Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer.
So if you're ready, let's jump right in.
Margaret Fitzgerald: Which of the following is consistent with the clinical presentation of placental abruption?
A. A 38-year-old with primary hypertension, who's now 28 weeks pregnant with her sixth child, presents with a one-hour history of sudden onset abdominal pain as well as dark red, vaginal bleeding, dizziness, tachycardia and BP of 88 over 55
B. A 32-year-old who's pregnant with her eighth child, now 32 weeks pregnant, presenting with a two-hour history of bright red vaginal bleeding, stating she does not have abdominal pain without a history of abdominal trauma. Vital signs are within normal limits.
C. A 28-year-old who states she had a positive home pregnancy test three days ago with last menstrual period six weeks ago. Normal timing and flow with an eight-hour history of intermittent bright red, vaginal spotting with mild cramping
D. A 26-year-old with a past medical history of pelvic inflammatory disease who's now eight weeks pregnant by LMP with a two-hour history of sudden onset, severe left sided abdominal pain radiating to the shoulder, small amount of bright red bleeding, poor vagina feeling lightheaded. Vital signs revealed tachycardia and a BP of 80 over 45.
The correct answer is A, a 38-year-old with primary hypertension who now is 28 weeks pregnant with her sixth child, presents with a one-hour history of sudden onset abdominal pain as well as dark red, vaginal bleeding, dizziness, tachycardia and a BP of 88 over 55.
Where should we start?
First, let's determine what kind of a question this is. Given that we're being asked to review four clinical scenarios, then report what is the most likely cause; this is, of course, a diagnosis question.
First, some background information. Actual bleeding during pregnancy is quite common, with upwards to one third of all women reporting bright red vaginal bleeding in the first trimester. The majority of these pregnancies, barring other complications, will actually be carried to term. Vaginal bleeding in the second trimester of pregnancy, and remember, those are weeks 13 to 25; and in the third trimester, from weeks 26 to term, and term is between 38 and 41 weeks, is less common and nearly always a cause for great concern. The reason for pregnancy related vaginal bleeding are numerous.
Knowledge of the most common and the most worrisome causes is key to say practice. What about placental abruption? Of course, the placenta naturally detaches from the uterine wall after childbirth. That's the way it's supposed to be. Placental abruption is defined as the placenta detaching from the uterus prematurely. Risk factors for this condition, particularly when seen in the early third trimester as it is in the correct answer here include maternal hypertension, which is reported in this case scenario, and this is pre-pregnancy maternal hypertension.
Additional risk factors include cigarette, smoking, which is actually not mentioned here, but high level multipolarity, in other words, having carried in a number of pregnancies, is a significant risk factors. There are additional risk factors which include pre-eclampsia, a history of prior abruption, abdominal trauma during pregnancy, cocaine use, and prior caesarean section.
Actually, the most potent of the risk factors for placental abruption is a history of prior placental abruption, but it's also among the least common of the risk factors. The clinical scenario of placental abruption is quite similar to what we see here with the sudden onset of abdominal pain accompanied by bright too dark red vaginal bleeding, and a woman who's usually in the third trimester of pregnancy.
Oftentimes, as is reported here, we also have deranged vital signs like tachycardia and lowered blood pressure. And this goes along with a clearly life threatening situation on physical exam and placental abruption. Usually, the uterus is noted to be contracting forcefully, due in part to the blood that's trapped in the uterus behind the placenta. The uterus will contract to try to get this blood out.
Placental abruption, of course, can occur on a spectrum from a small separation that can be managed with bedrest and pelvic rest, to a clearly life threatening situation that we have here. Invariably, of course, intervention includes transferring to an acute care facility from the primary care office, because if you'll remember, the primary care setting is the most common setting for a question on the NP boards.
And then once in the acute care facility, this can be managed as a clinical situation where truly both mother and child are at risk from dying. Management of placental abruption depends significantly on the severity of the abruption, where in the pregnancy the abruption has occurred and a number of other factors.
For the primary care provider, that's you, the most important part is to identify risk for abruption and quickly identify its clinical presentation. Then be aware of your local resources or transfer. With that in mind, let's take a look at the question and possible answers.
Which of the following is consistent with the clinical presentation of placental abruption?
