{"id":388,"date":"2020-08-13T20:22:25","date_gmt":"2020-08-13T20:22:25","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=388"},"modified":"2020-08-13T20:22:25","modified_gmt":"2020-08-13T20:22:25","slug":"second-and-third-trimester-bleeding","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/advanced-training\/second-and-third-trimester-bleeding\/","title":{"rendered":"Second and Third TM Bleeding"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/Z9ww1TGk-ZI\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 9:45<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57d181104068320832' value='69e9b57d181104068320832'><input type='hidden' id='bg-show-more-text-69e9b57d181104068320832' value='Show Teaching Script'><input type='hidden' id='bg-show-less-text-69e9b57d181104068320832' value='Hide Teaching Script'><button id='bg-showmore-action-69e9b57d181104068320832' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Teaching Script<\/button><div id='bg-showmore-hidden-69e9b57d181104068320832' ><\/p>\n<p>00:01<br \/>\nobjective video about placentation the<br \/>\n00:04<br \/>\nobjectives for this video are to<br \/>\n00:07<br \/>\nunderstand the role of embryonic since<br \/>\n00:09<br \/>\nSEO trophoblastic and Saito<br \/>\n00:10<br \/>\ntrophoblastic cells and placental<br \/>\n00:12<br \/>\ndevelopment describe the layers of the<br \/>\n00:15<br \/>\nchorion and how the phenyl percentual<br \/>\n00:16<br \/>\ndevelopment affects the maternal surface<br \/>\n00:19<br \/>\nappreciate the basic functions of the<br \/>\n00:21<br \/>\nplacenta be able to counsel a patient<br \/>\n00:23<br \/>\nregarding her risk factors for a<br \/>\n00:25<br \/>\nsuspected placenta previa or accreta and<br \/>\n00:28<br \/>\nthe subsequent impact on delivery and<br \/>\n00:30<br \/>\nunderstand the possible pathophysiology<br \/>\n00:32<br \/>\nrelated to the development of placenta<br \/>\n00:35<br \/>\nprevia or accreta<br \/>\n00:38<br \/>\nalright before you can appreciate<br \/>\n00:40<br \/>\nobstetrics you need to understand the<br \/>\n00:42<br \/>\ndevelopment of the placenta the most<br \/>\n00:44<br \/>\noverlooked part of pregnancy during the<br \/>\n00:47<br \/>\nsecond week of gestation the primary<br \/>\n00:49<br \/>\nvilli develop which is the first stage<br \/>\n00:51<br \/>\nof placental formation the trophoblastic<br \/>\n00:54<br \/>\nstem cells the outer sense issue of<br \/>\n00:56<br \/>\ntrophoblasts and the inner synote ROFL<br \/>\n00:58<br \/>\nblasts form finger-like extensions into<br \/>\n01:00<br \/>\nthe maternal decidua also known as the<br \/>\n01:03<br \/>\nmaternal uterine wall at week 3 the<br \/>\n01:06<br \/>\nsecondary villi form during this time<br \/>\n01:09<br \/>\nthe extraembryonic mesoderm grows into<br \/>\n01:11<br \/>\nthe villi and covers the entire surface<br \/>\n01:13<br \/>\nof the chorionic sac during the fourth<br \/>\n01:17<br \/>\nweek the tertiary villi form this weak<br \/>\n01:20<br \/>\nmesenchyme differentiates into blood<br \/>\n01:22<br \/>\nvessels and forms an arterial capillary<br \/>\n01:24<br \/>\nnetwork fuses with placental vessels and<br \/>\n01:27<br \/>\ndevelops connecting stalks the stem or<br \/>\n01:30<br \/>\nanchoring villi are formed as extra<br \/>\n01:32<br \/>\nBillis saito choko plastic cells and<br \/>\n01:35<br \/>\nattached to maternal tissue branched or<br \/>\n01:37<br \/>\nterminal villi grow from the sides of<br \/>\n01:39<br \/>\nthe stem villi in the third trimester<br \/>\n01:42<br \/>\nthe terminal villi emerge from the<br \/>\n01:44<br \/>\nproliferation of the trophoblastic cells<br \/>\n01:46<br \/>\nthey are induced by capillary coiling<br \/>\n01:49<br \/>\nduring the growth of fetal capillaries<br \/>\n01:51<br \/>\nwithin the mature villi at the base of<br \/>\n01:53<br \/>\nthe villi the placental arteries and<br \/>\n01:55<br \/>\nveins pass through the chorionic plate<br \/>\n01:57<br \/>\nterminal villi serve as the region of<br \/>\n02:00<br \/>\nMaine gas and nutrients exchange they<br \/>\n02:02<br \/>\nare surrounded by maternal blood in the<br \/>\n02:04<br \/>\ninterval of spaces there are four layers<br \/>\n02:07<br \/>\nseparating maternal and fetal blood<br \/>\n02:09<br \/>\nsince the shield trophoblast Saito<br \/>\n02:11<br \/>\ntrophoblast relied connective tissue and<br \/>\n02:14<br \/>\nfetal capillary endothelial vascular<br \/>\n02:18<br \/>\nendothelial growth factor or veg F<br \/>\n02:20<br \/>\ndrives two main phases of development in<br \/>\n02:22<br \/>\npregnancy<br \/>\n02:23<br \/>\ninitially the sign of truffle blast is<br \/>\n02:25<br \/>\nthe cellular stimulus to vascular<br \/>\n02:27<br \/>\ngenesis and angiogenesis later the<br \/>\n02:31<br \/>\nHofbauer cells placental macrophages of<br \/>\n02:33<br \/>\nthe Meza Connell origin and stromal<br \/>\n02:35<br \/>\ncells take over the stimulation of blood<br \/>\n02:37<br \/>\nvessel development the fibrin oeid layer<br \/>\n02:40<br \/>\nexisted to forms within the<br \/>\n02:41<br \/>\nextracellular matrix vibrant type fiber<br \/>\n02:45<br \/>\nenoyed is a maternal blood clotting<br \/>\n02:46<br \/>\nproduct which replaces degenerating<br \/>\n02:48<br \/>\nsyncytial trophoblasts matrix type<br \/>\n02:51<br \/>\nfibrin oyd is secreted by invasive extra<br \/>\n02:54<br \/>\nvillus trophoblastic cells the fibrin<br \/>\n02:56<br \/>\noyd layer or knitted book&#8217;s layer is<br \/>\n02:58<br \/>\nthought to present excessively deep<br \/>\n03:00<br \/>\nimplantation and the loss of this layer<br \/>\n03:02<br \/>\nmay lead to ad normal a cetacean<br \/>\n03:04<br \/>\ninvasion now let&#8217;s pause think and apply<br \/>\n03:07<br \/>\nthink fast the trophoblast consists<br \/>\n03:12<br \/>\nprimarily of two layers<br \/>\n03:13<br \/>\nwhat are these layers and how do they<br \/>\n03:15<br \/>\ncontribute to the phenol or maternal<br \/>\n03:16<br \/>\nsurface of the chorion the outer layer<br \/>\n03:19<br \/>\nof the trophoblast is the synthesis otro<br \/>\n03:22<br \/>\nthe blast and after implantation is<br \/>\n03:24<br \/>\nreplaced by fiber enoyed extracellular<br \/>\n03:26<br \/>\nmatrix to form knit a book&#8217;s layer<br \/>\n03:28<br \/>\nbetween the Quarian and the decidua lies<br \/>\n03:30<br \/>\nand de metrio surfaces the inner side of<br \/>\n03:33<br \/>\ntrophoblasts stimulates fetal vascular<br \/>\n03:36<br \/>\ngenesis in the chorion<br \/>\n03:38<br \/>\nnow that we&#8217;ve gone through placental<br \/>\n03:40<br \/>\ndevelopment let&#8217;s look at some clinical<br \/>\n03:42<br \/>\nimplications the placenta has four main<br \/>\n03:45<br \/>\nfunctions prevent fetal allograft<br \/>\n03:48<br \/>\nrejections metabolism and transport and<br \/>\n03:51<br \/>\nendocrine production there are several<br \/>\n03:54<br \/>\nrisk factors for abnormal placental<br \/>\n03:56<br \/>\ndevelopment increasing parody increasing<br \/>\n03:59<br \/>\nmaternal age infertility treatments<br \/>\n04:01<br \/>\nprevious abortion previous uterine<br \/>\n04:05<br \/>\nsurgeries such as dilation and curettage<br \/>\n04:07<br \/>\ncesarean section or myomectomy<br \/>\n04:09<br \/>\nmaternal smoking maternal cocaine use<br \/>\n04:12<br \/>\nmale fetus or non-white race of the<br \/>\n04:15<br \/>\nmother let&#8217;s look at two types of<br \/>\n04:17<br \/>\nplacental pathology a little closer the<br \/>\n04:20<br \/>\npathogenesis of placenta previa is<br \/>\n04:22<br \/>\nunknown one hypothesis is that previous<br \/>\n04:25<br \/>\nsurgeries or fetal