Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 19-14: Third-Trimester Bleeding + Key Features Download Section PDF Listen +++ ++ Vaginal bleeding occurs in 5–10% of women in late pregnancy + Clinical Findings Download Section PDF Listen +++ ++ Painless vaginal bleeding is characteristic of placenta previa Uterine contractions, pain, and tenderness are more often associated with abruptio placentae + Diagnosis Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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