last written: Nov 2011, David LaPierre
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:
What do you ask Robin?
Questions regarding the bleeding include:
Ask for symptoms of shock
Past obstetrical history
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:
Fetal wellbeing should be carried out with a non-stress test or biophysical profile.
Ultrasound reveals complete placenta previa.
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.