A-E Examination: Placenta Praevia
Author – Dr Kalyani Shinkar Editor – Dr James Mackintosh
Last updated 20/08/24
Table of Contents
How to Use
Candidate:
- Read the brief below (1 minute).
- Take a brief history and a perform a A-E examination (10 minute).
- Handover the patient (1 minute)
- Answer viva questions (2 minutes).
Patient/Examiner:
- Familiarise yourself with the history & examination findings
- After completing the history, viva the candidate
Candidate Brief
You are an F1 in A&E. Mrs Alexandra Keen is a 35-year-old woman who is 37 weeks pregnant with her second child. She has presented to A&E with painless vaginal bleeding. Please take a brief history and perform an A-E examination of this patient.
Background and Presenting Complaint
- Mrs Keen’s gestational age is 37 weeks
- She is gravida 2, para 1 (G2, P1)
- She has a 2-hour history of intermittent vaginal bleeding. The blood is bright red and there are no blood clots.
- She denies having any abdominal pain.
- She reports having foetal movements.
- She admits to not attending all her pregnancy scans. She attended the first pregnancy scan at 12 weeks, which was normal, but did not attend any subsequent scans.
- She has a history of a previous caesarean section with no associated complications.
Past Medical History
- Nil Comorbidities
Drug History and Allergies
- Nil
- NKDA
Introduce yourself, confirm the patient’s identify, and gain consent to examine the patient
- Patient confirms full name and DOB
- She gives consent for you to examine her
End of bed inspection
- She appears well and comfortable at rest
Airways
- Assess the patency of the patient’s airway, ensure that the patient is able to breathe effectively, and there are no airway obstructions.
- Her airway is patent, as she is able to talk in full sentences
- There are no airway obstructions
Breathing
- Inspect for signs of respiratory compromise (e.g. cyanosis, see-saw breathing, use of accessory muscles, nasal flaring, pursed lip breathing, or increased work of breathing)
- There are no signs of respiratory compromise
- Respiratory rate
- RR = 14
- O2 sats
- O2 sats = 98% on RA
- Palpate for tracheal deviation and symmetrical chest expansion
- Trachea is central and there is symmetrical chest expansion
- Percuss
- Percussion note is resonant throughout
- Auscultate for reduced breath sounds or added sounds
- Vesicular breathing bilaterally
- No added sounds
Circulation
- Inspection (e.g. pale, sweating, clammy)
- She appears pale
- Temperature of hands
- Warm and well-perfused
- CRT
- 2 seconds
- Heart Rate
- 88 bpm
- Blood pressure
- 125/85mmHg
- Insert 2 large bore IV cannulae into each antecubital fossae
- Take bloods (FBC for anaemia; U&Es, LFTs and CRP for baseline; coagulation studies to check for coagulopathies; group and save to determine blood group; crossmatch for possible blood transfusion, and VBG to check lactate levels)
- JVP
- Not raised
- Apex beat
- Palpable in the left 5th ICS midclavicular line
- Heart sounds
- Normal
- Fluid status
- Euvolaemic
- Perform an ECG
- Sinus Rhythm
Disability
- Level of consciousness (AVPU or GCS if a neurological cause for the patient’s presentation is suspected)
- Responsive to Voice
- Pupils
- Equal and reactive to light
- Blood glucose levels
- 6.0
- Temperature
- 37.0°C
Exposure
- Fully expose the patient by removing their clothing whilst preserving their dignity
- Look for any signs of trauma, swelling, bruises, scars, rashes, or signs of a DVT
- Obstetric examination:
- No abdominal or uterine tenderness. Foetal lie is longitudinal, presentation is cephalic, and head is not engaged.
- Careful Speculum Examination:
- Small amounts of bright red vaginal blood. Cervical os is closed. No vaginal or cervical lacerations are present.
After completing the initial A-E assessment, reassess! Re-assess the patient to identify any additional clinical changes and effectiveness of any interventions you have performed.
1. What are your differential diagnoses?
- Placenta praevia (due to history of painless bright red vaginal bleeding, previous caesarean section, and not attending 20-week anomaly scan)
- Vasa praevia (similar to placenta praevia, vasa praevia is associated with painless bright red vaginal bleeding and previous history of caesarean section)
- Placental abruption (an important cause of antepartum haemorrhage; however, placental abruption is more associated with dark red vaginal bleeding, sudden onset continuous severe abdominal pain +/- back pain, and a characteristic tense “woody” abdomen on palpation)
- Uterine Rupture (similar to placental abruption, uterine rupture typically presents with dark red vaginal bleeding and sudden-onset abdominal pain. Moreover, it is associated with cessation of uterine contractions and its main risk factor is previous caesarean section).
2. Given a likely diagnosis of Placenta praevia, how would you manage this patient?
- Escalate to obstetrics and gynaecology registrar
- Arrange for urgent TVUS to check for placenta praevia
- Arrange CTG monitoring to assess foetal well-being
- Consider emergency caesarean section if CTG reveals signs of foetal distress
3. Please Handover this patient to the obstetrics and gynaecology registrar using the SBAR or equivalent format.
- Hi, my name is Dr. Joe Bloggs and I’m calling from A&E. Can I please confirm who I am speaking to?
- I’m really worried about a patient I’ve just examined, I think she may have antepartum haemorrhage caused by placenta praevia.
