Pregnancy, 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