. It's in the wrong spot,
<v Speaker 1>positioned low in the uterus, covering or near the cervix,
<v Speaker 1>and a digital exam can reach this area and dislodge
<v Speaker 1>the placental's attachment site, causing severe bleeding. So remember that
<v Speaker 1>because it definitely could be a question. Okay, So now
<v Speaker 1>that we know what we should not do, what should
<v Speaker 1>we do to help make the diagnosis, Well, that's using ultrasound.
<v Speaker 1>So this is how you diagnose placenta previa. Ultrasound is
<v Speaker 1>what you need to know. So you'll usually start with
<v Speaker 1>trans abdominal ultrasound as a screening test, and then the
<v Speaker 1>gold standard is with transvaginal ultrasound, which provides better detail
<v Speaker 1>and better defines the placental position. Now we just said
<v Speaker 1>never do a digital vaginal exam on a patient with
<v Speaker 1>a suspected placenta previa, Why the heck can we do
<v Speaker 1>a transvaginal ultrasound? While with a transvaginal ultrasound you're able
<v Speaker 1>to visualize the anatomy, so you're not going in blind,
<v Speaker 1>and the optimal position of the vaginal probe is actually
<v Speaker 1>far enough away from the cervix to make this a
<v Speaker 1>safe test. So when you do the ultrasound, what are
<v Speaker 1>you looking for to confirm the diagnosis? So that's going
<v Speaker 1>to be placental tissue visualized over the internal cervical oss.
<v Speaker 1>So again diagnosis, do not perform a digital vaginal exam,
<v Speaker 1>do perform an ultrasound. What about treatment next? Just like
<v Speaker 1>with placental abruption, I don't think many or any questions
<v Speaker 1>will be asked about management, but just so you have
<v Speaker 1>a general idea. In asymptomatic patients where placenta previa is
<v Speaker 1>seen on routine ultrasound at eighteen to twenty two weeks,
<v Speaker 1>close monitoring is an option. If you have a mother
<v Speaker 1>with an actively bleeding placenta previa, this is a potential
<v Speaker 1>obstetric emergency, so monitoring maternal hemodynamic status, blood transfusions, monitoring
<v Speaker 1>fetal heart rate. Once the bleeding has resolved in some patient's,
<v Speaker 1>outpatient management is reasonable. You want to recommend to avoid
<v Speaker 1>excessive physical activity, avoid sexual intercourse. Some women will receive
<v Speaker 1>antenatal corticosteroid therapy and then when delivery is recommended in
<v Speaker 1>some patient's, vaginal delivery can be an option, but quite
<v Speaker 1>often a Cissaian birth is recommended. Okay, So, placenta previa.
<v Speaker 1>This is the abnormal presence of placental tissue that extends
<v Speaker 1>over or near the internal cervical oss. While this may
<v Speaker 1>be an asymptomatic finding on routine exam, the classic symptom
<v Speaker 1>of placenta previa that you will not forget is painless
<v Speaker 1>vaginal bleeding. Up to ninety percent of persistent cases will
<v Speaker 1>have painless painless painless fagional bleeding. Remember placenta stevia sugar
<v Speaker 1>free pain free diagnosis. Do not perform a digital vaginal exam,
<v Speaker 1>Do perform an ultrasound treatment, manage the bleeding, observe and
<v Speaker 1>deliver when appropriate. That's placenta previa. Now let's do a
<v Speaker 1>quick recap of what I feel are the highest yield
<v Speaker 1>things to know for both placental abruption and placenta previa. Okay, So,
<v Speaker 1>Placenta abruption is a premature separation of the placenta from
<v Speaker 1>the uterus. Placenta previa is abnormal placental tissue over or
<v Speaker 1>near the internal cervical os So placenta abruption placenta moving
<v Speaker 1>away from the uterus. Placenta previa is plugging up the uterus.
<v Speaker 1>Remember placental abruption has an A, so placenta is moving
<v Speaker 1>away from the uterus, and placenta previa has a p
<v Speaker 1>so the placenta is plugging up the uterus. Next presentation
<v Speaker 1>placental abruption painful bleeding cramping along with rigid hypertonic uterus
<v Speaker 1>on physical exam, remember your placental crab eruption and then
<v Speaker 1>placenta previa remember painless faginal bleeding. Remember placenta stevia sugar
<v Speaker 1>free pain free. Remember placenta previa. You do not perform
<v Speaker 1>a digital vaginal exam as this can cost of your hemorrhage.
<v Speaker 1>And finally, with placental abruption, a retroplacental hematoma is the
<v Speaker 1>classic ultrasound finding. So those are the most important things
<v Speaker 1>to remember about these two conditions. Let's do some questions.
<v Speaker 1>Next question one, A thirty two year old G three
<v Speaker 1>P twoter woman presents to the emergency department at twenty
<v Speaker 1>eight weeks gestation with painless vaginal bleeding that started an
<v Speaker 1>hour ago. She denies any contractions, abdominal pain, or trauma.
<v Speaker 1>Her pregnancy has been uncomplicated until now. On examination, she
<v Speaker 1>is hemo dynamically stable and the fetal heart rate is
<v Speaker 1>one hundred and forty five beats per minute. Which of
<v Speaker 1>the following should be avoided in the workup of this patient?
<v Speaker 1>A trans abdominal ultrasound, B, transvaginal ultrasound, C digital vaginal
<v Speaker 1>examination or d fetal heart rate monitoring? Again, which of
<v Speaker 1>the following should be avoided in the workup of this
<v Speaker 1>patient A trans abdominal ultrasound, B, transvaginal ultrasound, C, digital
<v Speaker 1>vagili examination or DE fetal heart rate monitoring. All right,
<v Speaker 1>So I'm sure you know the answer to that one,
<v Speaker 1>and that is going to be CE digital vaginal examination.
<v Speaker 1>All right. So we have a pregnant patient with vaginal
<v Speaker 1>bleeding after twenty weeks tessation. G three P two minting
<v Speaker 1>three pregnancies and two berths at term. The vignette clearly
<v Speaker 1>states there is no pain or contractions, so while we
<v Speaker 1>can't definitively say that this is a placenta previa without imaging,
<v Speaker 1>it should definitely be high on the list of differentials.
<v Speaker 1>Most important thing is to remember that anytime a patient
<v Speaker 1>has vaginal bleeding late in pregnancy, you do not perform
<v Speaker 1>a digital vaginal examination until you rule out a placenta previa,
<v Speaker 1>as this can lead to severe hemorrhage. So the other
<v Speaker 1>answer is ultrasound. For Answers A and B, this is
<v Speaker 1>first line imaging to assess placental position that includes transvaginal ultrasound,
<v Speaker 1>which can be safely performed even with placenta previa. And
<v Speaker 1>then finally, fetal heart rate monitoring always appropriate with active
<v Speaker 1>vaginal bleeding and a pregnant patient, So again answers CEE,
<v Speaker 1>digital vaginal examination is the only choice that is absolutely
<v Speaker 1>contraindicated until previa is ruled out. Question two. A thirty
<v Speaker 1>five year old G four P three female currently thirty
<v Speaker 1>six weeks pregnant, presents the emergency department after being involved
<v Speaker 1>in a motor vehicle accident she's complaining of severe abdominal
<v Speaker 1>pain and vaginal bleeding. She admits to using cigarettes and
<v Speaker 1>cocaine during her pregnancy. Abdominal exam reveals a rigid uterus
<v Speaker 1>with palpable uterine contractions and blood is observed in the
<v Speaker 1>vaginal vault. If an ultrasound were performed, which of the
<v Speaker 1>following findings would be most consistent with the likely diagnosis?
<v Speaker 1>A placenta covering the internal OS and extending posteriorly B
<v Speaker 1>low lying placenta one centimeter from the internal oss. C
<v Speaker 1>retro placental hematoma, D normal placental position with no abnormalities. Again,
<v Speaker 1>which of the following would be most consistent with the
<v Speaker 1>likely diagnosis if ultrasound were obtained. A placenta covering the
<v Speaker 1>internal OS and extending posteriorly B low lying placenta one
<v Speaker 1>centimeters from the internal oss see retroplacental hematoma or D
<v Speaker 1>normal placental position with no abnormalities. Okay, that is going
<v Speaker 1>to be ce retroplacental hematoma. So first, what is the
<v Speaker 1>likely diagnosis in this patient? Well, first, does this patient
<v Speaker 1>have She does? She has crab, which again we know
<v Speaker 1>is contractions. She has a rigid uterus. She has abdominal
<v Speaker 1>pain and she has bleeding, so a suspicion for a
<v Speaker 1>placental abruption should be high. The vignette also mentions she
<v Speaker 1>used in a motor vehicle accident, which we know is
<v Speaker 1>a risk factor for placental abruption, and then finally it
<v Speaker 1>mentions cocaine and cigarette use. Highly likely this patient has
<v Speaker 1>a placental abruption, and as we discussed earlier, while this
<v Speaker 1>may not be found in all patients, a retroplacental hematoma
<v Speaker 1>or clot is a classic ultrasound finding and strongly supports
<v Speaker 1>the diagnosis question three for the patient. Reference in the
<v Speaker 1>previous question, what underlying pathophysiological mecha mechanism is most likely
<v Speaker 1>responsible for their condition? So in the patient we just
<v Speaker 1>mentioned what underlying pathophysiological mechanism is most likely responsible for
<v Speaker 1>their condition? Okay, and remember that is going to be
<v Speaker 1>a rupture of maternal vessels in the decidua based sallus.
<v Speaker 1>So remember in a placental abruption, vessels in the decidua
<v Speaker 1>bas salice rupture. These ruptured vessels bleed and accumulate, which
<v Speaker 1>eventually causes the placenta to separate and peel away. Okay,
<v Speaker 1>so I hope that was helpful. Thank you so much
<v Speaker 1>for listening. If it's helping you, please leave a review
<v Speaker 1>in the podcast comments and if you really like it,
<v Speaker 1>a five star review would absolutely be helpful. And thank
<v Speaker 1>you so much again