- She is a 35-year-old woman called Alexandra Keen, who has presented with a 2-hour history of painless bright red intermittent vaginal bleeding.
- She is G2P1
- She has a history of a previous caesarean section.
- She did not attend her 20-week pregnancy scan.
- She has no comorbidities or allergies.
- On inspection, she appeared well and comfortable at rest.
- Her airway was patent
- She has no signs of respiratory distress and examination of her chest was unremarkable.
- She was haemodynamically stable. I have inserted 1 large bore IV cannula and have taken bloods, including FBC, U&Es, LFTs, CRP, coagulation studies, group and save, crossmatch, and VBG.
- She was alert, apyrexial and her BM was normal.
- Obstetric examination revealed no abdominal pain. It is a singleton pregnancy. Foetal lie is longitudinal, presentation is cephalic, and head is not engaged.
- Speculum examination revealed small amounts of bright red vaginal blood. The cervical os was closed and there were no vaginal or cervical lacerations.
- I have arranged an urgent TVUS to check for placenta praevia.
- Can you please come and see her? In the meantime, is there anything you would like me to do?
What is Placenta Praevia?
Placenta praevia is when the placenta implants in the lower uterine segment, partially or completely covering the internal cervical os. Normally, the placenta attaches to the upper uterine segment, away from the cervix, allowing for a safe passage during childbirth. In placenta praevia, however, the placenta’s abnormal positioning increases the risk of haemorrhage during pregnancy and delivery.
Causes and Risk Factors
The cause of placenta praevia is not fully understood, but several risk factors have been identified. These include:
- Previous placenta praevia
- Previous caesarean sections – due to scarring of the uterine wall, which can prevent normal placental implantation.
- Previous uterine surgeries e.g. myomectomy for removal of uterine fibroids or surgical treatment for adhesions
- Uterine abnormalities e.g. uterine fibroids
- Multiparity – due to uterine stretching
- Multiple gestation – due to uterine stretching
- Older maternal age
- Maternal smoking
- Assisted reproduction techniques e.g. IVF
Clinical Presentation
Many women with placenta praevia are asymptomatic and diagnosis may only be made during routine prenatal ultrasound scans. However, some women may experience symptoms later in pregnancy (often after 36 weeks), which commonly include:
- Painless bright red vaginal bleeding: This is a hallmark symptom of placenta praevia and typically occurs during the second or third trimester of pregnancy. The bleeding may be intermittent or continuous and can range from light spotting to severe haemorrhage.
- Abdominal pain: This may occur if bleeding is particularly significant or if there are associated uterine contractions.
- Pre-term Labour: Placenta praevia can increase the risk of pre-term labour.
Diagnosis
The diagnosis of ectopic pregnancy requires a combination of clinical assessment, laboratory tests, and imaging studies.
Clinical Assessment:
- History: It is important to take a thorough history from the patient, assessing for symptoms such as vaginal bleeding or abdominal pain.
- Physical Examination:
- Abdominal Exam: It is necessary to examine the patient’s abdomen to check for abdominal pain, uterine tenderness, or abnormal foetal presentation.
- Speculum Exam: A careful speculum exam should be carried out to ensure the foetal membranes have not ruptured, the cervical os is closed, and the bleeding is not coming from the cervix or vagina.
- Digital (finger) Vaginal Exam: This should NOT be performed in suspected cases of placenta praevia, as it may cause heavy bleeding.
Laboratory Tests:
- FBC and Coagulation studies may be performed to assess for anaemia or coagulopathies, which may be attributed to placenta praevia.
Imaging
- Transvaginal and transabdominal ultrasounds are the primary imaging studies to diagnose placenta praevia, as it enables visualisation of the placenta in relation to the internal cervical os.
Special Tests
- CTG monitoring to assess foetal well-being.
Management
The management of placenta praevia depends on the type and severity of the condition. Management options include:
- Antenatal Care and Monitoring: If placenta praevia is diagnosed during prenatal ultrasound scans, the patient should be closely monitored with serial ultrasound scans (at 32 and 36 gestation) to monitor placental location and guide decisions regarding delivery.
- Haemorrhage Resuscitation: In cases of severe haemorrhage and haemodynamic instability, major haemorrhage resuscitation should be commenced.
- Delivery Planning: Placenta praevia is associated with an increased risk of pre-term birth. Thus, if a woman is between 24 weeks and 24 weeks of gestation, she should be offered corticosteroids between 34 and 35+6 weeks gestation to aid foetal lung maturation. Moreover, she should have a planned early caesarean section between 36 weeks and 37 weeks gestation to reduce the risk of spontaneous labour and bleeding.
- Emergency Caesarean Section may be performed with preterm labour or antenatal haemorrhage.
- Postpartum Care: Close monitoring of the mother and baby is required following childbirth to assess for and manage any complications, including postpartum haemorrhage, infection, and neonatal respiratory problems.
- Future Pregnancy Planning: Women with placenta praevia are at increased risk of recurrence of placenta praevia and other placental abnormalities in future pregnancies and should therefore be counselled about these risks.
- Giordano, R et al. (2010). Antepartum Haemorrhage. Journal of Prenatal Medicine. 4(1), pp.12-16. [Online]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263934/ [Accessed 26 August 2024].
- https://www.ncbi.nlm.nih.gov/books/NBK539818/
- https://www.mayoclinic.org/diseases-conditions/placenta-previa/symptoms-causes/syc-20352768