WIDI - R2) Abdominal pain in a pregnant patient after an MVC

R2) Abdominal pain in a pregnant patient after an MVC

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a pregnant patient with abdominal pain.
Review the DDx considerations in a pregnant patient with abdominal pain.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a pregnant patient with abdominal pain.

History

A G1P0 32-year-old female at 32 weeks gestation presents as a trauma alert following a motor vehicle collision. She endorses severe abdominal pain and worsening contractions. She has a history of poorly controlled HTN and admits to smoking for 7 years prior to her pregnancy. She endorses no vaginal bleeding.

Physical Exam

BP: 90/60, HR 115 bpm, RR 22, Temp 97.2, O2 saturation 94%. Uterus firm and tender to palpation. There is vaginal bleeding. Fetal heart rate abnormalities detected. Fetal bradycardia with frequent decelerations. The tocometer reveals frequent contractions.

Labs

Hgb: 8g/dL (nl: 11.5-13.0 g/dL)

Provisional Diagnosis

Select the Dx you believe is most appropriate

Premature Labor

Placental Abruption

Placenta Previa

Of the above diagnoses, this pregnant patient with abdominal pain and hemodynamic instability following a trauma is most likely suffering from a placental abruption. Placenta previa would likely present with painless vaginal bleeding. Premature labor is also on the differential.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

Emergent. This patient requires emergent care to preserve the life of the mother and fetus.

First Imaging Study

What is the first imaging study you will order?

CT of chest, abdomen, and pelvis w/ contrast

CT of chest, abdomen, and pelvis w/o contrast

MRI of abdomen w contrast

MRI of abdomen w/o contrast

A CT of the abdomen with contrast will allow for assessment of an abnormal uterine enhancement pattern and intrauterine bleeding. Considering the patient’s hemodynamic instability, this should be evaluated as part of the trauma scan, which includes the chest, abdomen, and pelvis.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

CT of chest, abdomen, and pelvis w/ contrast

What best describes the findings on the CT?

Heterogenous enhancement of placenta

Appendiceal inflammation

Free intraperitoneal fluid

There is heterogeneous placental enhancement with a full-thickness area of hypodensity forming acute angles with the myometrium in the left lower uterus.

View Report

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View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

Ultrasound abdomen

MRI with contrast

Repeat CT w/o contrast

None

No further imaging is needed.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Placenta Previa

Placental Abruption

Uterine rupture

Bowel perforation

The patient’s risk factors, clinical presentation, and imaging findings are concerning for a placental abruption.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Emergent. The patient's diagnosis is potentially life threatening for the mother and fetus.

Assessment and Plan

Please provide your assessment and plan for this patient

This pregnant patient presenting with abdominal pain and vaginal bleeding following a trauma was found to have a placental abruption on CT. Considering the patient is hemodynamically unstable, an emergent OBGYN consultation is necessary for caesarean delivery evaluation. She also requires aggressive IV fluid rehydration and blood transfusion.

Lessons Learned:
- Placental abruptions can present with painful vaginal bleeding following blunt trauma.
Risk factors for placental abruption include chronic hypertension, history of abruption, smoking, cocaine use, polyhydramnios, preterm rupture of membranes, and advanced maternal age.
- Most placental abruptions occur in the third trimester.
- Ultrasound is the modality of choice but CT may be performed first in the unstable patient. CT may demonstrate areas of hypodensity forming acute angles with the myometrium.

Socioeconomic Factors:
- Low socioeconomic status is associated with the risk of placental abruptions. It is postulated that certain lifestyle factors and health behaviors (like smoking and cocaine use) that occur disproportionally in lower socioeconomic populations are contributory to spontaneous placental abruptions.
- African American mothers were found to be at significantly increased risk for placental abruption compared to Caucasian mothers.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
John Cerillo, MS2 - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator