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Speaker 1: All right, so in today's podcast, we're going to be

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going over a couple high old complications related to pregnancy.

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This is going to be the first of a few

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podcasts I plan on making on pregnancy related complications. Thank

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you everybody for the support, the really nice comments, the

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five star reviews on Apple Podcasts and Spotify. I truly

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do appreciate it. Thank you so much. And let's go

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ahead and get started. So let's start with placental abruption

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aka abruptio plucente. What is this, Well, it's a partial

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or complete separation of the placenta at or after twenty

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weeks of gestation. So we have this premature separation of

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the placenta from the uterus. We'll talk about why this

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happens in a moment, but first let's talk about timing.

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So why is timing so important? Why is it generally

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only considered a placental abruption if it occurs after twenty weeks. Well,

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if this happens prior to twenty weeks, in that case,

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it's usually considered to be part of a spontaneous abortion

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rather than an abruption, except for some rare cases, and

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then it also has to be prior to fetal expulsion,

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and this part is pretty obvious. After the fetus is delivered,

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the placenta naturally separates from the world the uterus, and

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so this is no longer an abnormal finding. So again

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timing it's after twenty weeks and prior to delivery of

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the fetus. All right, So we have this placental abruption,

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this separation of the placenta. Why is this happening, Well,

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it's due to a rupture of maternal vessels in something

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called the decidua basalus. So this is the main area

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to focus on for patho thrumb and also plays a

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role with the clinical consequences seen contractions, tissue brick down,

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et cetera. But rupture of the maternal vessels in the

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decidua basalus is what you need to know so quick

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anatomy review. The placenta is where the nutrient and gas

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exchange occurs between the mother and the fetus. It has

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two sides, the baby side called the coreon and the

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mother's side the decidua basalice, which is attached to the

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uterine wall. The deciduo basalus contains the maternal blood vessels,

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arteries and veins that supply oxygen rich blood to the fetus.

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In a placental abruption, the vessels in the deciduoa basalus

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mom's side become damaged or weakened, which causes them to rupture,

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which obviously leads to significant bleeding causing hematoma. And all

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of this just pushes the uterine wall in placenta apart

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and the separation it can be partial or complete, depending

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on the severity of the bleed. So basically to recap

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in a placental abruption, vessels in the decidu of basalus rupture.

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These ruptured vessels bleed and accumulate, which eventually causes the

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placenta to separate and peel away. So then the next

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question becomes why did these vessels rupture in the first place,

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And that takes us to our risk factors. So think,

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what are some things that damage and weaken blood vessels

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that disrupt vascular integrity. Let's start with an easy one,

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and that is smoking. So this is one of the

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few modifiable risk factors. It's also associated with a fourfold

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increased risk and it's thought to be related to its

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phasoconstrictive effects which cause placental hypoperfusion necrosis et cetera. Another

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one is cocaine again vasoconstriction, eschemia, et cetera. Up to

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ten percent of pregnant women using cocaine to the third

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trimester will develop an abruption hypertension. This one's really important,

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five fold increased risk compared to normal intensive Obviously, anytime

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the blood pressure is increased, you can have arterial wall damage.

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And then the next one is trauma, so blunt trauma,

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a motor vehicle accident, fall, et cetera. Even though this

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isn't the most common risk factor, it's definitely popular on

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exam questions and I have this one in school. So

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in trauma like a motor vehicle accident, for instance, you

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have this rapid acceleration deceleration of the uterus where the

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uterine wall stretches with the sudden movement. As the uterus

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is pretty flexible, but the placenta it's not so stretchy,

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so it stays in place. So you have this shearing

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force that just rips the two apart. And then we

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have our last risk factor, which is previous abruption. Like

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so many things in medicine, if you had it before,

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good chance you'll hap it again. And in the case

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of a placental abruption, very good chance. So there are

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some other risk factors, but those are the five to

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focus on, smoking, cocaine, hypertension, trauma, and previous abruption. All right,

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let's talk about something super high yield next, and that

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is your clinical manifestations. So for clinical manifestations, there's really

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two things that you need to know, pain and bleeding.