A 38-year-old with primary hypertension, who's now 28 weeks pregnant with her sixth child, presents with a one-hour history of sudden onset abdominal pain as well as dark red, vaginal bleeding, dizziness, tachycardia. And her BP is 88 over 55.
As mentioned, of course, this is the correct answer. She has risk factors for the placental abruption, including primary hypertension and multipolarity, and her clinical presentation is quite concerning, showing that she's physiologically unstable.
Option B, a 32-year-old who is pregnant with her eighth child, now 36 weeks pregnant, presenting with a two-hour history of bright red vaginal bleeding, stating she does not have abdominal pain without a history of abdominal trauma and vital signs are within normal limit.
This is, of course, incorrect, but as described another reason for vaginal bleeding in the third trimester and this is placenta previa. With previa, at least a portion of the placenta is covering the internal os. This bleeding can be triggered from a variety of reasons, depending on when in the pregnancy occurs. In later pregnancy, such as we have here with she's 36 weeks pregnant, cervical effacement could be one of the reasons for the bleeding. And if you recall, particularly in women who have carried many pregnancies, that the cervix tends to efface fairly early in that third trimester. If you're thinking that 40 weeks is term, actually more like 38 to 41 weeks is truly a term, maybe even 42 weeks.
But as that effacement takes place, the placenta will tear a bit and that's what's causing the bleeding. And given that the blood from the placenta previa can exit the uterus via the cervical os, there's no blood trapped in the uterus and usually no contractions and no abdominal pain. Quite often, women presenting with placenta previa are hemodynamically stable.
High level parity, which we see here. She's pregnant with her eighth child, is a potent risk factor for placenta previa, as is hypertension, cigarette smoking. And you'll also remember those, interestingly enough are risk factors for abruption. The correct intervention here would be again to transfer to a facility where appropriate assessment can be done determining the degree of placenta previa, whether vaginal birth would be possible, whether she needs an emergency C-section.
There are simply a number of factors that come into play. And by the way, if you're thinking, ouu, are they going to ask me what medical center I'd send her to or what kind of a facility I would send either one of these women with either previa or a abruption to, No, no, no, no. The boards never get that specific.
What they would do is say a general comment like higher level of care to the emergency department, whatever, whatever it would be. And they're certainly never going to ask you for the exact name of the facility that you would transfer somebody to, because this is a national exam. People all over the United States and the U.S. territories take this test and it would be unwieldy to try to customize the exam to local areas, period.
You also might say to yourself, well, then once I'm in practice, how do I know where to send someone? Well, this will be one of the things that you learn estimate by using your practice once you're actually settled in and where you will be providing care.
Option C, a 28-year-old who state she had a positive pregnancy test three days ago with LNP six weeks ago with normal timing and flow, with an eight-hour history of intermittent bright red vagnial spotting with mild cramping.
Well, now we're obviously talking about a very early pregnancy bleeding. As I mentioned, this can occur in a significant percentage of women in the first trimester. We're not given much information about this particular patient, but in evaluation for threatened early pregnancy loss needs to be carried out. This also describes a fairly common clinical scenario where the pregnancy then progresses without any particular problems.
Option D, a 26-year-old with a past medical history of pelvic inflammatory disease who's now eight weeks pregnant by LMP with a two-hour history of sudden onset, severe left sided abdominal pain radiating to the shoulder, small amount of bright red bleeding per vagina, feeling lightheaded. Her vital signs reveal tachycardia and a BP of 80 over 45.
One more time, we're looking at first trimester of pregnancy here. Abruption is an issue in either late second or throughout the third trimester of pregnancy. One part of this clinical scenario I want to bring to your attention is that she has a history of pelvic inflammatory disease, now with abdominal pain and unexpected or vaginal bleeding in the first trimester.
This should always put you on the alert for topic pregnancy. She's also at week eight of pregnancy where if an ectopic pregnancy is going to rupture, this will occur. Clearly, she's hemodynamically compromised in symptomatic with dizziness and lower blood pressure. This is an OB emergency and from transferred to a higher level of care is in order. Key takeaways in obstetrics.
Wonderful part of providing care to a family during a pregnancy is that most of the time there's a healthy mom and a healthy baby. However, when things don't go well, they often don't go well quickly. And being able to understand and recognize OB emergencies is critical to safe practice. I have been honored and privileged to provide OB care now for more than 30 years, and I honestly would not have it any other way in my practice.
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