Patient Name; Age



Author: Thomas Cook, MDReviewers:Michelle Sergel, MD, Sharon Griswold, MDCase Title: Painless Vaginal Bleeding in Late PregnancyTarget Audience: Residents and Medical StudentsPrimary Learning Objectives: Provides a differential diagnosis for the patient with vaginal bleeding in the 2nd and 3rd trimester of pregnancyManages the patient with significant 3rd trimester bleeding Appropriately refers patient with vaginal bleeding in the late stages of pregnancySecondary Learning Objectives:Avoids digital or speculum vaginal exam in the patient with 2nd or 3rd trimester pregnancy before location and status of the placenta is determinedImmediately refers to labor and delivery of the patient with 2nd or 3rd trimester bleedingProvides fluid resuscitation in late pregnancy with massive vaginal bleedingCritical actions checklist:Initiates fluid resuscitationIdentifies viability of pregnancyIdentifies location and status of placenta BEFORE digital and speculum exam (NOTE: If digital exam is performed, the patient’s bleeding should increase significantly)Orders and administers blood transfusion after minimal response to IV fluids Consults obstetrics quickly (notifies them of the need for emergent C-section)Prepares for transportation to Labor and DeliveryEnvironment for Simulation Medicine Case:Room Set Up – Emergency Department SuiteManikin Set Up – 3rd trimester pregnancy with vaginal bleedingPropsMonitor with sinus tachycardia and SBP at 80 mm/HgUltrasound exam showing placenta previaCBC with Hgb = 5.9 gm/dLDistractors – distraught husbandActorsRoles – nurse, husband, consultant (on phone)Played by other residents, other students, actorsAuthor: Thomas Cook, MDReviewer: Michelle Sergel, MD, Sharon Griswold, MDCase Title: Painless Vaginal Bleeding in Late PregnancyCORE CONTENT AREA Obstetrics, ResuscitationSYNOPSIS OF HISTORY/ Scenario Background This case is about a woman from a rural area without prenatal care who shows up with painless vaginal bleeding in late 3rd trimester pregnancy. The candidate should immediately recognize the need for fluid resuscitation, determine the viability of the pregnancy, establish the location of the placenta (if possible), immediately consult obstetrics, and prepare the patient for transport. SYNOPSIS OF PHYSICALThe patient is an obviously gravid female who appears pale and in distress.Vital Signs: T = 98.7; HR = 115; RR = 16; BP = 80/60; SaO2 = 96% on room airHEENT: Mucous membranes are dryAbdomen: Distended abdomen consistent with late 3rd trimester pregnancy. Soft and non-tender. Extremities: Distal extremities cold and clammy. Decreased to absent distal pulses. Mild edema to the distal lower extremities.Pelvic: Examination of external genitalia shows blood coming rapidly from the vaginal os. If the candidate does a digital or speculum exam, the bleeding increases dramatically and patient becomes unconscious. A digital exam will show the cervical os to be 3 cms dilated.For Examiner OnlyCRITICAL ACTIONSScenario branch points/ PLAY OF CASE GUIDELINESKey teaching points or branch points that result in changes in patient’s conditionCritical Action – Initiation of Fluid ResuscitationThis should be done very early in the patient interaction. She is tachycardic and hypotensive with an active source of bleeding. Two large bore intravenous catheters should be inserted and two liters of crystalloid fluid should be given as quickly as possible. Failure to do this will result in the patient becoming unconscious with a drop in blood pressure.Critical Action – Identify Viability of PregnancyThe patient is obviously pregnant. The candidate should determine the viability of the pregnancy as soon as possible after beginning the fluid resuscitation. The fetus will appear to be late stage 3rd trimester pregnancy with good fetal heart motion.Critical Action – Identify the status and location of the placentaAlthough placental abruption is often hard to diagnose by ultrasound (particularly in inexperienced hands), the location of the placenta is often pretty straightforward. The candidate should make an effort to determine if the placenta is low-lying or over the cervix. If the candidate attempts to perform a vaginal exam of any kind, the patient should begin to bleed more heavily and become unconscious.Critical Action – Administer blood when initial fluid bolus does not adequately stabilize the blood pressure.The patient should be type and crossed early in the scenario. Once the initial fluid resuscitation does not improve the cardiovascular status of the patient, emergency release blood (O negative) should be transfused.Critical Action – Immediate consultation of obstetrics for emergency C-section. This should be done early in the scenario after fluid resuscitation and determination of the viability of the pregnancy by