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Neither as one hundred percent in real life, but in

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preparation for an exam, you need to assume you'll be

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given the most common clinical presentation, which is abrupt onset

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of vaginal bleeding and mild to moderate abdominal pain. So

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let's talk about that vaginal bleeding. This is usually going

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to be abrupted onset, and this is a key component,

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but it's not very specific because there's obviously other causes

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of third trimester bleeding, like with placenta previa, which will

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go over next, and there is something called a concealed

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abruption where most of the blood is actually trapped behind

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the placenta, and in these cases, even in a very

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severe abruption, there may be little to no vaginal bleeding.

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So that's clinical knowledge, but for an exam, always be

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thinking classic presentation, which is abrupt onset of vaginal bleeding,

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as this will be how the vast majority of patients

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present around eighty percent of individuals with a placental abruption. Next,

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abdominal pain, so pain. This is associated with the uterine contractions,

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which are often high frequency in low amplitude, So the

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abdominal pain. It's important because on an exam, in some cases,

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the only thing to differentiate an abruption from placenta previa

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is the mention of some type of abdominal pain. So

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classic presentation mild to moderate abdominal pain is going to

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be typical. Back pain is also a possibility when the

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placenta is on the posterior wall of the uterus. In

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some cases the abdominal pain can be very severe, so

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abdominal pain very important to remember. So clinical manifestations. Nothing's

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one hundred percent in medicine, but for the exam, associate

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placental abruption with painful vaginal bleeding at or after twenty

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weeks gestation. Next is our physical exam, so really just

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one thing to focus on, and this is really important

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because it's another key to help you on your exam question,

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and that is the uterus it's going to be tender

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and rigid. On exam. You also may hear it being

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described as hypertonic, which just means high muscle tone, which

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is from those frequent contractions. So really important to remember rigid,

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tender or hypertonic uterus. Okay, diagnosis next, So in acute

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placental abruption, it's mainly a clinical diagnosis and you should

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suspect this in any pregnant patient that has abrupt onset

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of vaginal blas, abdominal pain contractions, especially in the presence

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of uterine tenderness and increase uterintone. As we talked about before,

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there are some other things that help support the diagnosis

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feudal heart rate, abnormalities, disseminated intravascular coagulation which can be

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associated with abruption. So remember again this is mainly a

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clinical diagnosis and you should suspect it in any pregnant

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patient with sudden onset vaginal bleeding, abdominal pain, contractions, tender

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and rigid uterus. With that being said, you should also

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know ultrasound can be helpful and what you should know

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for your ultrasound finding is something that's known as a

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retro placental hematoma. So a clot behind the placenta. If

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this is present, this strongly supports the diagnosis and on

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an exam question, if you see this mentioned, slam dunk,

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it's a placental abruption. In real life it can be

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absent and a good deal of patience, So it's great

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if it's present, but not so helpful when it's not.

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Ultrasound is also helpful to rule out your differentials such

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as placenta previa, which will go over next. So again,

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diagnosis mainly clinical, but the ultrasound what you're looking for.

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The classic finding is going to be a retro placental hematoma,

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all right, So treatment it depends on a lot of factors,

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including hemodynamic stability of the mother, the status of the fetus,

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and I don't think the questions you'll get will be

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about treatment, but just so you have an idea. Part

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of the treatment is focused on hemodynamic support for the mother,

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so things like blood transfusion, IV fluids, et cetera. Of

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course continuous fetal heart rate monitoring, and then depending on

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a number of factors, often emergent delivery is indicated, whether

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by vaginal or cesarean birth. Okay, so quick recap placental abruption.

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Placenta is peeling away from the uterus prematurely. This is

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at or after twenty weeks of gestation and prior to birth.

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Those maternal vessels, whether diseased from hypertension, smoking, or damaged

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from car accident fall, have ruptured and are filling that

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separated space with blood. Most often will see bleeding on

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physical exam. In some cases the bleeding can be hidden.

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One thing I want you to remember is this patient

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will likely be in pain, very likely contractions, et cetera.

