Vaginal Bleeding in Late Pregnancy Objectives
Identify major causes of vaginal bleeding in the second half of pregnancy
Describe a systematic approach to identifying the cause of bleeding
Describe specific treatment options based on diagnosis Causes of Late Pregnancy Bleeding
Placenta Previa Abruption Life-Threatening Ruptured vasa previa Uterine scar disruption Cervical polyp Bloody show Cervicitis or cervical ectropion Vaginal trauma Cervical cancer Prevalence of Placenta Previa
Occurs in 1/200 pregnancies that reach 3rd trimester Low-lying placenta seen in 50% of ultrasound scans at 16-20 weeks
90% will have normal implantation when scan repeated at >30 weeks
No proven benefit to routine screening ultrasound for this diagnosis Risk Factors for Placenta Previa
Previous cesarean delivery
Previous uterine instrumentation
High parity
Advanced maternal age
Smoking
Multiple gestation Morbidity with Placenta Previa
Maternal hemorrhage
Operative delivery complications
Transfusion
Placenta accreta, increta, or percreta
Prematurity Patient History – Placenta Previa
Painless bleeding
2nd or 3rd trimester, or at term
Often following intercourse
May have preterm contractions
“Sentinel bleed” Physical Exam – Placenta Previa
Vital signs Assess fundal height Fetal lie Estimated fetal weight (Leopold) Presence of fetal heart tones Gentle speculum exam NO digital vaginal exam unless placental location known Laboratory – Placenta Previa
Hematocrit or complete blood count
Blood type and Rh
Coagulation tests
While waiting – serum clot tube taped to wall Ultrasound – Placenta Previa
Can confirm diagnosis
Full bladder can create false appearance of anterior previa
Presenting part may overshadow posterior previa
Transvaginal scan can locate placental edge and internal os Treatment – Placenta Previa
With no active bleeding
Expectant management
No intercourse, digital exams With late pregnancy bleeding
Assess overall status, circulatory stability
Full dose Rhogam if Rh-
Consider maternal transfer if premature
May need corticosteroids, tocolysis, amniocentesis Double Set-Up Exam
Appropriate only in marginal previa with vertex presentation Palpation of placental edge and fetal head with set up for immediate surgery Cesarean delivery under regional anesthesia if: Complete previa Fetal head not engaged Non-reassuring tracing Brisk or persistent bleeding Mature fetus
Placental Abruption
Premature separation of placenta from uterine wall
Partial or complete
“Marginal sinus separation” or “marginal sinus rupture”
Bleeding, but abnormal implantation or abruption never established Epidemiology of Abruption
Occurs in 1-2% of pregnancies Risk factors Hypertensive diseases of pregnancy Smoking or substance abuse (e.g. cocaine) Trauma Overdistention of the uterus History of previous abruption Unexplained elevation of MSAFP Placental insufficiency Maternal thrombophilia/metabolic abnormalities Abruption and Trauma
Can occur with blunt abdominal trauma and rapid deceleration without direct trauma
Complications include prematurity, growth restriction, stillbirth
Fetal evaluation after trauma
Increased use of FHR monitoring may decrease mortality Bleeding from Abruption
Externalized hemorrhage
Bloody amniotic fluid
Retroplacental clot
20% occult
“uteroplacental apoplexy” or “Couvelaire” uterus
Look for consumptive coagulopathy Patient History - Abruption
Pain = hallmark symptom Varies from mild cramping to severe pain Back pain – think posterior abruption Bleeding May not reflect amount of blood loss Differentiate from exuberant bloody show Trauma Other risk factors (e.g. hypertension) Membrane rupture Physical Exam - Abruption
Signs of circulatory instability Mild tachycardia normal Signs and symptoms of shock represent >30% blood loss Maternal abdomen Fundal height Leopold’s: estimated fetal weight, fetal lie Location of tenderness Tetanic contractions Ultrasound - Abruption
Abruption is a clinical diagnosis!