implantation leads to<br \/>\n04:27<br \/>\nareas of sub-optimal vascularized<br \/>\n04:30<br \/>\ndecidua this promotes movement of<br \/>\n04:34<br \/>\ntrophoblast to the lower uterine cavity<br \/>\n04:35<br \/>\nanother theory is that a large placenta<br \/>\n04:38<br \/>\nsuch as with multiples increases the<br \/>\n04:41<br \/>\nprobability that the placenta will<br \/>\n04:42<br \/>\nencroach or cover the internal AHS a<br \/>\n04:44<br \/>\nspecial type of previa is a vasopressin<br \/>\n04:48<br \/>\nvessels from the placenta or the<br \/>\n04:50<br \/>\numbilical cord across the internal<br \/>\n04:51<br \/>\ncervical us these \u00e5berg vessels result<br \/>\n04:54<br \/>\nfrom filament discordant searches and by<br \/>\n04:57<br \/>\nlobed or suck Centurion lobed placentas<br \/>\n05:00<br \/>\nplacental bleeding can be devastating<br \/>\n05:02<br \/>\nsecurely a placenta praevia uterine<br \/>\n05:05<br \/>\ncontractions are gradual cervical change<br \/>\n05:08<br \/>\napply shearing forces to the inelastic<br \/>\n05:10<br \/>\nplacental sites resulting in a partial<br \/>\n05:12<br \/>\ndetachment Digital vaginal exams of<br \/>\n05:16<br \/>\npenetrative intercourse can also cause<br \/>\n05:19<br \/>\nsimilar disruptions bleeding in a previa<br \/>\n05:22<br \/>\nis mainly maternal while Ave is a<br \/>\n05:24<br \/>\npreview bleeding is mainly fetal another<br \/>\n05:28<br \/>\nmajor placental pathology is placenta<br \/>\n05:30<br \/>\naccreta<br \/>\n05:30<br \/>\nthis results from abnormal placental<br \/>\n05:33<br \/>\nimplantation in which anchoring<br \/>\n05:35<br \/>\nplacental villi attached to the<br \/>\n05:37<br \/>\nmyometrium rather than the decidua<br \/>\n05:39<br \/>\nresulting in a net here<br \/>\n05:41<br \/>\nAscenta pasetta accreta is a consequence<br \/>\n05:44<br \/>\nof abnormal adherence and absence of the<br \/>\n05:47<br \/>\ndecidua base Alice the incidence is<br \/>\n05:50<br \/>\nhigher in women with higher cesarean<br \/>\n05:52<br \/>\nsection over 80% are associated with a<br \/>\n05:55<br \/>\ndisruption in knit a book&#8217;s layer<br \/>\n05:57<br \/>\nplacenta accreta occurs when the<br \/>\n06:00<br \/>\nplacenta grows in to the uterine muscle<br \/>\n06:02<br \/>\nbut does not penetrate the serosa this<br \/>\n06:06<br \/>\naccounts for about 15% of all abnormal<br \/>\n06:08<br \/>\nimplantation cases finally in a placenta<br \/>\n06:12<br \/>\npercreta the placenta penetrates both<br \/>\n06:14<br \/>\nthe myometrium and the serosa this<br \/>\n06:17<br \/>\naccounts for 5% of all cases and is the<br \/>\n06:19<br \/>\nmost morbid the causes of placenta<br \/>\n06:23<br \/>\naccreta are unknown but may be related<br \/>\n06:25<br \/>\nto defective decidua lies ation from<br \/>\n06:27<br \/>\nprior surgeries or anatomic factors this<br \/>\n06:30<br \/>\nis supported by observation that 80% of<br \/>\n06:32<br \/>\nthese cases occur in women with a<br \/>\n06:34<br \/>\nhistory of a prior cesarean section<br \/>\n06:37<br \/>\ndilation and curettage or myomectomy Wow<br \/>\n06:43<br \/>\nI have to admit I never really gave the<br \/>\n06:44<br \/>\nplacenta much thought especially not the<br \/>\n06:46<br \/>\nclinical impact of the placental<br \/>\n06:48<br \/>\ndevelopment<br \/>\n06:48<br \/>\nI wonder if I will get to put this<br \/>\n06:50<br \/>\ndidactic to you soon now let&#8217;s pause<br \/>\n06:53<br \/>\nthink and apply think fast a 30 year old<br \/>\n06:57<br \/>\ngrab at a 3 para 2 0 0 2 at 30 weeks<br \/>\n07:00<br \/>\ngestation and a history of two prior<br \/>\n07:03<br \/>\ncesarean deliveries presents with<br \/>\n07:05<br \/>\nhematuria and sonographic evidence of an<br \/>\n07:07<br \/>\nanterior placenta in the lower uterine<br \/>\n07:08<br \/>\nsegment she has told she will possibly<br \/>\n07:11<br \/>\nneed a bladder resection at the time of<br \/>\n07:12<br \/>\ndelivery name the type of abnormal<br \/>\n07:14<br \/>\npresentation described and briefly<br \/>\n07:16<br \/>\ndescribed the histopathology the patient<br \/>\n07:20<br \/>\nlikely has placenta percreta which<br \/>\n07:22<br \/>\noccurs when the anchoring villi<br \/>\n07:23<br \/>\npenetrate the myometrium and neuter and<br \/>\n07:25<br \/>\nserosa and possibly adjacent organs in<br \/>\n07:28<br \/>\nthis case the bladder wall theoretically<br \/>\n07:30<br \/>\nthis may happen due to defected vascular<br \/>\n07:32<br \/>\nremodeling of the uterine scar or<br \/>\n07:34<br \/>\npartial or complete dehiscence of a<br \/>\n07:36<br \/>\nprevious history t&#8217;me<br \/>\n07:38<br \/>\nI have your ultrasound report the fetal<br \/>\n07:45<br \/>\nAnatomy does not show any signs of<br \/>\n07:46<br \/>\nconcerns but we should talk about your<br \/>\n07:48<br \/>\nplacenta a little at this point we think<br \/>\n07:51<br \/>\nyou have pasetta previa we will repeat<br \/>\n07:54<br \/>\nimaging at the start of the third<br \/>\n07:55<br \/>\ntrimester to see if it has resolved Oh<br \/>\n07:58<br \/>\nwhat are the chances that the placenta<br \/>\n08:00<br \/>\nwill move the more the placenta extends<br \/>\n08:03<br \/>\nover the US and the more interior it is<br \/>\n08:06<br \/>\nsituated the more likely it will be<br \/>\n08:08<br \/>\nprevia at delivery although our models<br \/>\n08:12<br \/>\nare not good if the placenta extends<br \/>\n08:14<br \/>\nover the ausf I 50 to 25 millimeters the<br \/>\n08:17<br \/>\nlikelihood of previa at delivery is<br \/>\n08:19<br \/>\nabout 20%<br \/>\n08:20<br \/>\ncontrast that with someone whose<br \/>\n08:22<br \/>\nplacenta is more than 25 millimeters<br \/>\n08:24<br \/>\nacross the US their likelihood of a<br \/>\n08:27<br \/>\nprevia at delivery is over 40%<br \/>\n08:29<br \/>\nour biggest concern if the premia does<br \/>\n08:32<br \/>\nnot resolve is maternal hemorrhage<br \/>\n08:34<br \/>\nhowever we can start to address that<br \/>\n08:37<br \/>\nfurther once we get closer oh that<br \/>\n08:40<br \/>\nsounds great for now I&#8217;ll let you know<br \/>\n08:42<br \/>\nif I have any vaginal bleeding and we<br \/>\n08:45<br \/>\ncan reevaluate as you recommend thanks<br \/>\n08:47<br \/>\nso much<br \/>\n08:48<br \/>\nboy am I glad I reviewed my placental<br \/>\n08:50<br \/>\nphysiology with dr. Smith this concludes<br \/>\n08:54<br \/>\nthe aapko basic science video on<br \/>\n08:56<br \/>\nabnormal presentation you should now<br \/>\n08:59<br \/>\nunderstand the role of embryonic since<br \/>\n09:01<br \/>\nCiccio trophoblastic and Saito<br \/>\n09:02<br \/>\ntrophoblastic cells in placental<br \/>\n09:05<br \/>\ndevelopment be able to describe the<br \/>\n09:07<br \/>\nlayers of the chorion appreciate the<br \/>\n09:09<br \/>\nbasic functions of the placenta and<br \/>\n09:11<br \/>\nunderstand the basic pathophysiology of<br \/>\n09:13<br \/>\nplacenta previa or accreta<br \/>\n09:28<br \/>\n[Music]<br \/>\n09:36<br \/>\n[Music]<br \/>\n<\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" title=\"vimeo-player\" src=\"https:\/\/player.vimeo.com\/video\/121616905\" width=\"640\" height=\"360\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 8:56<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57d18a9e9006845161' value='69e9b57d18a9e9006845161'><input type='hidden' id='bg-show-more-text-69e9b57d18a9e9006845161' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b57d18a9e9006845161' value='Hide Transcript'><button id='bg-showmore-action-69e9b57d18a9e9006845161' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b57d18a9e9006845161' ><\/p>\n<p>Bleeding during the second and third trimester has special clinical significance, encompassing problems that are quite serious and those that are normal or expected. It\u2019s important to be able to distinguish between them.