ultrasound. Anesthesia and Labor and Delivery should be notified of the need for emergent C-section as well.Critical Action – Prepare the patient for transport to Labor and Delivery Once the candidate determines the need for emergent C-section, the patient needs to be prepared for immediate transport to Labor and Delivery.SCORING GUIDELINESSuccessful management of the case includes the following actions:Appropriate resuscitation of the patient includes immediate initiation of crystalloid fluid resuscitation and administration of blood after minimal response to crystalloid IVF. The candidate must correctly identify pregnancy viability and the location/ status of placentaAppropriate management of the patient to include an emergent obstetric consult and preparation for transfer to Labor & DeliveryFor Examiner OnlyHISTORYChief Complaint:SyncopePast Medical Hx: G3P2 without complication. Children are 6 and 3 years old. Mode of Arrival: Personally owned vehicleRegular physician: noneHistory of Present Illness: The patient is a G3P2 female in the 3rd trimester of pregnancy. She is unsure of her exact dates, but she is obviously pregnant. She is from a rural area and has delivered all her previous children at home without prenatal care and only a midwife in attendance. She noted some vaginal spotting a few days prior. This has progressed to soaking a pad each hour for the past six hours. She passed out about two hours ago, and her husband brought her to the emergency department. She denies any pain. She has never had this problem before. She had some vaginal spotting a week ago, but this went away. No previous syncope in the past. No dysruria, chest pain, shortness of breath, vaginal bleeding, fever, vaginal discharge. There is no recent or remote history of trauma.Medication: Takes acetaminophen on occasion. Allergies: none Social history: Husband is a farmer. She is a homemaker. No tobacco, alcohol, illicit drugs. Lives with husband and two children. All are healthy.ROS: NegativeFor Examiner OnlyPHYSICAL EXAMPatient Name: Janet SmithAge & Sex: 37 yo femaleGeneral Appearance: Well-formed, well-nourished white female in apparent distressVital Signs: T = 98.7; HR = 115; RR = 16; BP = 80/60; SaO2 = 96% on room airHEENT: Pupils equally round and reactive, mucous membranes are dry, throat is normal, Atraumatic scalp.Neck: No thyromegaly, JVD, or lymphadenopathySkin: NormalChest: NormalLungs: ClearHeart: Rapid regular rhythm. No murmurs.Back: NormalAbdomen: Distended abdomen consistent with late 3rd trimester pregnancy. Soft and non-tender. Extremities: Distal extremities cold and clammy. Decreased to absent distal pulses. Mild edema to the distal lower extremities.Rectal: No gross bleeding. Normal sphincter tone.Pelvic: Examination of external genitalia shows blood coming rapidly from the vaginal os. If the candidate does a digital or speculum exam, the bleeding increases dramatically and patient becomes unconscious. A digital exam will show the cervical os to be 3 cms dilated.Musculoskeletal: NormalSkin: NormalNeurological: NormalFor Examiner OnlySTIMULUS INVENTORY#1Emergency Admitting Form#2CBC#3BMP#4U/A#5Coagulation Labs#6Transabdominal Pelvic UltrasoundFor Examiner OnlyLAB DATA & IMAGING RESULTSStimulus #2Stimulus #5Complete Blood Count (CBC) CoagsWBC/mm3PTHgbg/dLPTTHct%INRPlatelets/mm3DifferentialSegs%Stimulus #6Bands%Transabdominal Pelvic UltrasoundLymphs %Monos %Eos %Stimulus #3 Basic Metabolic Profile (BMP) Na+ mEq/LK+ mEq/LCO2 mEq/LCl- mEq/LGlucose mg/dLBUN mg/dLCreatinine mg/dLStimulus #4 Urinalysis (U/A)Color yellowSp gravity 1.010Glucose negProtein negKetone negLeuk. Est. negNitrite negWBC 0-1RBC 0-1Learner Stimulus #1ABEM General HospitalEmergency Admitting FormName:Janet SmithAge: 37 yearsSex: FemaleMethod of Transportation: Private carPerson giving information: HusbandPresenting complaint: Late 3rd Trimester BleedingBackground: Patient is a G3P2 white female in the late stages of pregnancy who began to have painless vaginal bleeding 6 hours ago. Three hours ago she passed out when she got up to go the bathroom. Triage or Initial Vital Signs BP:80/60P:115R:16T :98.7 SaO2:96% on room airLearner Stimulus #2Complete Blood Count (CBC)WBC10 /mm3Hgb8.5 g/dLHct26 %Platelets120 /mm3DifferentialSegs75%Bands5%Lymphs15%Monos4%Eos1%Learner Stimulus #3Basic Metabolic Profile (BMP)Na+140 mEq/LK+4.0 mEq/LCO216 mEq/LCl-109 mEq/LGlucose98 mg/dLBUN22 mg/dLCreatinine0.7 mg/dLLearner Stimulus #4UrinalysisColorYellowSpedific Gravity1.025GlucosenegProteinnegKetonenegLeuk. EsterasenegNitriteNegWBC0-1RBC0-1Learner Stimulus #5STIMULUS #5CoagsPT31.0 secondsPTT13.9 secondsINR1.0 Learner Stimulus #6Feedback/ Assessment FormVaginal Bleeding in Late PregnancyCandidate ________________________ Examiner _________________________Critical Actions: Critical Action #1 – Initiates fluid resuscitationCritical