Placental location and appearance
Retroplacental echolucency
Abnormal thickening of placenta
“Torn” edge of placenta
Fetal lie
Estimated fetal weight Laboratory - Abruption
Complete blood count
Type and Rh
Coagulation tests + “Clot test”
Kleihauer-Betke not diagnostic, but useful to determine Rhogam dose
Preeclampsia labs, if indicated
Consider urine drug screen Sher’s Classification - Abruption mild, often retroplacental Grade I clot identified at delivery tense, tender abdomen and Grade II live fetus
Grade III with fetal demise
III A - without coagulopathy (2/3)
III B - with coagulopathy (1/3) Treatment – Grade II Abruption
Assess fetal and maternal stability
Amniotomy
IUPC to detect elevated uterine tone
Expeditious operative or vaginal delivery
Maintain urine output > 30 cc/hr and hematocrit > 30%
Prepare for neonatal resuscitation
Treatment – Grade III Abruption
Assess mother for hemodynamic and coagulation status
Vigorous replacement of fluid and blood products
Vaginal delivery preferred, unless severe hemorrhage Coagulopathy with Abruption
Occurs in 1/3 of Grade III abruption
Usually not seen if live fetus
Etiologies: consumption, DIC
Administer platelets, FFP
Give Factor VIII if severe Epidemiology of Uterine Rupture
Occult dehiscence vs. symptomatic rupture
0.03 – 0.08% of all women
0.3 – 1.7% of women with uterine scar
Previous cesarean incision most common reason for scar disruption
Other causes: previous uterine curettage or perforation, inappropriate oxytocin usage, trauma Risk Factors – Uterine Rupture
Previous uterine surgery Adenomyosis Congenital uterine Fetal anomaly anomaly Uterine overdistension Vigorous uterine pressure Gestational trophoblastic Difficult placental neoplasia removal
Placenta increta or percreta Morbidity with Uterine Rupture
Maternal Hemorrhage with anemia Bladder rupture Hysterectomy Maternal death Fetal Respiratory distress Hypoxia Acidemia Neonatal death Patient History – Uterine Rupture
Vaginal bleeding Pain Cessation of contractions Absence of FHR Loss of station Palpable fetal parts through maternal abdomen Profound maternal tachycardia and hypotension Uterine Rupture
Sudden deterioration of FHR pattern is most frequent finding Placenta may play a role in uterine rupture Transvaginal ultrasound to evaluate uterine wall MRI to confirm possible placenta accreta Treatment Asymptomatic scar disruption – expectant management Symptomatic rupture – emergent cesarean delivery Vasa Previa
Rarest cause of hemorrhage Onset with membrane rupture Blood loss is fetal, with 50% mortality Seen with low-lying placenta, velamentous insertion of the cord or succenturiate lobe Antepartum diagnosis Amnioscopy Color doppler ultrasound Palpate vessels during vaginal examination Diagnostic Tests – Vasa Previa
Apt test – based on colorimetric response of fetal hemoglobin
Wright stain of vaginal blood – for nucleated RBCs
Kleihauer-Betke test – 2 hours delay prohibits its use Management – Vasa Previa
Immediate cesarean delivery if fetal heart rate is non- reassuring
Administer normal saline 10 – 20 cc/kg bolus to newborn, if found to be in shock after delivery Summary
Late pregnancy bleeding may herald diagnoses with significant morbidity/mortality
Determining diagnosis important, as treatment dependent on cause
Avoid vaginal exam when placental location not known
Vasa previa
SECOND AND THIRD TRIMESTER BLEEDING — Vaginal bleeding is less common in the second and third trimesters. The major causes of bleeding at these times are:
Bloody show associated with cervical insufficiency or labor Placenta previa Abruptio placenta Uterine rupture Vasa previa
Placenta previa
INTRODUCTION — Placenta previa refers to the presence of placental tissue that extends over or lies proximate to the internal cervical os. Sequelae include the potential for severe bleeding and preterm birth, as well as the need for cesarean delivery. Placenta previa should be suspected in any woman beyond 20 weeks of gestation who presents with painless vaginal bleeding. For women who have not had a second trimester ultrasound examination, antepartum bleeding after 20 weeks of gestation should prompt sonographic determination of placental location before digital vaginal examination is performed because palpation of the placenta can cause severe hemorrhage.
PREVALENCE AND RISK FACTORS
Purported risk factors, some of which are interdependent, include [ 2-12 ]:
Previous placenta previa
Previous cesarean delivery
Multiple gestation
Multiparity
Advanced maternal age
Infertility treatment
Previous abortion
Previous intrauterine surgical procedure
Maternal smoking
Maternal cocaine use
Male fetus
Non-white race
PATHOGENESIS
— The pathogenesis of placenta previa is unknown. One hypothesis is that the presence of areas of suboptimal endometrium in the upper uterine cavity due to previous surgery or pregnancies promotes implantation of trophoblast in, or unidirectional growth of trophoblast toward, the lower uterine cavity [ 1,2,13 ]. Another hypothesis is that a particularly large placental surface area, as in multiple gestation or in response to reduced uteroplacental perfusion, increases the likelihood that the placenta will cover or encroach upon the cervical os. PATHOPHYSIOLOGY
— Placental bleeding is thought to occur when gradual changes in the cervix and lower uterine segment apply shearing forces to the inelastic placental attachment site, resulting in partial detachment. Vaginal examination or coitus can also disrupt the intervillous space and cause bleeding. Bleeding is primarily maternal, but fetal bleeding can occur if a fetal vessel is disrupted. CLINICAL FEATURES
Ultrasound presentation and course
Bleeding
Associated conditions
Placenta accreta —1 to 5 percent of pregnancies with placenta previa and an unscarred uterus.
