Robin Burke

last written: Nov 2011, David LaPierre
last reviewed:





Robin is a 19 year-old woman who is perhaps 36 weeks pregnant (neither she, nor anyone else, is really sure). She has spent some time during her pregnancy living on the streets of Vancouver. You know she smokes and has used drugs of various types during her pregnancy.

She has had very poor prenatal care, and has not had any investigations during her pregnancy.


She comes to the emergency department with vaginal bleeding that started approximately 8 hours ago.


What do you assess first?

It is important to first assess her vital signs for any evidence of shock, and treat it accordingly.

What might be the cause of her bleeding?

Potential causes of bleeding for Robin include:

  • placenta previa
  • placental abruption
  • vasa previa
  • uterine rupture
  • cervical polyp, vaginitis, malignancy (bleeding often following intercourse)
  • genital tract trauma
  • initiation of labour
  • also consider bleeding from the rectum or urinary tract


What do you ask Robin?

Inquire into:

Questions regarding the bleeding include:

  • gestational age
  • onset of bleeding
  • amount and frequency of bleeding
  • pain (location, radiation), or contractions
  • previous bleeding
  • trauma or intercourse
  • colour or consistency (water vs frank blood)

Ask for symptoms of shock

  • dizziness, lightheadedness
  • diaphoresis
  • nausea
  • confusion
  • chest pain

Past obstetrical history

  • history of placenta previa, abruption
  • previous uterine surgery or Cesarian delivery


Medical history

  • coagulopathy
  • sexually transmitted diease
  • fibroids, polyps
  • abnormal pap tests






Part II

Robin's vitals reveal a HR of 88 and a BP of 120/72.

She states the bleeding began after intercourse this morning. She has had no pain with any of this and feels fine as well. The bleeding began with a gush and has been steady all day. She estimates she has lost "a few cups" of blood.

She has not had any contractions, and her baby is moving well.

How do you investigate Robin's bleeding?

A pelvic and speculum exam should be deferred until an ultrasound can be carried out, as a placenta or vasa previa can lead to significant hemorrhage if disturbed.

Bloodwork should include:

  • CBC to assess hemoglobin and to set a baseline
  • type and screen
  • liver enzymes
  • coagulation profiles (PTT, INR) to assess for DIC
  • Apt test to assess for maternal vs fetal blood
  • Kleihauer-Betke test to assess abruption

Fetal wellbeing should be carried out with a non-stress test or biophysical profile.


Investigations reveal...

Ultrasound reveals complete placenta previa.

Bloodwork shows:

  • hemoglobin 108
  • A-ve blood type
  • positive Kleihauer-Betke test
  • labs otherwise normal

Nonstress test reveals a rate of 130, good variability, and accelerations.

Robin's is stable, but her bleeding continues. How do you proceed?

Fluid recuscitation should continue. Rhogamm should be given.

You do not know the exact age of her fetus, and corticosteroids may be helpful (indicated for gestational age <34 weeks).

Given her ongoing bleeding, delivery by Caesarean section should be encouraged.

There is no need for GBS prophylaxis, even though her status is unknown, as she is not giving birth vaginally.



Robin's C/S goes well, and her baby boy is born with Apgar scores of 8 at one minute, though her bleeding requires uterine suturing at the placental site. She is advised of increased risk in subsequent pregnancy.




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