<\/p>\n<p><strong>One normal occurrence of bleeding is called Bloody show<\/strong><\/p>\n<p>As the cervix thins and begins to dilate in preparation for labor, the patient may notice the passage of some bloody mucous. This is a normal event during the days leading up to the onset of labor at term. If this is the only symptom, the patient can be reassured of its normalcy. If the patient is also having significant contractions, she should be evaluated for the possible onset of labor.<\/p>\n<p>If this bloody mucous show appears prior to full term, then it may signal the imminent onset of preterm labor. These patients are evaluated for possible pre-term labor.<\/p>\n<p>Bleeding that is more than bloody mucous (bright red, no mucous, passage of clots) requires further evaluation.<\/p>\n<p><strong>Cervicitis and cervical trauma ARE relatively innocent causes for bleeding.<\/strong><\/p>\n<p>During pregnancy, the cervix becomes softer, more\u00a0fragile, and more vulnerable to the effects of trauma and microbes.<\/p>\n<p>Cervical ectropion, in which the soft, mucous- producing endocervical mucosa grows out onto the exocervix is common among pregnant women. This friable endocervical epithelium bleeds easily when touched. This situation can lead to spotting after intercourse, a vaginal examination, or placement of a vaginal speculum.<\/p>\n<p>Cervical ectropion also can lead to cervicitis. The normal squamous cell cervical epithelium is relatively resistant to bacterial attack. The endocervical mucosa is less resistant. If infected, the cervical ectropion is even more likely to bleed if touched.<\/p>\n<p>These changes are usually easily seen during a vaginal speculum exam.<\/p>\n<p><strong>Placental abruption can be a very serious cause for bleeding at this time.<\/strong><\/p>\n<p>Placental abruption is also known as a premature separation of the placenta. All placentas normally detach from the uterus shortly after delivery of the baby. If any portion of the placenta detaches prior to birth of the baby, this is called a placental abruption. Placental abruption occurs in about 1% of all pregnancies.<\/p>\n<p>A placental abruption may be partial or complete.<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>A complete abruption is a disastrous event. The fetus will die within 15-20 minutes. The mother will die soon afterward, from either blood loss or the coagulation disorder which often Women with complete\u00a0placental abruptions are generally desperately ill with severe abdominal pain, shock, hemorrhage, a rigid and unrelaxing uterus.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>\n<p class=\"p2\">Partial placental abruptions may range from insignificant to the striking abnormalities seen in complete abruptions.<\/p>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Clinically, an abruption presents after 20 weeks gestation with abdominal cramping, uterine tenderness, contractions, and usually some vaginal bleeding. Occasionally, the blood loss is trapped inside the uterus. These cases are called \u201cconcealed abruptions.\u201d<\/p>\n<p>A number of factors are associated with an increased risk of placental abruption.<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>\n<p class=\"p2\">Prior placental abruption roughly doubles the risk of abruption in a subsequent pregnancy.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">Abdominal trauma, including motor vehicle accidents are associated with placental abruption.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">Many previous babies, Low socio-economic status , and Poor nutrition have an association.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">Use of cocaine or its derivatives and Cigarette smoking , as well as Maternal hypertension, including pre-eclampsia and eclampsia are all associated with abruption.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">Abnormalities in amniotic fluid volume, including Polyhydramnios and Oligohydramnios have the association.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">Finally, Multiple gestations are associated with abruption.<\/p>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Abruptions are often diagnosed clinically, based on the symptoms of bright red vaginal bleeding, frequent contractions and uterine tenderness.<\/p>\n<p>There are no laboratory findings that are specific for placental abruption. In mild cases, laboratory tests are usually normal. In more advanced cases, the\u00a0<u>Hgb\u00a0<\/u>and\u00a0<u>Hct<\/u>\u00a0go down, as do the\u00a0<u>platelets<\/u>\u00a0and fibrinogen (due to the massive bleeding and consumption of coagulation factors) while fibrin split products go up. Fetal RBCs may be identified in the maternal blood.<\/p>\n<p>In the case of large abruptions, ultrasound may identify a retroplacental blood clot. In milder cases, ultrasound scans are frequently normal.<\/p>\n<p>Mild abruptions may resolve with bedrest and observation, but the moderate to severe abruptions generally result in rapid labor and delivery of the baby. If fetal distress is present (and it sometime is), an emergency cesarean section may be needed.<\/p>\n<p>Because so many coagulation factors are consumed with the internal hemorrhage, coagulopathy is common. This means that even after delivery, the patient may continue to bleed because she can no longer effectively clot. In a hospital setting, this can be treated with infusions of platelets, fresh frozen plasma and cryoprecipitate. If these products are unavailable, fresh whole blood transfusion can give good results.<\/p>\n<p><strong>Placenta previa is another potentially disastrous cause of bleeding during the second and third trimester.<\/strong><\/p>\n<p>Normally, the placenta is attached to the uterus in\u00a0an area remote from the cervix. Sometimes, the placenta is located in such a way that it covers the cervix. This is called a placenta previa.<\/p>\n<p>There are degrees of placenta previa:<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>A complete placenta previa means the entire cervix is This positioning makes it impossible for the fetus to pass through the birth canal without causing maternal hemorrhage. This situation can only be resolved through cesarean section.<\/li>\n<li>A marginal placenta previa means that only the margin or edge of the placenta is covering the In this condition, it may be possible to achieve a vaginal delivery if the maternal bleeding is not too great and the fetal head exerts enough pressure on the placenta to push it out of the way and tamponade bleeding which may occur.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Clinically, these patients present after 20 weeks with painless vaginal bleeding, usually mild. This is in contrast to patients with placental abruption, who usually experience significant pain and contractions. An old rule of thumb is that the first bleed from a placenta previa is not very heavy. For this reason, the first bleed is sometimes called a \u201csentinel bleed.\u201d<\/p>\n<p>Later episodes of bleeding can be very substantial and very dangerous. This can lead to hypovolemic shock and maternal death. Because a pelvic exam may provoke further bleeding it is important to avoid a vaginal or rectal examination in pregnant women during the second half of their pregnancy unless you are certain there is no placenta previa.