one previous cesarean birth (11 to 25 percent)
, two previous cesarean births (35 to 47 percent),
three previous cesarean births (40 percent),
and ≥four previous cesarean births (50 to 67 percent) [ 35-37 ].
Preterm labor and rupture of the membranes
Malpresentation Intrauterine growth restriction
Vasa previa and velamentous umbilical cord
Congenital anomalies
Amniotic fluid embolism DIAGNOSIS
— Placenta previa should be suspected in any woman beyond 20 weeks of gestation who presents with vaginal bleeding. For women who have not had a second or third trimester ultrasound examination, antepartum bleeding should prompt sonographic determination of placental location before digital vaginal examination is performed because palpation of the placenta can cause severe hemorrhage.
The diagnosis of placenta previa is based on identification of placental tissue covering or proximate to the internal cervical os on an imaging study, typically ultrasound. Transabdominal ultrasound examination is performed as the initial examination; if it shows placenta previa or the findings are uncertain, transvaginal sonography should be performed to better define placental position.
Ultrasonography
Transabdominal — Transabdominal ultrasonography is used for initial placental localization requires the identification of echogenic homogeneous placental tissue covering or proximate to the internal cervical os (a distance greater than 2 cm from the os excludes the diagnosis of previa). Sagittal, parasagittal, and transverse sonographic views should be obtained with the patient's bladder partially full.
Specific points that should be appreciated when performing sonographic examination for placenta previa include:
An over-distended bladder can compress the anterior lower uterine segment against the posterior lower uterine segment to give the appearance of a previa ( image 1 ). The diagnosis of placenta previa should not be made without confirming placental position after the patient has emptied her bladder. Care should be taken to not make the diagnosis of placenta previa when the lower uterine segment is contracting, which commonly occurs after a woman empties her bladder.
A previa can be missed near term if the fetal head is low in the pelvis since acoustic shadowing from or compression of placental tissue by the fetal skull may obscure the placental location. In these cases, the cervix may be better visualized by placing the patient in Trendelenburg position and/or gently pushing the fetal head cephalad.
The sonographic diagnosis of a complete central previa is readily made since the placenta is centered over the cervix and placental tissue is imaged anterior and posterior to the cervix. Complete noncentral previas, particularly when lateral, are more difficult to confirm. Transverse views at and above the internal cervical os should facilitate an accurate diagnosis.
The placental location may also be obscured by a hematoma or a lower uterine segment contraction.
Transvaginal
— Randomized trials and prospective comparative studies have established the superior performance of transvaginal sonography (TVS) over transabdominal sonography for diagnosis of placenta previa [ 39,53,54 ]. Transabdominal ultrasound examination is performed as the initial examination; if it shows placenta previa or the findings are uncertain, TVS should be performed to better define placental position. TVS generally provides a clearer image of the relationship of the edge of the placenta to the internal cervical os than transabdominal ultrasound. In one study of 100 suspected cases, sensitivity, specificity, and positive and negative predictive values of TVS for diagnosis of placenta previa were 87.5, 98.8, 93.3, 97.6 percent, respectively [ 55 ].
TVS can be performed safely in patients with previa since the optimal position of the vaginal probe for visualization of the internal os is 2 to 3 cm away from the cervix and the angle between the cervix and vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervical canal [ 56 ].
Translabial (transperineal) ultrasound imaging is an alternative technique that provides excellent images of the cervix and placenta [ 57 ]. The use of three-dimensional (3D) ultrasound may also improve accuracy [ 58 ]
Complete placenta previa — The placenta completely covers the internal os ( image 2 ). A central placenta previa occurs when the internal os is approximately equidistant between the anterior and posterior edges of the placenta (20 to 30 percent of cases).
Partial placenta previa — The placental edge appears to cover part, but not all, of the internal cervical os.