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Uterus is going to be tender and rigid. Diagnosis is

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made clinically ultrasound. If it shows a retro placental hematoma,

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slam dunk, But it doesn't always For things you need

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to remember that always come up in the description on

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an exam question. That's pain, bleeding, the rigid uterus, and contractions.

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This is how I remembered it and hopefully it will

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help you too. Instead of placental abruption, I used to

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remember it as placental crab eruption. Think of a crab

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with its little claws literally snipping the placenta away from

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the uterine wall and crab and placental crab eruption stands

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for four super important things you need to remember that

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will be on an exam question. So C and crab

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is for contractions, R is for rigid, as in a

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rigid or hypertonic uterus, A is for abdominal pain, which

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is so important, and then B is for bleeding. So again,

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placental crab eruption, crab contractions, rigid, abdominal pain, bleeding. All right,

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let's talk about the next condition which will be very

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similar in many ways to placental abruption, and that is

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going to be placenta previa. And this is the presence

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of placental tissue that extends over or near the internal

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cervical os. So really straightforward. In a normal pregnancy, the

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placenta is usually right around the top of the uterus.

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In placenta previa, the placenta is at the bottom of

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the uterus, sometimes covering the entire cervical oss. This can

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cause a number of problems which will go over but

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again placenta previa. The placenta is in the wrong spot,

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plugging up the internal cervical oss and varying degrees. Now

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why this happens, we're not really sure, which is good news.

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From an exam standpoint. As one less thing to remember.

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But one hypothesis is that the upper uterine cavity where

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the placenta normally in plants, is not well vascularized, whether

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this is due to previous surgery, multi parity, or other issues.

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So I do have a quick knuomonic placenta abruption which

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we just went over. The placenta was moving away from

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the uterus. Remember it is kind of being ripped apart

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and placenta previa. The placenta is plugging up the uterus.

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So placenta abruption placenta away. Placenta previa placenta plug essentially,

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so placenta abruption has an a. Remember the placenta is

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moving away from the uterus. Placenta previa has a p

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so remember the placenta is plugging up the uterus. Just

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another way to help you remember the differences between the two.

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All right, So with placenta previa, what are some risk

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factories you should know? There's three main ones to focus on.

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Starting with a previous placenta previa. Again, like so many

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things in medicine, if you had it before, higher risk

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of having it again. Previous cesarean birth and then finally,

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multiple gestation, so carrying more than one baby at a time, twins,

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et cetera. One study found placenta previa was forty percent

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higher among twin berths than among singleton berths. There's other

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risk factors, increasing maternal age, smoking, cocaine use, male fetus,

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but focus on the three we went over above, if

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you're even going to bother them memorizing risk factors at all,

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because to be honest, they're not the highest deeled thing

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to know. With that being said, though, let's talk about

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something that is very high yield, and that's the clinical manifestations.

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So let's start with the fact that this may be

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an asymptomatic finding on routine ultrasound at approximately eighteen to

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twenty weeks of gestation. So the majority of placenta previus

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will be an asymptomatic finding on mid trimester ultrasound examination,

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and luckily about ninety percent identified on ultrasound at eighteen

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to twenty weeks will resolve before delivery, So many women

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may be asymptomatic. But this isn't what you should remember

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for the exam. On the exam, they're not going to

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give you an asymptomatic patient what they're going to give

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you is a patient with painless vaginal bleeding. Painless I'll

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repeat it again, painless vaginal bleeding. In the second half

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of pregnancy, the most common symptom of placenta previa is

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painless vaginal bleeding, which occurs in up to ninety percent

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of cases. Compared this to placental abruption, which again, remember

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more often than not had painful bleeding. So placenta previa

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painless bleeding. Now in real life, ten to twenty percent

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of patients with placenta previa may have some pain from

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uterine contractions, et cetera. But we're preparing for an exam,

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and for an exam, remember the most common which is

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painless vaginal bleeding. So how do you remember that? While

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instead of placenta previa, remember it as placenta stevia. Placenta

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previa is now placenta stevia. Stevia as we know, is

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that sugar free or a sugarless sweetener, and placenta previa

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is the pain free or painless vaginal bleeding. It works

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for me. I know it's a little weird, but hopefully

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it helps you too. Placenta stevia sugar free sweetener pain

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free vaginal bleeding. Okay, diagnosis, Let's first talk about what

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you do not want to do, and this will often

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be tested on. So you don't want to perform a

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digital vaginal exam anytime there is any vaginal bleeding in

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the second or third trimester. A digital examination is absolutely

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contraindicated until you perform ultrasound and rule out a placenta previa.