<\/p>\n<p>Factors associated with an increased risk of placenta previa include:<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>High maternal parity, Increased maternal age, previous cesarean section, previous uterine surgery, and uterine malformations.<\/li>\n<li>It may also be associated with the use of cocaine or its derivatives, cigarette smoking, Ascherman\u2019s syndrome, and large numbers of D&amp;Cs.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>The location of the placenta is best established by ultrasound. If ultrasound is not available, one reliable clinical method of ruling out placenta previa is to check for fetal head engagement just above the pubic symphysis.<\/p>\n<p>Using a thumb and forefinger and pressing into the maternal abdomen, the fetal head can be palpated. If it is deeply engaged in the pelvis, it is basically impossible for a placenta previa to be present because there is not enough room in the birth canal for both the fetal head and a placenta previa. An x-ray of the pelvis (pelvimetry) can likewise rule out a placenta previa, but only if the fetal head is deeply engaged. Otherwise, an x-ray will usually not show the location of the placenta.<\/p>\n<p><strong>Clinical<\/strong><strong>\u00a0approach to third trimester bleeding<\/strong><\/p>\n<p>The clinical approach depends on the clinical situation. For example:<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>A 3rd trimester patient who is actively hemorrhaging bright red blood should go directly to the operating room for a cesarean section to deliver her from the placental abruption or placenta previa. While en route\u00a0to the OR, call for blood transfusions and labs to determine coagulopathy.<\/li>\n<li>A patient at term with regular contractions and a small amount of bloody mucous can be examined vaginally after confirming (through ultrasound or clinical exam of the abdomen) that there is no placenta previa.<\/li>\n<li>Patients with bright red vaginal bleeding that is less than hemorrhage should be carefully evaluated prior to performing a pelvic Ultrasound can be helpful in locating the placenta and looking for retroplacental blood clot. Laboratory tests for coagulopathy can be helpful. Hgb is useful, not to determine whether to transfuse or not (that is a clinical, not laboratory decision), but to indicate the margin of safety available to the clinician in caring for this patient.<\/li>\n<li>Continuous electronic fetal monitoring is important to determine the degree of tolerance the fetus has for this bleeding and the extent to which uteroplacental circulation has been disrupted. After ruling out a placenta previa, examine the patient with a speculum to determine the source of the bleeding (from the cervical os? from the surface of the cervix? from a laceration of the vaginal wall? etc.)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/HRGyVRmYh5E\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 9:27<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57d18f131060233449' value='69e9b57d18f131060233449'><input type='hidden' id='bg-show-more-text-69e9b57d18f131060233449' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b57d18f131060233449' value='Hide Transcript'><button id='bg-showmore-action-69e9b57d18f131060233449' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#faf7f7;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b57d18f131060233449' ><\/p>\n<p>00:01<br \/>\n-My name is Dr. Melody Russell<br \/>\n00:02<br \/>\nand I&#8217;m a resident physician<br \/>\n00:03<br \/>\nin the Department of Obstetrics<br \/>\n00:05<br \/>\nand Gynecology.<br \/>\n00:06<br \/>\nThis presentation is entitled<br \/>\n00:07<br \/>\n&#8220;Placenta Previa.&#8221;<br \/>\n00:11<br \/>\n00:12<br \/>\nThe learning objectives<br \/>\n00:13<br \/>\nof this presentation<br \/>\n00:14<br \/>\nare to understand<br \/>\n00:15<br \/>\nthe definitions, epidemiology,<br \/>\n00:17<br \/>\nand risk factors<br \/>\n00:18<br \/>\nfor placenta previa; to review<br \/>\n00:20<br \/>\nclinical manifestations<br \/>\n00:21<br \/>\nof placenta previa<br \/>\n00:22<br \/>\nand associated conditions;<br \/>\n00:24<br \/>\nand to discuss the management<br \/>\n00:26<br \/>\nof asymptomatic and symptomatic<br \/>\n00:28<br \/>\nplacenta previa.<br \/>\n00:29<br \/>\n00:32<br \/>\nWe will begin by reviewing<br \/>\n00:33<br \/>\ndefinitions relevant to placenta<br \/>\n00:35<br \/>\nprevia followed by a discussion<br \/>\n00:37<br \/>\nof the pathogenesis, risk<br \/>\n00:39<br \/>\nfactors, and epidemiology<br \/>\n00:40<br \/>\nof placenta previa.<br \/>\n00:42<br \/>\nLastly, we will review diagnosis<br \/>\n00:44<br \/>\nand management.<br \/>\n00:45<br \/>\n00:48<br \/>\nPlacenta previa describes<br \/>\n00:50<br \/>\na situation in which<br \/>\n00:51<br \/>\nthe placenta is overlying<br \/>\n00:52<br \/>\nor near the internal cervical<br \/>\n00:53<br \/>\nos.<br \/>\n00:54<br \/>\nThis occurs in one of 300<br \/>\n00:56<br \/>\ndeliveries.<br \/>\n00:57<br \/>\nFirst, let&#8217;s review<br \/>\n00:58<br \/>\nthe classification for placenta<br \/>\n01:00<br \/>\nprevia.<br \/>\n01:01<br \/>\nMarginal previa is when<br \/>\n01:02<br \/>\nthe placenta is immediately<br \/>\n01:04<br \/>\nadjacent to the internal<br \/>\n01:05<br \/>\ncervical os<br \/>\n01:06<br \/>\nbut does not cover it.<br \/>\n01:07<br \/>\nIn a complete previa,<br \/>\n01:09<br \/>\nthe placenta covers<br \/>\n01:09<br \/>\nthe entire internal cervical os.<br \/>\n01:12<br \/>\nOf complete previas, 20% to 30%<br \/>\n01:15<br \/>\nare central previas in which<br \/>\n01:17<br \/>\nthe os is<br \/>\n01:17<br \/>\nequidistant from the anterior<br \/>\n01:19<br \/>\nand posterior edges<br \/>\n01:20<br \/>\nof the placenta.<br \/>\n01:22<br \/>\nLastly, a low-lying placenta<br \/>\n01:24<br \/>\nis one in which the placenta is<br \/>\n01:25<br \/>\nwithin two centimeters<br \/>\n01:26<br \/>\nof the internal cervical os.<br \/>\n01:28<br \/>\n01:31<br \/>\nNext we will review proposed<br \/>\n01:32<br \/>\npathogenetic mechanisms<br \/>\n01:34<br \/>\nand associated risk factors<br \/>\n01:35<br \/>\nfor placenta previa.<br \/>\n01:37<br \/>\nConditions that cause<br \/>\n01:38<br \/>\nendometrial scarring<br \/>\n01:40<br \/>\nincrease the risk of placenta<br \/>\n01:41<br \/>\nprevia.<br \/>\n01:43<br \/>\nEndometrial scarring may allow<br \/>\n01:44<br \/>\nfor trophoblastic invasion<br \/>\n01:46<br \/>\ninto the lower uterine segment.<br \/>\n01:48<br \/>\nRisk factors for scarring<br \/>\n01:49<br \/>\ninclude prior cesarean delivery,<br \/>\n01:52<br \/>\nincreasing parity,<br \/>\n01:54<br \/>\nand prior curettage.<br \/>\n01:56<br \/>\nIncreasing demand<br \/>\n01:57<br \/>\nfor uteroplacental exchange<br \/>\n01:59<br \/>\nis another proposed mechanism<br \/>\n02:00<br \/>\nfor previa, as this may result<br \/>\n02:03<br \/>\nin the need for increasing<br \/>\n02:04<br \/>\nplacental surface area.<br \/>\n02:06<br \/>\nAssociated risk factors include<br \/>\n02:08<br \/>\nmaternal smoking, high altitude,<br \/>\n02:10<br \/>\nand multiple gestation.<br \/>\n02:11<br \/>\n02:14<br \/>\nThe incidence of placenta previa<br \/>\n02:16<br \/>\nis one in 300 deliveries.<br \/>\n02:19<br \/>\nThe incidence of previa<br \/>\n02:20<br \/>\nin early gestational age<br \/>\n02:22<br \/>\nis 5% to 15% of all deliveries.<br \/>\n02:25<br \/>\nAnd prior cesarean section<br \/>\n02:27<br \/>\nincidence is 1% to 4%.