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Snapshot
  • A 29-year-old G2P1 female presents to labor and delivery triage with bleeding in the third trimester. Her first pregnancy was a cesarean delivery delivered at 37 weeks. She describes her bleeding as painless spotting without abdominal pain. An urgent transabdominal ultrasound is performed, showing a viable fetus and normal amniotic fluid. A transvaginal ultrasound is subsequently performed, and shows the placental edge located 1cm from the internal cervical os.
Introduction
 placenta previa
  • Overview
    • placenta previa is a condition characterized placental tissue extending over or < 2 cm from the internal cervical os and is associated with painless third trimester bleeding
  • Epidemiology
    • incidence
      • occurs in approximately 1 per 250 births
    • risk factors
      • previous placenta previa
      • previous cesarean delivery
      • multiple gestations
  • Associated conditions
    • placenta previa-accreta spectrum
      • placenta previa is present along with placenta accreta, placenta increta, or placenta percreta
Presentation
  • Most common presentation is asymptomatic finding on routine ultrasound at 16-20 weeks of gestation
  • Symptoms  
    • painless vaginal bleeding
      • up to 90% of cases
    • uterine contractions, pain, and bleeding
      • 10-20% of cases
  • Physical exam  
    • digital vaginal examination is contraindicated until placenta previa is excluded (may result in severe hemorrhage)
    • findings may include the following
      • hemorrhage
        • usually spontaneously ceases after 1-2 hours
      • hypotension
      • tachycardia
      • usually no fetal distress (in contrast with vasa previa) 
Imaging
  • Ultrasonography
    • transvaginal ultrasound
      • gold standard for diagnosis of placenta previa
      • identification of placental tissue extending over the internal cervical os on 2nd or 3rd trimester imaging
    • transabdominal ultrasound 
      • can be used as a screening test or in conjunction with transvaginal ultrasound
        • if distance between edge of placenta and cervical os is ≤ 2 cm on transabdominal ultrasound, perform transvaginal ultrasound to better visualize placental position
Studies
  • Rh compatability test
  • Complete blood cell (CBC) count
  • Prothrombin time (PT) and activated partial thromboplastin time (aPTT)
  • Blood type and cross
  • Levels of fibrin split products (FSP) and fibrinogen
Differential
  • Abruptio placentae
    • key distinguishing factors
      • placenta prematurely separates from the uterine wall
      • presents with painful bleeding that does not spontaneously cease
  • Placenta accreta
    • key distinguishing factors
      •  placenta invades the uterine wall
      • placenta does not separate after delivery, which may lead to postpartum bleeding
  •  Vasa previa 
    • key distinguishing factors
      • fetal vessels extend over the internal cervical os
      • presents with fetal heart decelerations due to compression of umbilical vessels
Treatment
  • Medical
    • monitoring
      • in the case of asymptomatic placenta previa
        • monitor placental position
        • determine whether placenta accreta is also present
        • if persistent placenta previa, plan for cesarean delivery
    • hemostasis
      • in the case of actively bleeding placenta previa
        • admit for maternal and fetal monitoring
        • achieve and maintain maternal hemodynamic stability
  • Surgical
    • cesarean delivery
      • cesarean delivery should be performed in these cases
        • active labor
        • fetal distress (category III fetal heart rate tracing that does not respond to in utero resuscitation) 
        • inability to achieve maternal hemodynamic stability
        • significant vaginal bleeding after 34 weeks of gestation 
Complications
  • Congenital malformations
    • associated with 2-fold increase
  • Fetal malpresentation
  • Vasa previa
    • rupture of fetal vessels that cross the membranes covering the cervix
    • cesarean delivery indicated
  • Postpartum hemorrhage
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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