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7/29/21, 4:09 PM

Dalton LaBarge

A 23yF G2P0100 presents to the ED at 34w5d with acute, severe abdominal pain and intermittent vaginal bleeding. She is hypervigilant and diaphoretic. Her HR 120 and BP 160/95. She has a history of Substance Use Disorder and 6-pack year Tobacco Use. She reports using several grams of cocaine in the past 24hrs. She reports no vision changes, fluid loss or contractions. Pelvic exam shows a firm, diffusely tender uterus and undilated cervix with dark blood draining from the external os. Which of the following is the most likely cause of her presentation?

Diffuse vessel proliferation with thickened myometrium

Endometrial vessel sheering from serosal tissue

Placental vessel constriction with ischemic injury

Fetal vessel extension over the internal os

Correct Answer:

C

(c) The patient's hypertension, tobacco and recent cocaine use are high risk factors for placental abruption. Cocaine induces placental hypoxic vasoconstriction which can result in premature placental separation. Severe abdominal pain, uterine tenderness and variable bleeding are concerning for abruption.

(a) Adenomyosis can cause abdominopelvic pain and heavy bleeding but would not manifest acutely. It is not associated with maternal substance use.

(b) Uterine rupture risk increases in patients with history of C-sections

(d) Placenta Previa risk increases with tobacco and cocaine use but presents as painless bleeding.

Chapter 16. “Third Trimester Bleeding” Casanova, Robert et al. Beckmann and Ling’s Obstetrics and Gynecology. Eighth edition. Philadelphia: Wolters Kluwer, 2019.