<br \/>\n02:29<br \/>\nOther risk factors for placenta<br \/>\n02:31<br \/>\nprevia include advancing<br \/>\n02:33<br \/>\nmaternal age,<br \/>\n02:35<br \/>\nearly gestational age,<br \/>\n02:36<br \/>\nmale fetus, maternal race,<br \/>\n02:39<br \/>\nand elevated maternal serum<br \/>\n02:40<br \/>\nalpha-fetoprotein.<br \/>\n02:41<br \/>\n02:45<br \/>\nThe classic clinical<br \/>\n02:46<br \/>\npresentation for placenta previa<br \/>\n02:48<br \/>\nis painless vaginal bleeding.<br \/>\n02:50<br \/>\nA significant minority<br \/>\n02:52<br \/>\nof patients<br \/>\n02:52<br \/>\npresent<br \/>\n02:53<br \/>\nwith uterine contractions<br \/>\n02:54<br \/>\naccompanied by vaginal bleeding.<br \/>\n02:57<br \/>\nSymptoms occur<br \/>\n02:58<br \/>\nin the third trimester<br \/>\n02:59<br \/>\nas the lower uterine segment<br \/>\n03:00<br \/>\ndevelops<br \/>\n03:01<br \/>\nand uterine contractions start<br \/>\n03:03<br \/>\nto cause cervical change.<br \/>\n03:04<br \/>\nAs the cervix dilates<br \/>\n03:06<br \/>\nand effaces, the lower uterine<br \/>\n03:08<br \/>\nsegment develops.<br \/>\n03:09<br \/>\nThis produces shearing forces<br \/>\n03:11<br \/>\nthat cause the placenta to shear<br \/>\n03:13<br \/>\nand bleed.<br \/>\n03:14<br \/>\nPlacenta previa is associated<br \/>\n03:16<br \/>\nwith<br \/>\n03:16<br \/>\nother abnormal placentation,<br \/>\n03:18<br \/>\nwhich we will review<br \/>\n03:20<br \/>\nmomentarily,<br \/>\n03:21<br \/>\nas well as<br \/>\n03:21<br \/>\nfetal malpresentation, preterm<br \/>\n03:24<br \/>\npremature rupture of membranes,<br \/>\n03:26<br \/>\nfetal growth restriction, vasa<br \/>\n03:28<br \/>\nprevia, which is vessels<br \/>\n03:30<br \/>\npresenting at the cervical os,<br \/>\n03:32<br \/>\nvelamentous cord insertion,<br \/>\n03:34<br \/>\ncongenital anomalies,<br \/>\n03:36<br \/>\nand amniotic fluid embolism.<br \/>\n03:38<br \/>\n03:41<br \/>\nPlacenta accreta occurs with 5%<br \/>\n03:43<br \/>\nto 10% of all placenta previa.<br \/>\n03:46<br \/>\nPlacenta accreta occurs<br \/>\n03:48<br \/>\ndue<br \/>\n03:48<br \/>\nto abnormal placental<br \/>\n03:50<br \/>\nimplantation when placental<br \/>\n03:52<br \/>\nvilli attach to the myometrium,<br \/>\n03:54<br \/>\nresulting<br \/>\n03:54<br \/>\nin an abnormally adherent<br \/>\n03:56<br \/>\nplacenta.<br \/>\n03:58<br \/>\nIncreta occurs when<br \/>\n03:59<br \/>\nchorionic villi invade<br \/>\n04:00<br \/>\nthe myometrium.<br \/>\n04:02<br \/>\nAnd placental percreta occurs<br \/>\n04:04<br \/>\nwhen chorionic villi penetrate<br \/>\n04:06<br \/>\nthe uterine serosa,<br \/>\n04:08<br \/>\nand may involve surrounding<br \/>\n04:09<br \/>\norgans, such as the bladder,<br \/>\n04:11<br \/>\nas shown in the ultrasound<br \/>\n04:12<br \/>\nimage.<br \/>\n04:13<br \/>\n04:16<br \/>\nPlacenta previa is included<br \/>\n04:18<br \/>\nin the differential diagnosis<br \/>\n04:20<br \/>\nfor third trimester bleeding.<br \/>\n04:22<br \/>\nOther conditions that cause<br \/>\n04:23<br \/>\nthird trimester bleeding include<br \/>\n04:25<br \/>\nplacental abruption, which<br \/>\n04:27<br \/>\nis a premature separation<br \/>\n04:29<br \/>\nof the placenta<br \/>\n04:30<br \/>\nfrom the uterus; vasa previa,<br \/>\n04:34<br \/>\nwhen fetal vessels course<br \/>\n04:35<br \/>\nthe internal cervical os;<br \/>\n04:37<br \/>\nuterine rupture; and lastly,<br \/>\n04:39<br \/>\nvaginal, cervical, or uterine<br \/>\n04:41<br \/>\npathology.<br \/>\n04:44<br \/>\nThe diagnosis of placenta previa<br \/>\n04:46<br \/>\nis made by localizing<br \/>\n04:48<br \/>\nthe placenta<br \/>\n04:49<br \/>\non diagnostic imaging.<br \/>\n04:51<br \/>\nTransabdominal ultrasound<br \/>\n04:53<br \/>\nis the safest, simplest,<br \/>\n04:54<br \/>\nand most accurate way<br \/>\n04:56<br \/>\nto localize the placenta.<br \/>\n04:58<br \/>\nTransvaginal ultrasound is safe<br \/>\n05:00<br \/>\nand offers<br \/>\n05:01<br \/>\nexcellent visualization<br \/>\n05:02<br \/>\nof the internal cervical os.<br \/>\n05:05<br \/>\nTransperineal sonography<br \/>\n05:07<br \/>\nis reported to be accurate,<br \/>\n05:09<br \/>\nbut is not routinely used<br \/>\n05:11<br \/>\nfor placental localization.<br \/>\n05:13<br \/>\nMagnetic resonance imaging<br \/>\n05:14<br \/>\nis not routinely used<br \/>\n05:16<br \/>\nfor placental localization,<br \/>\n05:17<br \/>\nbut is often used when there is<br \/>\n05:19<br \/>\na strong suspicion for accreta<br \/>\n05:21<br \/>\nbased on ultrasound findings.<br \/>\n05:23<br \/>\nMagnetic resonance imaging<br \/>\n05:25<br \/>\nfindings suggestive of accreta<br \/>\n05:27<br \/>\nare uterine bulging,<br \/>\n05:29<br \/>\nheterogeneous signal intensity<br \/>\n05:31<br \/>\nwithin the placenta,<br \/>\n05:32<br \/>\nand the presence<br \/>\n05:33<br \/>\nof dark intraplacental bands.<br \/>\n05:35<br \/>\n05:38<br \/>\nNow we will review management<br \/>\n05:40<br \/>\nof placenta previa.<br \/>\n05:42<br \/>\nAsymptomatic patients<br \/>\n05:44<br \/>\nwith placenta previa<br \/>\n05:45<br \/>\nare followed with repeat<br \/>\n05:46<br \/>\nultrasounds<br \/>\n05:47<br \/>\nthrough the third trimester,<br \/>\n05:49<br \/>\nas the placenta may become<br \/>\n05:50<br \/>\nfarther<br \/>\n05:51<br \/>\nfrom the internal cervical os<br \/>\n05:52<br \/>\nas the uterus expands<br \/>\n05:54<br \/>\nand the lower uterine segment<br \/>\n05:55<br \/>\ndevelops.<br \/>\n05:56<br \/>\nThese patients are instructed<br \/>\n05:57<br \/>\nto continue pelvic rest,<br \/>\n05:59<br \/>\nand then nothing should be put<br \/>\n06:00<br \/>\nin the vagina.<br \/>\n06:02<br \/>\nThis includes<br \/>\n06:02<br \/>\nvaginal intercourse as well as<br \/>\n06:05<br \/>\ndigital cervical examinations<br \/>\n06:07<br \/>\nby their physician.<br \/>\n06:08<br \/>\nAfter an episode<br \/>\n06:09<br \/>\nof vaginal bleeding, patients<br \/>\n06:11<br \/>\nare hospitalized for close<br \/>\n06:12<br \/>\ninpatient monitoring.<br \/>\n06:14<br \/>\nIf they are stable and have<br \/>\n06:15<br \/>\nno further bleeding<br \/>\n06:17<br \/>\nfor several days,<br \/>\n06:18<br \/>\nthey may be discharged.<br \/>\n06:20<br \/>\nBefore discharge, patients must<br \/>\n06:22<br \/>\nunderstand that they should be<br \/>\n06:23<br \/>\nable to reliably return<br \/>\n06:25<br \/>\nto the hospital quickly<br \/>\n06:27<br \/>\nshould they develop<br \/>\n06:28<br \/>\nfurther vaginal bleeding.<br \/>\n06:30<br \/>\nImportantly, the plan<br \/>\n06:31<br \/>\nis<br \/>\n06:32<br \/>\ncontingent on gestational age,<br \/>\n06:34<br \/>\nas it may be more<br \/>\n06:35<br \/>\nprudent to move toward delivery<br \/>\n06:36<br \/>\nafter a significant bleed<br \/>\n06:38<br \/>\nif the patient is over 34 weeks,<br \/>\n06:41<br \/>\nwhile conservative management is<br \/>\n06:43<br \/>\npreferred in earlier<br \/>\n06:44<br \/>\ngestational ages given<br \/>\n06:45<br \/>\nthe risks of morbidity<br \/>\n06:47<br \/>\nassociated with premature birth.<br \/>\n06:48<br \/>\n06:51<br \/>\nIn the setting<br \/>\n06:52<br \/>\nof acute vaginal bleeding,<br \/>\n06:54<br \/>\npatients must have adequate IV<br \/>\n06:56<br \/>\naccess, often two large bore<br \/>\n06:58<br \/>\nIVs,<br \/>\n06:59<br \/>\nin case aggressive resuscitation<br \/>\n07:00<br \/>\nis required.<br \/>\n07:02<br \/>\nPatients should receive<br \/>\n07:03<br \/>\nantenatal steroids to promote<br \/>\n07:05<br \/>\nfetal lung maturity if they are<br \/>\n07:07<br \/>\nless than 34 weeks<br \/>\n07:08<br \/>\ngestational age,<br \/>\n07:09<br \/>\nas delivery may be imminent<br \/>\n07:11<br \/>\ndepending on the severity<br \/>\n07:12<br \/>\nof the hemorrhage.<br \/>\n07:13<br \/>\nA blood type and antibody screen<br \/>\n07:15<br \/>\nshould be obtained for Rh<br \/>\n07:17<br \/>\nstatus,<br \/>\n07:18<br \/>\nas patients should receive Rh<br \/>\n07:20<br \/>\nimmune globulin<br \/>\n07:21<br \/>\nafter the initial bleed<br \/>\n07:22<br \/>\nif they are Rh negative.<br \/>\n07:24<br \/>\nThis should also be sent<br \/>\n07:25<br \/>\nin anticipation<br \/>\n07:26<br \/>\nof possible blood transfusion<br \/>\n07:28<br \/>\nif required.<br \/>\n07:30<br \/>\nThe fetus should be monitored<br \/>\n07:31<br \/>\ncontinuously as any signs<br \/>\n07:33<br \/>\nof nonreassuring fetal status<br \/>\n07:35<br \/>\nsuggest fetal anemia<br \/>\n07:36<br \/>\nand\/or hypoxemia.<br \/>\n07:39<br \/>\nUltimately, providers should<br \/>\n07:40<br \/>\nmove toward delivery<br \/>\n07:42<br \/>\nif fetal status is nonreassuring<br \/>\n07:44<br \/>\ndespite resuscitative measures,<br \/>\n07:46<br \/>\nif hemorrhage is<br \/>\n07:47<br \/>\nlife-threatening, if the patient<br \/>\n07:49<br \/>\nis in active labor,<br \/>\n07:51<br \/>\nor if significant bleeding<br \/>\n07:52<br \/>\noccurs after 34 weeks<br \/>\n07:54<br \/>\ngestational age.<br \/>\n07:55<br \/>\nCesarean delivery<br \/>\n07:57<br \/>\nis necessary in nearly all women<br \/>\n07:59<br \/>\nwith placenta previa.<br \/>\n08:00<br \/>\nIn the case of placenta accreta,<br \/>\n08:03<br \/>\nspecial precautions should be<br \/>\n08:04<br \/>\ntaken as there is a very<br \/>\n08:06<br \/>\nsignificant chance of hemorrhage<br \/>\n08:07<br \/>\nat the time of surgery.<br \/>\n08:09<br \/>\nThese precautions include<br \/>\n08:11<br \/>\npre-operative arterial catheter<br \/>\n08:13<br \/>\nplacement for possible uterine<br \/>\n08:14<br \/>\nartery embolization,<br \/>\n08:16<br \/>\ncoordination with the blood bank<br \/>\n08:18<br \/>\nfor transfusion services,<br \/>\n08:20<br \/>\nand consultation<br \/>\n08:21<br \/>\nwith gynecologic oncology<br \/>\n08:23<br \/>\nfor surgical assistance<br \/>\n08:24<br \/>\nif cesarean hysterectomy is<br \/>\n08:25<br \/>\nrequired.<br \/>\n08:26<br \/>\n08:29<br \/>\nIn conclusion, placenta previa<br \/>\n08:32<br \/>\noccurs when there is<br \/>\n08:33<br \/>\nabnormal placental implantation<br \/>\n08:35<br \/>\nat or near the internal cervical<br \/>\n08:37<br \/>\nos.<br \/>\n08:38<br \/>\nIt classically presents<br \/>\n08:39<br \/>\nwith painless vaginal bleeding<br \/>\n08:42<br \/>\nand is diagnosed by imaging<br \/>\n08:44<br \/>\nwith ultrasound<br \/>\n08:45<br \/>\nand magnetic resonance imaging<br \/>\n08:47<br \/>\nfollow-up if necessary<br \/>\n08:49<br \/>\nwhen there is concern<br \/>\n08:50<br \/>\nfor placenta accreta.<br \/>\n08:52<br \/>\nPlacenta previa can be managed<br \/>\n08:54<br \/>\nas an outpatient if the patient<br \/>\n08:56<br \/>\nis asymptomatic<br \/>\n08:57<br \/>\nor after one episode<br \/>\n08:59<br \/>\nof bleeding.<br \/>\n09:01<br \/>\nActive bleeding in placenta<br \/>\n09:02<br \/>\nprevia should be considered<br \/>\n09:04<br \/>\na potential obstetric emergency.<br \/>\n09:06<br \/>\nMode of delivery<br \/>\n09:08<br \/>\nshould be by cesarean section.<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/bapkzeEFPmI\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 10:06<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57d19c3d8095970598' value='69e9b57d19c3d8095970598'><input type='hidden' id='bg-show-more-text-69e9b57d19c3d8095970598' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b57d19c3d8095970598' value='Hide Transcript'><button id='bg-showmore-action-69e9b57d19c3d8095970598' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfafa;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b57d19c3d8095970598' ><\/p>\n<p>00:01<br \/>\nToday, we&#8217;ll be talking<br \/>\n00:02<br \/>\nabout placental abruption.<br \/>\n00:03<br \/>\n00:07<br \/>\nAt the end of this presentation<br \/>\n00:08<br \/>\nstudents should be<br \/>\n00:09<br \/>\nable to describe<br \/>\n00:09<br \/>\nthe clinical presentation<br \/>\n00:11<br \/>\nof placental abruption,<br \/>\n00:12<br \/>\ndescribe the epidemiology<br \/>\n00:14<br \/>\nand risk factors<br \/>\n00:14<br \/>\nfor placental abruption,<br \/>\n00:16<br \/>\ndescribe the diagnosis<br \/>\n00:17<br \/>\nof third trimester bleeding,<br \/>\n00:19<br \/>\nunderstand the pathogenesis<br \/>\n00:20<br \/>\nof placental abruption,<br \/>\n00:22<br \/>\ndescribe treatment options<br \/>\n00:23<br \/>\nfor a placental abruption,<br \/>\n00:25<br \/>\nand understand the range<br \/>\n00:26<br \/>\nof possible outcomes.<br \/>\n00:27<br \/>\n00:30<br \/>\nWe&#8217;ll start with a case<br \/>\n00:31<br \/>\nvignette.<br \/>\n00:32<br \/>\nOur first patient is<br \/>\n00:33<br \/>\na 23-year-old gravid 2 para 001<br \/>\n00:36<br \/>\nat 37 weeks and four days,<br \/>\n00:38<br \/>\ngestational age, who presents<br \/>\n00:39<br \/>\nto labor and delivery triage<br \/>\n00:41<br \/>\nwith intense cramping, which<br \/>\n00:42<br \/>\nstarted approximately one hour<br \/>\n00:44<br \/>\nago.<br \/>\n00:45<br \/>\nIn the last 15 minutes,<br \/>\n00:46<br \/>\nshe&#8217;s developed<br \/>\n00:46<br \/>\nprofuse vaginal bleeding.<br \/>\n00:48<br \/>\nHer physical exam reveals<br \/>\n00:49<br \/>\nincreased uterine tone<br \/>\n00:50<br \/>\nand fetal tachycardia.<br \/>\n00:53<br \/>\nThis case just demonstrates<br \/>\n00:55<br \/>\nthat the clinical presentation<br \/>\n00:56<br \/>\nof abruption can vary.<br \/>\n00:57<br \/>\nOur patient here has<br \/>\n00:58<br \/>\nthe classical presentation<br \/>\n00:59<br \/>\nof painful third trimester<br \/>\n01:00<br \/>\nbleeding.<br \/>\n01:01<br \/>\n01:04<br \/>\nAbruption presents with varying<br \/>\n01:05<br \/>\ndegrees of severity.<br \/>\n01:07<br \/>\nAcute onset vaginal bleeding<br \/>\n01:09<br \/>\nwith painful contracting uterus<br \/>\n01:10<br \/>\nin the third trimester<br \/>\n01:11<br \/>\nis classic.<br \/>\n01:12<br \/>\nIn these cases, the blood<br \/>\n01:14<br \/>\nin the uterus has an irritating<br \/>\n01:15<br \/>\neffect causing hearing<br \/>\n01:16<br \/>\ncontractions.<br \/>\n01:18<br \/>\nAdditionally, the mother<br \/>\n01:19<br \/>\nexperiences abdominal or lower<br \/>\n01:20<br \/>\nback pain,<br \/>\n01:21<br \/>\nsecondary to this irritation.<br \/>\n01:23<br \/>\nThe fetus<br \/>\n01:24<br \/>\ncan be without effects,<br \/>\n01:25<br \/>\nbut, most likely,<br \/>\n01:26<br \/>\nwill demonstrate tachycardia<br \/>\n01:27<br \/>\nand decreased variability.<br \/>\n01:29<br \/>\nOf note, vaginal bleeding is not<br \/>\n01:31<br \/>\nrequired for the diagnosis<br \/>\n01:32<br \/>\nas the bleeding can be trapped<br \/>\n01:33<br \/>\nbehind the placenta.<br \/>\n01:35<br \/>\nAdditionally,<br \/>\n01:35<br \/>\na couvelaire uterus can occur,<br \/>\n01:37<br \/>\nwhich is when the bleeding<br \/>\n01:38<br \/>\npasses through the uterine wall<br \/>\n01:40<br \/>\ninto the perinatal cavity<br \/>\n01:41<br \/>\nor retroperitoneum.<br \/>\n01:44<br \/>\nAcute abruption is thought to be<br \/>\n01:45<br \/>\nsecondary to an arterial bleed<br \/>\n01:47<br \/>\nat the utero-placental junction.<br \/>\n01:49<br \/>\nConversely, placental abruption<br \/>\n01:51<br \/>\ncan also present<br \/>\n01:52<br \/>\nwith light chronic bleeding.<br \/>\n01:54<br \/>\nThis bleeding can be<br \/>\n01:54<br \/>\ndifficult to differentiate<br \/>\n01:56<br \/>\nfrom other etiologies<br \/>\n01:57<br \/>\nof third trimester bleeding,<br \/>\n01:59<br \/>\nand a careful search<br \/>\n01:59<br \/>\nfor the most common cause<br \/>\n02:01<br \/>\nmust ensue.