A pregnant patient presents with sudden, painful vaginal bleeding and a rigid, tender uterus. What is the likely diagnosis and the priority intervention?

• A. Placenta previa; avoid vaginal examinations and monitor maternal and fetal status.
• B. Placental abruption; stabilize mother and fetus and prepare for possible emergent delivery.
• C. Vasa previa; plan cesarean delivery.
• D. Uterine rupture; emergency cesarean delivery.

Answer: (B)

Recognizing placental abruption based on the presentation. When a pregnant patient has sudden, painful vaginal bleeding together with a rigid, tender uterus, it suggests the placenta is separating from the uterine wall. That separation irritates the uterus, leading to a firm, inelastic feel and painful bleeding. This is a classic pattern for placental abruption, and it carries a real risk of significant maternal hemorrhage and fetal distress.

The priority is to stabilize both mother and fetus and be ready for possible emergent delivery. Clinically, that means securing the airway and ensuring circulation with IV access, starting fluids and blood products as needed, and continuously monitoring the fetal heart rate and maternal status. Because abruption can progress quickly, providers prepare for delivery if there is ongoing heavy bleeding, signs of maternal instability, or fetal compromise.

This presentation helps differentiate it from placenta previa, which typically causes painless bleeding with a soft, non-tender uterus; vasa previa, which is usually painless bleeding with fetal distress but a normal or soft uterus; and uterine rupture, which can involve severe pain and rapid maternal-fetal deterioration, often in the setting of a prior uterine scar.