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If you perform a digital vaginal exam on a patient

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with placenta previa, remember the placenta. It's in the wrong spot,

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positioned low in the uterus, covering or near the cervix,

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and a digital exam can reach this area and dislodge

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the placental's attachment site, causing severe bleeding. So remember that

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because it definitely could be a question. Okay, So now

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that we know what we should not do, what should

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we do to help make the diagnosis, Well, that's using ultrasound.

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So this is how you diagnose placenta previa. Ultrasound is

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what you need to know. So you'll usually start with

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trans abdominal ultrasound as a screening test, and then the

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gold standard is with transvaginal ultrasound, which provides better detail

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and better defines the placental position. Now we just said

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never do a digital vaginal exam on a patient with

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a suspected placenta previa, Why the heck can we do

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a transvaginal ultrasound? While with a transvaginal ultrasound you're able

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to visualize the anatomy, so you're not going in blind,

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and the optimal position of the vaginal probe is actually

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far enough away from the cervix to make this a

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safe test. So when you do the ultrasound, what are

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you looking for to confirm the diagnosis? So that's going

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to be placental tissue visualized over the internal cervical oss.

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So again diagnosis, do not perform a digital vaginal exam,

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do perform an ultrasound. What about treatment next? Just like

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with placental abruption, I don't think many or any questions

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will be asked about management, but just so you have

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a general idea. In asymptomatic patients where placenta previa is

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seen on routine ultrasound at eighteen to twenty two weeks,

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close monitoring is an option. If you have a mother

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with an actively bleeding placenta previa, this is a potential

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obstetric emergency, so monitoring maternal hemodynamic status, blood transfusions, monitoring

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fetal heart rate. Once the bleeding has resolved in some patient's,

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outpatient management is reasonable. You want to recommend to avoid

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excessive physical activity, avoid sexual intercourse. Some women will receive

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antenatal corticosteroid therapy and then when delivery is recommended in

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some patient's, vaginal delivery can be an option, but quite

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often a Cissaian birth is recommended. Okay, So, placenta previa.

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This is the abnormal presence of placental tissue that extends

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over or near the internal cervical oss. While this may

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be an asymptomatic finding on routine exam, the classic symptom

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of placenta previa that you will not forget is painless

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vaginal bleeding. Up to ninety percent of persistent cases will

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have painless painless painless fagional bleeding. Remember placenta stevia sugar

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free pain free diagnosis. Do not perform a digital vaginal exam,

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Do perform an ultrasound treatment, manage the bleeding, observe and

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deliver when appropriate. That's placenta previa. Now let's do a

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quick recap of what I feel are the highest yield

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things to know for both placental abruption and placenta previa. Okay, So,

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Placenta abruption is a premature separation of the placenta from

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the uterus. Placenta previa is abnormal placental tissue over or

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near the internal cervical os So placenta abruption placenta moving

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away from the uterus. Placenta previa is plugging up the uterus.

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Remember placental abruption has an A, so placenta is moving

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away from the uterus, and placenta previa has a p

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so the placenta is plugging up the uterus. Next presentation

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placental abruption painful bleeding cramping along with rigid hypertonic uterus

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on physical exam, remember your placental crab eruption and then

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placenta previa remember painless faginal bleeding. Remember placenta stevia sugar

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free pain free. Remember placenta previa. You do not perform

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a digital vaginal exam as this can cost of your hemorrhage.

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And finally, with placental abruption, a retroplacental hematoma is the

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classic ultrasound finding. So those are the most important things

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to remember about these two conditions. Let's do some questions.

