Advanced Obstetric, Neonatal, and Pediatric Emergencies

Advanced Obstetric, Neonatal, and Pediatric Emergencies

1. Antepartum bleeding: painful versus painless

Two conditions bleed late in pregnancy, and the exam builds almost every question around telling them apart. Start with the mechanism — it's what generates the symptom.

Abruptio placentae is the placenta separating from the uterine wall early, before delivery. That separation tears blood vessels, and it also irritates the uterine muscle. So you get two things at once: painful bleeding, and a rigid, tender uterus. Here's the part that gets missed — the bleeding can be concealed behind the placenta instead of coming out. So your patient can be in shock with very little visible blood. Treat that shock as real even when the pad looks clean.

Placenta previa is the placenta covering the cervical os instead of implanting higher up. As the cervix starts to efface and dilate, it tears the placenta sitting over it. That bleeding is painless, bright red, and the uterus stays soft and non-tender. Nothing is irritating the muscle. The separation is happening at the cervix, not across the wall.

Because previa means the placenta sits over the cervix, you never do a vaginal exam on a previa patient. An instrument near that cervix can tear the placenta further and turn a manageable bleed catastrophic. Field care for both is otherwise the same: treat for shock, left-lateral tilt off the vena cava, rapid transport.

A pregnant patient's blood volume expands by the third trimester, so she can lose a real fraction of it before her vitals move. Treat the mechanism, not the numbers on the monitor.