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Obstetrical Complications of Pregnancy

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A 32-year-old G2P1 at 28 weeks' gestation presents to labor and delivery with a chief complaint of vaginal bleeding. Her vital signs are—blood pressure 115/67 mm Hg, pulse 87 beats per minute, temperature 37.0°C, respiratory rate 18 breaths per minute. She reports no contraction and states that the baby is moving normally. On ultrasound, the placenta is located on the anterior wall of the uterus, and completely covers the internal cervical os. Which of the following would most increase her risk for hysterectomy?

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a. Desire for sterilization

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b. Development of disseminated intravascular coagulopathy (DIC)

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c. Placenta accreta

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d. Prior vaginal delivery

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e. Smoking

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The answer is c. Prior cesarean delivery and placenta previa, especially with an anteriorly located placenta, increase the risk of placenta accreta, increta, and percreta. These are situations where the placenta is abnormally adherent to the uterine wall. In placenta accreta, the placental villi are abnormally attached to the myometrium. In placenta increta, the villi invade into the myometrium, and in placenta percreta, the villi penetrate through the myometrium. Placenta accreta, increta, or percreta typically require treatment with hysterectomy. The incidence of these disorders has increased due to the increased cesarean delivery rate. Placenta accrete may be suspected on ultrasound, but MRI is often required to confirm the diagnosis. Advanced maternal age, multiparity, prior cesarean delivery, and smoking are all risk factors for placenta previa. Painless bleeding is the most common symptom, and is rarely fatal. Vaginal examination to evaluate for placenta previa is contraindicated, unless the woman is in the operating room prepared for immediate cesarean delivery, because even the most gentle examination can cause significant hemorrhage. Vaginal examinations are rarely necessary, because ultrasound is usually readily available to make the diagnosis of placenta previa. Cesarean delivery is necessary in essentially all cases of placenta previa. Because of the poor contractile nature of the lower uterine segment, uncontrollable hemorrhage may follow removal of the placenta. Hysterectomy may be indicated if conservative methods to control hemorrhage fail. Resuscitation with blood products is the treatment for disseminated intravascular coagulopathy, not hysterectomy. Sterilization itself is not an indication for hysterectomy at the time of cesarean delivery, because the complications of surgery are much increased with a cesarean hysterectomy.

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A patient at 17 weeks' gestation is diagnosed with an intrauterine fetal demise. She desires expectant management. She returns to your office 5 weeks later, and her vital signs are—blood pressure 110/72 mm Hg, pulse 93 beats per minute, temperature 36.38°C, respiratory rate 16 breaths per minute. She has not had a miscarriage, although she has had some occasional spotting. Her cervix is closed on examination. This ...

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