<br \/>\n02:03<br \/>\nAs there is decreased<br \/>\n02:04<br \/>\nplacental oxygen in transfer,<br \/>\n02:05<br \/>\nfetal effects include<br \/>\n02:06<br \/>\noligohydramnios, fetal growth<br \/>\n02:08<br \/>\nrestriction, and preeclampsia.<br \/>\n02:11<br \/>\nOf concern is<br \/>\n02:11<br \/>\nthat this chronic type bleeding<br \/>\n02:13<br \/>\ncan rapidly convert<br \/>\n02:14<br \/>\nto an acute abruption<br \/>\n02:15<br \/>\nwith catastrophic consequences.<br \/>\n02:16<br \/>\n02:20<br \/>\nPlacental abruption is quite<br \/>\n02:21<br \/>\nsimply the premature separation<br \/>\n02:23<br \/>\nof the placenta<br \/>\n02:24<br \/>\nfrom the uterine wall.<br \/>\n02:25<br \/>\nAs mentioned earlier,<br \/>\n02:26<br \/>\nthere are many risk factors<br \/>\n02:27<br \/>\nand events which can lead<br \/>\n02:28<br \/>\nto this.<br \/>\n02:30<br \/>\nThe most recent theories argue<br \/>\n02:31<br \/>\nthat the majority<br \/>\n02:32<br \/>\nof placental abruption<br \/>\n02:33<br \/>\nis related<br \/>\n02:34<br \/>\nto chronic pathologic vascular<br \/>\n02:35<br \/>\nprocesses, hence the association<br \/>\n02:38<br \/>\nwith smoking,<br \/>\n02:39<br \/>\nmaternal hypertension,<br \/>\n02:40<br \/>\nand ischemic placental disease.<br \/>\n02:42<br \/>\nTraumatic events can also cause<br \/>\n02:44<br \/>\nabruption by creating shear<br \/>\n02:46<br \/>\nforces between the placenta<br \/>\n02:47<br \/>\nand the uterus.<br \/>\n02:48<br \/>\nThese lead<br \/>\n02:49<br \/>\nto a common final pathway<br \/>\n02:50<br \/>\ninvolving<br \/>\n02:51<br \/>\nretroplacental hemorrhage.<br \/>\n02:53<br \/>\nThis separation causes impaired<br \/>\n02:55<br \/>\nmaternal-fetal oxygen<br \/>\n02:56<br \/>\nand nutrient exchange leading<br \/>\n02:58<br \/>\nto fetal hypoxemia<br \/>\n03:00<br \/>\nand eventual metabolic acidosis.<br \/>\n03:02<br \/>\nAdditionally, this bleeding<br \/>\n03:04<br \/>\ncan activate<br \/>\n03:05<br \/>\nthe maternal coagulation cascade<br \/>\n03:07<br \/>\nleading<br \/>\n03:07<br \/>\nto disseminated intravascular<br \/>\n03:09<br \/>\ncoagulation, hemorrhage, ARDS,<br \/>\n03:12<br \/>\nrenal failure,<br \/>\n03:13<br \/>\nmulti-organ system failure,<br \/>\n03:15<br \/>\nand eventually death,<br \/>\n03:16<br \/>\nif rapid aggressive treatment is<br \/>\n03:18<br \/>\nnot pursued.<br \/>\n03:19<br \/>\n03:22<br \/>\nThere are many risk factors<br \/>\n03:23<br \/>\nfor placental abruption,<br \/>\n03:25<br \/>\nhowever, the most important<br \/>\n03:26<br \/>\nis pregnancy, meaning this can<br \/>\n03:28<br \/>\nhappen to any pregnant woman<br \/>\n03:29<br \/>\nregardless of risk factors.<br \/>\n03:32<br \/>\nRisk factors can be separated<br \/>\n03:33<br \/>\ninto several themes.<br \/>\n03:35<br \/>\nFirst, are acute events<br \/>\n03:36<br \/>\nassociated with rapid uterine<br \/>\n03:37<br \/>\ndecompression.<br \/>\n03:39<br \/>\nWhen the uterine volume rapidly<br \/>\n03:40<br \/>\ndecreases, such as with trauma,<br \/>\n03:42<br \/>\nrupture of membranes,<br \/>\n03:43<br \/>\nor delivery of the first twin,<br \/>\n03:45<br \/>\nshear forces<br \/>\n03:46<br \/>\nbetween the placenta<br \/>\n03:47<br \/>\nand the uterine wall ensue,<br \/>\n03:48<br \/>\nwhich can cause separation.<br \/>\n03:50<br \/>\nAnother theme<br \/>\n03:51<br \/>\nis maternal hypertensive<br \/>\n03:52<br \/>\ndisorders.<br \/>\n03:53<br \/>\nMaternal hypertension<br \/>\n03:54<br \/>\nand cocaine use<br \/>\n03:55<br \/>\nlead to increased vascular<br \/>\n03:56<br \/>\npressure, which can cause<br \/>\n03:57<br \/>\nvascular rupture and ensuing<br \/>\n03:59<br \/>\nhemorrhage.<br \/>\n04:00<br \/>\nFinally, smoking<br \/>\n04:01<br \/>\nand ischemic placental disease<br \/>\n04:03<br \/>\ncan cause microvascular damage,<br \/>\n04:05<br \/>\nwhich can lead<br \/>\n04:05<br \/>\nto retro-placental bleeding.<br \/>\n04:07<br \/>\n04:10<br \/>\nThe differential diagnosis<br \/>\n04:11<br \/>\nof third trimester bleeding<br \/>\n04:12<br \/>\nis long.<br \/>\n04:13<br \/>\nPlacental abruption<br \/>\n04:14<br \/>\nis the first and presents<br \/>\n04:15<br \/>\nwith painful vaginal bleeding.<br \/>\n04:18<br \/>\nPlacenta previa occurs when<br \/>\n04:19<br \/>\nthe placenta is implanted<br \/>\n04:20<br \/>\non or near the cervix,<br \/>\n04:22<br \/>\nand bleeding occurs<br \/>\n04:22<br \/>\nwith cervical dilation<br \/>\n04:24<br \/>\nor cervical manipulation.<br \/>\n04:26<br \/>\nThis is classically painless<br \/>\n04:27<br \/>\nvaginal bleeding.<br \/>\n04:29<br \/>\nUterine rupture is a rarer<br \/>\n04:30<br \/>\nevent, but can occur in labor<br \/>\n04:32<br \/>\nwhen the uterine muscle tears<br \/>\n04:33<br \/>\nopen.<br \/>\n04:34<br \/>\nThis typically occurs<br \/>\n04:35<br \/>\nat the site<br \/>\n04:36<br \/>\nof a previous uterine scar<br \/>\n04:37<br \/>\nsuch as cesarean scar<br \/>\n04:38<br \/>\nor myomectomy scar.<br \/>\n04:41<br \/>\nVasa previa occurs when there is<br \/>\n04:42<br \/>\na marginal cord insertion<br \/>\n04:44<br \/>\ninto the placenta and the cord<br \/>\n04:45<br \/>\ncomes across the cervical os.<br \/>\n04:48<br \/>\nOf note, this is often bleeding<br \/>\n04:49<br \/>\nof fetal blood, which can be<br \/>\n04:50<br \/>\ncatastrophic as the fetal blood<br \/>\n04:52<br \/>\nvolume is very small.<br \/>\n04:54<br \/>\nOther cervical<br \/>\n04:55<br \/>\nor vaginal pathology<br \/>\n04:56<br \/>\ncan lead to vaginal bleeding,<br \/>\n04:57<br \/>\nincluding<br \/>\n04:58<br \/>\ncervicitis cervical cancer,<br \/>\n05:00<br \/>\ncervical laceration,<br \/>\n05:01<br \/>\nor vaginitis.<br \/>\n05:03<br \/>\nFinally, vaginal bleeding<br \/>\n05:05<br \/>\ncan be physiologic and occur<br \/>\n05:06<br \/>\nwith cervical dilation.<br \/>\n05:07<br \/>\nThis is referred to as bloody<br \/>\n05:08<br \/>\nshow.<br \/>\n05:09<br \/>\n05:12<br \/>\nPlacental abruption is primarily<br \/>\n05:14<br \/>\na clinical diagnosis.<br \/>\n05:15<br \/>\nDiagnosis is based<br \/>\n05:16<br \/>\non patient history and risk<br \/>\n05:18<br \/>\nfactors, as mentioned earlier.<br \/>\n05:19<br \/>\nPhysical exam is performed<br \/>\n05:21<br \/>\nrapidly, yet thoughtfully.<br \/>\n05:23<br \/>\nAbdominal exam will likely<br \/>\n05:24<br \/>\nreveal uterine tenderness<br \/>\n05:25<br \/>\nand hypertonicity.<br \/>\n05:27<br \/>\nSpeculum exam should always<br \/>\n05:28<br \/>\nbe performed prior<br \/>\n05:29<br \/>\nto digital exam.<br \/>\n05:30<br \/>\nThis is used to rule out<br \/>\n05:31<br \/>\nplacenta previa.<br \/>\n05:33<br \/>\nIf a digital exam is performed<br \/>\n05:35<br \/>\nin the face of placenta previa,<br \/>\n05:36<br \/>\nthen the placenta can be further<br \/>\n05:38<br \/>\ndisturbed leading<br \/>\n05:38<br \/>\nto fetal hemorrage.<br \/>\n05:40<br \/>\nHistorically, speculum exam<br \/>\n05:42<br \/>\nwas performed<br \/>\n05:42<br \/>\nunder double set-up,<br \/>\n05:44<br \/>\nmeaning that the exam was<br \/>\n05:45<br \/>\nperformed in the operating room,<br \/>\n05:46<br \/>\nwith the capability<br \/>\n05:47<br \/>\nof performing<br \/>\n05:47<br \/>\nboth vaginal or cesarean<br \/>\n05:49<br \/>\ndelivery expediently.<br \/>\n05:52<br \/>\nNow bedside ultrasound has been<br \/>\n05:53<br \/>\nadded to the obstetricians&#8217;<br \/>\n05:55<br \/>\narmamentarium.