Case Study Paper: Bleeding During Pregnancy
Ashley Deal
University of Central Florida
Case Presentation
S.W. is a 28 year old female patient G1P0 who came into the office complaining of
frequent vaginal bleeding without cramping. She is 26 weeks and 2 days pregnant based on last
menstrual period consistent with eight week sonogram with an estimated due date of January 22,
2014. She is not currently bleeding.
She states that she has had bleeding throughout her pregnancy. S.W. has gone to the
emergency department twice during her pregnancy for episodes of excessive vaginal bleeding.
She received a comprehensive work up including a transvaginal ultrasound and blood work. The
patient states she would saturate a menses pad with frank red blood in about an hour lasting
between three and four hours at a time. She has noted a small amount of blood daily throughout
her pregnancy since about 12 weeks. She denies any pain and cramping associated with bleeding
episodes.
S.W. denies any past medical or surgical history. She started her menses at the age of 14
and she reports normal monthly periods. Her last menstrual period was April 17, 2013. The
patient denies any surgical history. The patient has no known allergies. The patient is currently
taking a daily prenatal vitamin with iron supplement by mouth and Tums as needed for heartburn
typically one to two times per week. The patient denies any family medical history. She currently
lives in a single family home with her husband. Both the patient and her husband are nonsmokers
and the patient denies alcohol or illicit drug use. She is in a monogamous relationship with her
husband and has not been sexually active since the confirmation of pregnancy. She denies any
previous sexually transmitted infections. The patient works as a paralegal in a small law firm.
She sits at a desk for the majority of the day. She is not currently exercising or engaging in any
strenuous physical activity. The patients’ last Pap smear was in May 2013 and was within normal
limits. The patient denies any previous abnormal pap smears. The prenatal lab work was all
within normal limits. The patients’ blood type is A+, rubella: immune, HIV: negative, STI’s:
negative, HSV: negative, RPR: negative, CMV: positive. The patient had a normal one hour
glucose tolerance test done at 24 weeks and 4 days of 93. Her hemoglobin in the office today is
13.1. Her urine dipstick in the office today is within normal limits.
The patient denies any headaches, head trauma, lesions or masses. The patient denies
cough, sputum production, wheezing, or hemoptysis. The patient denies any chest pain,
dizziness, palpitations, or edema. The patient denies any skin lesions, rashes, or breakdowns. The
patient denies nausea, vomiting, or cramping. The patient denies any difficult urinating, pain,
frequency, or hesitation. No foul smelling urine or vaginal discharge. The patient notes frequent
vaginal bleeding during pregnancy, but denies bleeding at this time. The patient denies any
syncope or weakness. The patient denies any history of anemia or blood disorder and denies any
bruising. The patient denies muscle aches, swelling, or joint pain. The patient denies any
depression, anxiety, or suicidal thoughts or ideation. The patient denies any intolerance to heat or
cold, any changes in weight, hair or hat, shoe size. The patient states positive fetal movement on
a daily basis. The patient denies any preterm labor.
S.W. is a 29 year old well- nourished Caucasian female in no apparent distress. She is 26
weeks pregnant today. The patient is 5’3” and weighs 143 pounds with a 12 pound weight gain
during her pregnancy thus far. Her vitals are all within normal limits with a temperature of 98.2,
respirations of 16, heart rate of 82, and blood pressure of 112/64. The fetal heart rate is in the
140’s. Her physical exam is unremarkable. She is alert and oriented to person, place, time, and
situation. The patient has normal skin turgor, no edema, no rashes, erythema, or lesions noted.
Her skin is warm, dry, and intact. Her heart rate and rhythm are normal, no murmur auscultated,
no palpable thrills or heaves. Her lungs are clear bilaterally to auscultation, her breathing is nonlabored with no use of accessory muscles, no clubbing noted. The abdomen is soft, non-tender
with no palpable masses and no guarding present, positive bowel sounds in all four quadrants.
The fundal height is 24.5 cm. The patient is able to move all extremities without pain or
tenderness. Full ROM in all extremities, no crepitus or limitation noted. Muscle strength is +5,
equal bilaterally. Deep tendon reflexes are symmetrical bilaterally in the upper and lower
extremities, measuring 2 +. Gait is even and coordinated. The external genitalia are normal with
no masses or lesions noted. The cervix is tight and closed today. Scant amount of dark brown
discharge noted in the vaginal canal, no other discharged noted. The patient appears healthy
today.
Differential Diagnosis
Based upon the patients’ presentation, assessment, and diagnostic testing the most likely
differential diagnosis for this patient are placenta praevia, placental accrete, and ectopic
pregnancy. The patient is having abnormal vaginal bleeding during pregnancy without cramping,
nausea, or vomiting. About half of patients who have bleeding during pregnancy have no known
cause (Yang et al, 2004).
