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For further information, see CMDT Part 19-14: Third-Trimester Bleeding

Key Features

  • Vaginal bleeding occurs in 5–10% of women in late pregnancy

Clinical Findings

  • Painless vaginal bleeding is characteristic of placenta previa

  • Uterine contractions, pain, and tenderness are more often associated with abruptio placentae

Diagnosis

  • Placental causes (placenta previa, placental abruption, vasa previa) must be differentiated from nonplacental causes (infection, disorders of the lower genital tract, systemic disease)

  • Complete blood count with platelets and a prothrombin time (INR) should be obtained and repeated serially if the bleeding continues

  • Coagulation studies may be indicated

  • Ultrasonography can determine placental location

  • Digital pelvic examinations are done only after placenta previa has been excluded

  • Amniocentesis may be performed to assess for fetal lung maturity in patients < 36 weeks' gestational age

Treatment

  • Approach should be conservative and expectant unless fetal distress or risk of severe maternal hemorrhage occurs

  • Patients should initially be observed closely with fetal monitoring to assess for fetal distress

  • Hospitalization and bed rest are continued if the patient is < 36 weeks' gestation

  • Home management may be considered in selected patients

  • Corticosteroid therapy is indicated if fetal lung immaturity is present

  • If hemorrhage is significant or if there is evidence of acute hypovolemia, the need for transfusion should be anticipated and an appropriate volume of red cells prepared with cross matching

  • Administration of anti-D immune globulin may be required for women who are Rh negative

  • For placenta previa,

    • Hospitalization for extended evaluation is initial management approach

    • Cesarean delivery is generally indicated for pregnancies that have reached 37 weeks' gestation or beyond with continued bleeding

  • For morbidly adherent placenta,

    • Evidence-based recommendations regarding delivery timing are lacking

    • However, the goal is to have a planned, late-preterm cesarean delivery

    • Delivery at 34–36 weeks in a stable patient seems a reasonable approach

  • For placental abruption, immediate cesarean delivery is indicated because of the high risk of fetal death

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