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Next question one, A thirty two year old G three

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P twoter woman presents to the emergency department at twenty

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eight weeks gestation with painless vaginal bleeding that started an

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hour ago. She denies any contractions, abdominal pain, or trauma.

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Her pregnancy has been uncomplicated until now. On examination, she

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is hemo dynamically stable and the fetal heart rate is

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one hundred and forty five beats per minute. Which of

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the following should be avoided in the workup of this patient?

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A trans abdominal ultrasound, B, transvaginal ultrasound, C digital vaginal

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examination or d fetal heart rate monitoring? Again, which of

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the following should be avoided in the workup of this

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patient A trans abdominal ultrasound, B, transvaginal ultrasound, C, digital

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vagili examination or DE fetal heart rate monitoring. All right,

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So I'm sure you know the answer to that one,

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and that is going to be CE digital vaginal examination.

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All right. So we have a pregnant patient with vaginal

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bleeding after twenty weeks tessation. G three P two minting

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three pregnancies and two berths at term. The vignette clearly

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states there is no pain or contractions, so while we

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can't definitively say that this is a placenta previa without imaging,

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it should definitely be high on the list of differentials.

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Most important thing is to remember that anytime a patient

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has vaginal bleeding late in pregnancy, you do not perform

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a digital vaginal examination until you rule out a placenta previa,

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as this can lead to severe hemorrhage. So the other

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answer is ultrasound. For Answers A and B, this is

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first line imaging to assess placental position that includes transvaginal ultrasound,

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which can be safely performed even with placenta previa. And

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then finally, fetal heart rate monitoring always appropriate with active

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vaginal bleeding and a pregnant patient, So again answers CEE,

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digital vaginal examination is the only choice that is absolutely

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contraindicated until previa is ruled out. Question two. A thirty

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five year old G four P three female currently thirty

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six weeks pregnant, presents the emergency department after being involved

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in a motor vehicle accident she's complaining of severe abdominal

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pain and vaginal bleeding. She admits to using cigarettes and

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cocaine during her pregnancy. Abdominal exam reveals a rigid uterus

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with palpable uterine contractions and blood is observed in the

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vaginal vault. If an ultrasound were performed, which of the

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following findings would be most consistent with the likely diagnosis?

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A placenta covering the internal OS and extending posteriorly B

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low lying placenta one centimeter from the internal oss. C

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retro placental hematoma, D normal placental position with no abnormalities. Again,

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which of the following would be most consistent with the

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likely diagnosis if ultrasound were obtained. A placenta covering the

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internal OS and extending posteriorly B low lying placenta one

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centimeters from the internal oss see retroplacental hematoma or D

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normal placental position with no abnormalities. Okay, that is going

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to be ce retroplacental hematoma. So first, what is the

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likely diagnosis in this patient? Well, first, does this patient

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have She does? She has crab, which again we know

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is contractions. She has a rigid uterus. She has abdominal

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pain and she has bleeding, so a suspicion for a

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placental abruption should be high. The vignette also mentions she

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used in a motor vehicle accident, which we know is

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a risk factor for placental abruption, and then finally it

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mentions cocaine and cigarette use. Highly likely this patient has

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a placental abruption, and as we discussed earlier, while this

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may not be found in all patients, a retroplacental hematoma

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or clot is a classic ultrasound finding and strongly supports

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the diagnosis question three for the patient. Reference in the

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previous question, what underlying pathophysiological mecha mechanism is most likely

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responsible for their condition? So in the patient we just

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mentioned what underlying pathophysiological mechanism is most likely responsible for

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their condition? Okay, and remember that is going to be

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a rupture of maternal vessels in the decidua based sallus.

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So remember in a placental abruption, vessels in the decidua

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bas salice rupture. These ruptured vessels bleed and accumulate, which

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eventually causes the placenta to separate and peel away. Okay,

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so I hope that was helpful. Thank you so much

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for listening. If it's helping you, please leave a review

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in the podcast comments and if you really like it,

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a five star review would absolutely be helpful. And thank

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you so much again