Placenta praevia is a condition in which the placenta covers all or part of the cervix,
which can lead to antepartum bleeding (Rao et al, 2012). Placenta praevia typically presents with
third trimester painless bleeding (Rao et al, 2012). The third trimester begins at 28 weeks. S.W.
is still in her second trimester, but she is reporting painless bleeding. Guidelines from the Society
of Obstetricians and Gynecologists of Canada recommend the use of transvaginal ultrasound to
diagnosis and evaluate placenta praevia (Oppenheimer, 2007).
Placenta accrete refers to when the placenta is implanted into the uterus with varying
degrees and can lead to bleeding during the pregnancy (Wortman & Alexander, 2013). Patients
at greatest risk for developing placenta accreta are those who have a history of myometrial
damage secondary to previous cesarean delivery (ACOG, 2012). S.W. has not had a previous
cesarean delivery and has no myomentrial damage at this time. Placenta accreta is diagnosed
with the use of grayscale ultrasonography and MRI can be performed in ambiguous cases
(ACOG, 2012).
Ectopic pregnancy is a condition in which the fetus develops outside of the uterus and
presents with vaginal bleeding, pelvic pain, and palpable adrenal mass (Lozeau & Potter, 2005).
S.W. reports vaginal bleeding, but does not report pelvic pain and no mass was palpated on
exam.
Diagnostics
A transvaginal or pelvic ultrasound is performed to diagnosis placenta previa and
placental accraeta (ACOG, 2012. Fetal heart rate should be monitored to assess for abnormalities
(RCOG, 2011). Laboratory results that are important to evaluate bleeding in patients include a
complete blood count, PT, aPTT, and fibrogen level to evaluate blood count for anemia and
coaguability (Buttaro, 2013).
The patient had a non-stress test done today. The fetus had a reactive non-stress test with
an average heart rate in the 140’s. While hospitalized the patient had a transvaginal ultrasound
performed which showed a partial placenta previa with minimal pooling. The patient also had a
fetal ultrasound while hospitalized which was within normal limits for gestational age. A
hemoglobin result was obtained in the office which showed a hemoglobin level of 13.1.
Treatment Plan
Follow up transvaginal ultrasound should be performed at 32 weeks for patients with
placenta previa to assess the position of the placenta and a final ultrasound should be performed
at 36 weeks (Rao et al, 2012). The American Congress of Obstetricians and Gynecologists
recommends late preterm or early term delivery for patients with placenta previa (ACOG, 2013).
The patient should be educated on the likelihood of an early delivery. Proper education is vital to
ensure the patient is compliant with her prenatal care to decrease the likelihood of further
complications during her pregnancy.
In order to reduce the risk of antepartum hemorrhage there is no evidence to support bed
rest, reduced activity, or avoidance of sexual intercourse (Rao et al, 2012). Aerobic exercise is
contraindicated in patients with placenta previa and persistent bleeding during the second and
third trimester (ACOG, 2002).
Discussion
The patient was placed on bed rest with minimal activity as well as no sexual intercourse
although there is no clear evidence to support that those interventions will decrease the risk of
antepartum bleeding. The patient was informed to continue taking a prenatal vitamin with folic
acid daily. The patient was ordered to have non-stress tests twice a week as well as serial
ultrasounds for fetal growth and development per the maternal fetal specialist in the office. The
patient was advised to monitor for fetal movement daily. Education in regards to early preterm
labor was provided to the patient consistent with the recommends from The American College of
Obstetricians and Gynecologists. S.W. was informed that if she has another episode of excessive
bleeding, saturating a menses pad within an hour, then to immediately go to the hospital for
evaluation. She was advised to return to the office in two weeks and as needed.
This patient was pregnant for the first time and is experiencing a pregnancy complicated
by frequent vaginal bleeding. Due to the complications during her pregnancy so far this patient
was suffering from anxiety as well. Maternal anxiety can lead to neurobiobehavioral
dysregularities in infants (Parcells, 2010). It is important to monitor this patient for her anxiety
and to prevent further pregnancy complications as well as impacting the infant. Vaginal bleeding
during pregnancy is common and often undiagnosed, but it is important to provide patients with
a full work up to rule out any severe complications.
The treatment plan in place for the patient followed conservative management and were
primarily based upon guidelines, but also components of the plan were based on the provider’s
personal preference. I felt as though the treatment plan for the patient was appropriate and agree
with the conservative management to ensure the best possible outcome for the patient and baby.
References
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Collaborative Practice (4th ed.). St. Louis: Elsevier.
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