A 32-Year-Old Woman, Gravida 2 Para 1, with Dichorionic-Diamniotic Twins

A 32-year-old woman, gravida 2 para 1, with dichorionic-diamniotic twins at 34 weeks gestation is brought to the emergency department after developing leakage of fluid an hour ago.  While in the emergency department, the patient has a sudden large gush of fluid that is followed by heavy vaginal bleeding and constant lower abdominal pain.  Her pregnancy has been complicated by gestational hypertension, but the patient has not required any antihypertensive therapy.  The patient's last pregnancy ended in a cesarean delivery for breech presentation.  Her prior prenatal ultrasounds showed 2 fundal placentas.  Blood pressure is 160/100 mm Hg and pulse is 118/min.  Fetal heart rate tracing shows both fetuses with baselines of 110/min and no variability.  The uterus is firm, tender, and has a fundal height of 38 cm.  Speculum examination shows approximately 75 mL of red blood in the vagina.  After evacuation of the blood, a moderate amount of continued bleeding is observed coming from the cervical os that is 3 cm dilated.  Which of the following is the most likely cause of this patient's presentation?

A) Direct attachment of the placenta to the myometrium
B) Full-thickness disruption of the uterine wall
C) Injury to fetal placental vessels
D) Laceration of cervical blood vessels
E) Premature placental separation

Correct Answer:

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