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Tuesday, February 6, 2018 10:45 PM
CC: vaginal bleeding
HPI: 28 y/o female, G2P1001, 38 WGA | husband ‐> office ‐‐> sudden vaginal bleeding. Occurred 2 hrs ago, watching TV, noticed gush of bright red
blood soaking thru pants. Bleeding = heavy, soaked multiple pads, not stopping. Never happened to her before.
Prenatal office notes ‐‐> unremarkable course of preg. | borderline high BP (140/75) during 1st prenatal visit, resolved spontaneously | GBS ‐ @
37wks, Rh+. Normal dating US at 12 wks, 2nd trimester fetal scan showed fundal placenta, normal fetal growth, no abnormalities noticed.
ROS: admits to mild lower abdominal pain, palpitation, lightheadedness. Normal FM is felt. Denies painful/regular contractions, recent trauma,
sexual intercourse, abnormal vaginal discharge. Denies fever/chills, n/v/d, rashes, bowel or urinary changes.
PMH PHYSICAL EXAM
OBHx: 2014 NSVD, male, term, 7#14 Weight: 140 lbs (BMI 19)
GYNHx: menarche @ 14, normal menses 26‐28 days cycle, BP: 110/70 (Previous BPs ~ 125‐135/70‐80)
‐fibroids / ‐abnormal pap smear / ‐STD RR 20, Pulse 100; T 99F, O2sat 99%
SurgHx & Medical Hx = none Fundal height: 33 cm
Meds: Prenatal vitamin, Zantac, stool softener
Allergy: none Gen: slight pale, very anxious and worried, in mild pain
CV & Lung = normal
FH: Mom‐ HTN, Hyperlipid (alive) | Father‐ CHF (alive) Abd: gravid, soft, non‐tender, no guarding/rebound tenderness
GU: SSE (speculum) = normal vaginal rugae with adequate mucous, no vaginal
SH: Unstable housing, staying with mom | monogamous discharge, cervix is closed, not friable, no erythema, bright red blood from cervix.
with current FOB | recently incarcerated and just got out Bimanual exam reveals no adnexal masses, tender and hard/hypertonic uterus.
Smoke 4‐5 cig/day for past 10 years Ext: no edema, no petechia, full ROM
Denies EtOH
Previous drug use ‐ Marijuana, Cocaine (clean past 2 years) EFM:
A lot stress due to living situation Base line 140s with moderate variation, + accel, ‐ decels
Toco: no discrete contractions
A/P
Assessment:
28 y/o female, G2P1001 with previous C/S, 32 wks pregnant, current smoker and previous cocaine user who presents with acute onset of painful
vaginal bleeding. Reassuring fetal status with category I fetal tracing. Maternal status is hemodynamically unstable with soft BP and tachycardic.
Concerned mostly for placentae abruption. Other ddx remains uterine rupture, vasa previa, placenta previa.
Plan:
- Continuous fetal status assessment: external fetal monitor (category II and III prompt C/S)
- Monitor maternal hemo status:
○ 2 large bore IV, IV fluid bolus, T/S, get transfusion consent
○ Tox screen for cocaine/amphetamine
○ Monitor blood and coagulation profiles: CBC (platelet counts), BMP (renal function), coag panels (fibrinogen ‐ to r/o DIC)
○ Monitor vital signs, oxygen sat, urine output
Vital signs are not improved (aggressive volume resuscitation ‐ crystalloid, packed RBCs, Platelets, FFP, Cryoprecipitate is
indicated)
- Transvaginal U/S to confirm placental location (r/o placenta previa), can show abruption if it's large enough (not a reliable diagnostic test)
- Baby is term so once mother is hemodynamically stable, vaginal delivery can be attempted
- If mother's status is not improved (DIC occurs), C/S is indicated