Action #2 – Identifies viability of pregnancyCritical Action #3 – Identifies location and status of placentaCritical Action #4 – Administers blood after minimal response to crystalloid IVFCritical Action #5 – Consults obstetricsCritical Action #6 – Prepares for transfer to Labor & DeliveryDangerous Actions: (Performance of one dangerous action results in failure of the case)Dangerous Action #1 – Fails to initiate fluid resuscitation in timely mannerDangerous Action #1 – Performs a digital and/or speculum exam of vaginaDangerous Action #1 – Fails to administer blood if patient becomes unstableDangerous Action #1 - Fails to consult obstetrics in a timely mannerOverall Score:PassFailAddendum 2:Core Competency Assessment Vaginal Bleeding in Late Pregnancy Candidate ________________________ Examiner _________________________Does Not Meet ExpectationsMeets ExpectationsExceeds ExpectationsPatient CareMedical KnowledgeInterpersonal Skills and CommunicationProfessionalismPractice-based Learning and ImprovementSystems-basedPracticeCore Competency Assessment Vaginal Bleeding in Late PregnancyDate: Examiner: Examinee(s):Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)The learner should be scored (based on level of training) for each item above with one of the following:NI = Needs ImprovementME = Meets ExpectationsAE = Above ExpectationsNA= Not Assessed Critical Actions NIMEAENACategoryRecognizes shock and initiate fluid resuscitationPC, MK, PBLIdentifies viability of pregnancyPC, MKDetermines location and status of placentaPC, MKType and Cross blood and begins transfusion with O-negative bloodPC, MK, PBLConsults obstetrics in a timely manner PC, MK, SBPPrepares for transportation to labor and deliveryPC, MK, SBPDemonstrates / utilizes effective communication techniques such as specifying order details and closed loop communicationMK, ICSCategory: One or more of the ACGME Core Competencies as defined in the SDOTPC= Patient CareCompassionate, appropriate, and effective for the treatment of health problems and the promotion of healthMK= Medical KnowledgeResidents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision makingPBL= Practice Based Learning & ImprovementInvolves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient careICS= Interpersonal Communication SkillsResults in effective information exchange and teaming with patients, their families, and other health professionalsP=ProfessionalismManifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient populationSBP= Systems Based PracticeManifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value CASE DEBRIEFING Vaginal Bleeding in Late PregnancyThe differential diagnosis of vaginal bleeding in late pregnancyPlacenta previa- usually painless bleedingPlacental abruption- usually painful bleedingBloody show associated with onset of labor or cervical incompetencyUterine ruptureVasa previa- refers to vessels that traverse the membranes located in the lower uterine segment in advance of the fetal presenting part. Rupture of these vessels can occur with or without rupture of the membranes and result in fetal exsanguination. Maternal monitoring?—OB consultation should be initiated promptly upon patients’ arrival to the ED.?Maternal cardiac, maternal contractions, BP and maternal urine output should all be monitored during an acute vaginal bleed in patients with placenta previa. Indications for maternal transfusion-?Transfusion should be considered if resuscitation with 2 liters of crystalloid does not resolve hemodynamic instability.Indications for delivery?—?Delivery (C-Section delivery is the delivery route of choice) is indicated if any of the following occur:A non-reassuring fetal heart rate tracing unresponsive to maternal?oxygen therapy, left-sided positioning, and intravascular volume replacementLife-threatening refractory maternal hemorrhageSignificant vaginal bleeding after 34 weeks of gestationFigure: 18 week gestation with complete placenta previa. Marked as PLC. Retrieved from Google images, October 25, 2010. 3173730120015 REFERENCES Vaginal Bleeding in Late PregnancyKeadey M, Houry D. Complications in Pregnancy Part 2: Hypertensive Disorders of Pregnancy and Vaginal Bleeding. Emergency Medicine Practice. 2009; 11 (5):1-19.Arkbarnia H, Marco C. Complications of Pregnancy - Part 2: Emergency Medicine Reports. 2008; 29(4):37-48. Lockwood, CJ, Russo-Stieglitz, K; Vasa previa and velamentous umbilical cord; UpToDate; Last literature review version 18.2:?May 2010?|?This topic last updated:?June 1, 2010. ; Retrieved October 25, 2010.Lockwood, CJ, Russo-Stieglitz, Management of placenta previa; UpToDate; Last literature review version 18.2:?May 2010?|?This topic last updated:?June 14, 2010. ; Retrieved October 25, 2010. ................
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