<br \/>\n05:56<br \/>\nAlthough ultrasonographic<br \/>\n05:57<br \/>\nexamination is<br \/>\n05:58<br \/>\ninsensitive for the diagnosis<br \/>\n06:00<br \/>\nof placental abruption,<br \/>\n06:01<br \/>\nit can be used to rule out<br \/>\n06:03<br \/>\nother pathology,<br \/>\n06:03<br \/>\nsuch as placenta previa or vasa<br \/>\n06:05<br \/>\nprevia.<br \/>\n06:07<br \/>\nIf ultrasound does demonstrate<br \/>\n06:08<br \/>\na retroplacental blood<br \/>\n06:09<br \/>\ncollection or clot,<br \/>\n06:10<br \/>\nthen the diagnosis is confirmed.<br \/>\n06:12<br \/>\n06:16<br \/>\nManagement<br \/>\n06:16<br \/>\nof placental abruption.<br \/>\n06:18<br \/>\nIf abruption is suspected<br \/>\n06:19<br \/>\nor diagnosed at greater than 34<br \/>\n06:21<br \/>\nweeks, an expeditious delivery<br \/>\n06:23<br \/>\nshould be pursued.<br \/>\n06:25<br \/>\nIn the absence of signs<br \/>\n06:26<br \/>\nof fetal distress,<br \/>\n06:28<br \/>\nand if the mother is<br \/>\n06:28<br \/>\nhemodynamically stable,<br \/>\n06:30<br \/>\nthen vaginal delivery<br \/>\n06:31<br \/>\nis optimal.<br \/>\n06:33<br \/>\nLabor augmentation in the form<br \/>\n06:34<br \/>\nof intravenous Platosin<br \/>\n06:36<br \/>\nand artificial rupture<br \/>\n06:37<br \/>\nof membranes<br \/>\n06:37<br \/>\nshould be undertaken.<br \/>\n06:39<br \/>\nIn the event of fetal distress<br \/>\n06:41<br \/>\nor maternal hemodynamic<br \/>\n06:42<br \/>\ninstability,<br \/>\n06:43<br \/>\nthen emergent Cesarean delivery<br \/>\n06:45<br \/>\nmay be necessary.<br \/>\n06:46<br \/>\nIn either case, blood products<br \/>\n06:48<br \/>\nshould be prepared<br \/>\n06:48<br \/>\nfor rapid delivery, particularly<br \/>\n06:50<br \/>\npacked red blood cells,<br \/>\n06:51<br \/>\nfresh frozen plasma, platelets,<br \/>\n06:53<br \/>\nand cryofibrinogen.<br \/>\n06:57<br \/>\nIn the pre-term gestation<br \/>\n06:59<br \/>\ncomplicated by placenta previa,<br \/>\n07:01<br \/>\nthe risks of prematurity<br \/>\n07:02<br \/>\nmust be balanced with the risks<br \/>\n07:03<br \/>\nof reduced maternal fetal oxygen<br \/>\n07:05<br \/>\nand nutrient exchange.<br \/>\n07:07<br \/>\nIf there are no signs<br \/>\n07:08<br \/>\nof fetal distress and the mother<br \/>\n07:09<br \/>\nis hemodynamically<br \/>\n07:10<br \/>\nstable without evidence<br \/>\n07:12<br \/>\nof coagulopathy,<br \/>\n07:13<br \/>\nthen expectant management<br \/>\n07:14<br \/>\nis the optimal course.<br \/>\n07:17<br \/>\nRegular fetal assessment<br \/>\n07:18<br \/>\nwith non-stress testing<br \/>\n07:19<br \/>\nand ultrasonography<br \/>\n07:20<br \/>\nshould be performed and delivery<br \/>\n07:22<br \/>\npursued if fetal distress is<br \/>\n07:24<br \/>\nuncovered.<br \/>\n07:25<br \/>\nRhoGAM should be administered<br \/>\n07:26<br \/>\nif the mother is Rh negative.<br \/>\n07:29<br \/>\nLikewise,<br \/>\n07:30<br \/>\nmaternal hemodynamic status<br \/>\n07:31<br \/>\nand coagulation should be<br \/>\n07:32<br \/>\nregularly monitored<br \/>\n07:34<br \/>\nand, if abnormal, then a move<br \/>\n07:35<br \/>\nshould be made toward delivery.<br \/>\n07:37<br \/>\nIf neither of these occur<br \/>\n07:38<br \/>\nand the pregnancy<br \/>\n07:39<br \/>\ncontinues to progress, delivery<br \/>\n07:41<br \/>\nshould occur at or before 37<br \/>\n07:43<br \/>\nweeks, with the exact timing<br \/>\n07:44<br \/>\nbeing provider dependent<br \/>\n07:46<br \/>\nand ranging from 34 to 37 weeks.<br \/>\n07:48<br \/>\n07:51<br \/>\nTragically, fetal demise<br \/>\n07:53<br \/>\nsecondary to hemorrhage<br \/>\n07:54<br \/>\nor asphyxia does occur.<br \/>\n07:56<br \/>\nIn these instances,<br \/>\n07:57<br \/>\nthe care of the mother<br \/>\n07:58<br \/>\nbecomes the primary concern<br \/>\n07:59<br \/>\nof the obstetrical team.<br \/>\n08:01<br \/>\nIn these situations,<br \/>\n08:02<br \/>\nexpeditious delivery should<br \/>\n08:04<br \/>\noccur no matter<br \/>\n08:04<br \/>\nthe gestational age.<br \/>\n08:07<br \/>\nVaginal delivery is ideal<br \/>\n08:08<br \/>\nbecause of the decreased<br \/>\n08:09<br \/>\nmaternal morbidity associated<br \/>\n08:10<br \/>\nwith this procedure.<br \/>\n08:12<br \/>\nIn these cases,<br \/>\n08:13<br \/>\nthe risk<br \/>\n08:13<br \/>\nof maternal coagulopathy<br \/>\n08:15<br \/>\nis greatly increased.<br \/>\n08:17<br \/>\nDIC is a frequent occurrence<br \/>\n08:19<br \/>\nand should be managed by rapid<br \/>\n08:20<br \/>\nand aggressive blood product<br \/>\n08:21<br \/>\nreplacement.<br \/>\n08:22<br \/>\nThe latest data derived<br \/>\n08:24<br \/>\nfrom the trauma literature<br \/>\n08:25<br \/>\nindicate<br \/>\n08:26<br \/>\nthat massive transfusion should<br \/>\n08:27<br \/>\ninclude both PRBCs, FFP,<br \/>\n08:29<br \/>\nplatelets, and cryoprecipitate.<br \/>\n08:32<br \/>\nBlood products should be<br \/>\n08:33<br \/>\nadministered based<br \/>\n08:33<br \/>\non the clinical exam,<br \/>\n08:35<br \/>\nas laboratory of coagulopathy<br \/>\n08:37<br \/>\noften lags<br \/>\n08:37<br \/>\nbehind the clinical situation<br \/>\n08:39<br \/>\nwhich can lead<br \/>\n08:40<br \/>\nto catastrophic hemorrhage.<br \/>\n08:42<br \/>\nFinally, Cesarean delivery,<br \/>\n08:44<br \/>\nreferred to as a hysterotomy,<br \/>\n08:45<br \/>\nin the case of fetal demise,<br \/>\n08:47<br \/>\nshould be used<br \/>\n08:47<br \/>\nfor maternal indications<br \/>\n08:49<br \/>\nsuch as uncontrolled hemorrhage.<br \/>\n08:50<br \/>\n08:53<br \/>\nOutcomes for placental abruption<br \/>\n08:55<br \/>\nare widely varied and largely<br \/>\n08:56<br \/>\ndependent on the degree<br \/>\n08:57<br \/>\nof placental separation.<br \/>\n09:00<br \/>\nIn cases where there is<br \/>\n09:01<br \/>\nminimal or marginal separation<br \/>\n09:02<br \/>\nat term, there may be<br \/>\n09:03<br \/>\nno adverse maternal<br \/>\n09:05<br \/>\nor fetal affects.<br \/>\n09:07<br \/>\nChronic abruption can lead<br \/>\n09:08<br \/>\nto pre-term birth<br \/>\n09:09<br \/>\nand intrauterine growth<br \/>\n09:10<br \/>\nrestriction which carry a range<br \/>\n09:11<br \/>\nof neonatal outcomes ranging<br \/>\n09:13<br \/>\nfrom NICU admission<br \/>\n09:14<br \/>\nto permanent, neurologic sequela<br \/>\n09:15<br \/>\nor death.<br \/>\n09:17<br \/>\nMaternal mortality is generally<br \/>\n09:18<br \/>\nlow, but morbidity can be high.<br \/>\n09:21<br \/>\nEmergent DIC can lead<br \/>\n09:22<br \/>\nto renal failure<br \/>\n09:23<br \/>\nand multi-organ failure.<br \/>\n09:25<br \/>\nEven when blood products are<br \/>\n09:26<br \/>\naggressively supplemented,<br \/>\n09:27<br \/>\nICU admission is common.<br \/>\n09:29<br \/>\nHysterectomy may also be<br \/>\n09:31<br \/>\nperformed if uterine bleeding<br \/>\n09:32<br \/>\ncannot be controlled in any<br \/>\n09:33<br \/>\nother way.<br \/>\n09:34<br \/>\n09:36<br \/>\nIn summary,<br \/>\n09:37<br \/>\npainful third trimester bleeding<br \/>\n09:39<br \/>\nis placental abruption<br \/>\n09:40<br \/>\nuntil proven otherwise.<br \/>\n09:42<br \/>\nRisk factors<br \/>\n09:43<br \/>\nfor placental abruption<br \/>\n09:44<br \/>\nare varied.<br \/>\n09:44<br \/>\nBoth acute and chronic abruption<br \/>\n09:46<br \/>\ncan occur.<br \/>\n09:48<br \/>\nTreatment is<br \/>\n09:48<br \/>\ndependent on gestational age.<br \/>\n09:51<br \/>\nAnd outcomes depend<br \/>\n09:52<br \/>\non the degree<br \/>\n09:53<br \/>\nof placental separation.<br \/>\n09:54<br \/>\n09:56<br \/>\nHere are a list of references<br \/>\n09:58<br \/>\nfor further reading.<\/p>\n<p><\/div>\n<hr \/>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Duration 9:45 Duration 8:56 Duration 9:27 Duration 10:06 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