Marginal placenta previa — The placental edge is adjacent to or at the margin of the internal os, but does not cover it ( image 3 ).
Low placenta — Low placentas are associated with an increased risk of bleeding, and possibly other adverse perinatal outcomes, but the risk is less than with true placenta previas [ 60,61 ].
An apparent placenta previa in the second trimester, or
A placenta that lies in the lower uterine segment, but the exact relationship of the placenta to the os has not been determined, or
A placental edge in close proximity to the internal os. There is no universal standard; a common definition is a placental edge >0 but <2 cm from the os.
SUMMARY AND RECOMMENDATIONS
Placenta previa should be suspected in any woman beyond 20 weeks of gestation who presents with painless vaginal bleeding. For women who have not had a second trimester ultrasound examination, antepartum bleeding after 20 weeks of gestation should prompt sonographic determination of placental location before digital vaginal examination is performed because palpation of the placenta can cause severe hemorrhage.
Previous placenta previa, previous cesarean deliveries, and multiple gestation are major risk factors for placenta previa
The distance from the placental edge to the internal cervical os is the best predictor of placenta previa at delivery, but available data correlating gestational age, millimeters of extension over the cervical os, and outcome are insufficient to make precise predictions
The characteristic clinical presentation is painless vaginal bleeding, which occurs in 70 to 80 percent of cases. An additional 10 to 20 percent of women present with both uterine contractions and bleeding, which is similar to the presentation of abruptio placenta. In approximately one-third of affected pregnancies, the initial bleeding episode occurs prior to 30 weeks of gestation.
Some conditions that may be associated with placenta previa include placenta accreta, malpresentation, preterm labor or premature rupture of the membranes, vasa previa and velamentous insertion of the umbilical cordThe diagnosis of placenta previa is based upon identification of placental tissue covering or proximate to the internal cervical os on transvaginal ultrasound examination Placental abruption
Placental abruption (also called abruptio placentae) refers to bleeding at the decidual-placental interface that causes partial or total placental detachment prior to delivery of the fetus.
The diagnosis is typically reserved for pregnancies over 20 weeks of gestation. The major clinical findings are vaginal bleeding and abdominal pain, often accompanied by hypertonic uterine contractions, uterine tenderness, and a nonreassuring fetal heart rate (FHR) pattern.
Abruption is a significant cause of maternal and perinatal morbidity, and perinatal mortality. The perinatal death rate is approximately 12 percent (versus 0.6 percent in non-abruption births) [ 1 ].
The majority of perinatal deaths (up to 77 percent) occur in utero; deaths in the postnatal period are primarily related to preterm delivery [ 1-4 ]. However, perinatal mortality associated with abruption appears to be decreasing [ 1 ].
INCIDENCE
— Placental abruption complicates 0.4 to 1 percent of pregnancies [ 5-7 ]. In one review, 40 to 60 percent of abruptions occurred before 37 weeks of gestation 14 percent occurred before 32 weeks [ 6 ]. gestational age-specific incidence rates vary considerably depending on the etiology [ 9,10 ]. The production of thrombin can lead to the following clinical sequelae:
Uterine hypertonus and contractions, as thrombin is a potent, direct uterotonic agent [ 25 ].
Enhanced expression of matrix metalloproteinases [ 23 ], up-regulation of genes involved in apoptosis [ 24 ], and induced expression of inflammatory cytokines (predominantly interleukin-8), leading to tissue necrosis and degradation of extracellular matrix [ 24,26,27 ]. A vicious cycle then ensues, resulting in further vascular disruption, and often leading to initiation of labor and rupture of membranes ( algorithm 1 ).
In women with premature rupture of membranes, the risk of placental abruption increases with increasing latency, which suggests that inflammation subsequent to membrane rupture can induce rather than result from the cascade of events leading to placental separation [ 28-32 ].
Triggering of coagulation. If a massive amount of tissue factor (thromboplastin) is released, a massive amount of thrombin is generated and enters the maternal circulation over a brief period of time [ 33 ]. This overwhelms hemostatic control mechanisms, without allowing sufficient time for recovery of compensatory mechanisms. The clinical consequence is a profound systemic bleeding diathesis and, due to widespread intravascular fibrin deposition, ischemic tissue injury and microangiopathic hemolytic anemia (ie, disseminated intravascular coagulation [DIC]).
Functional progesterone withdrawal by reduced expression of progesterone receptors in decidual cells, which initiates or contributes to uterine contractility [ 34 ].
Risk factors — The major risk factors for placental abruption in singleton and twin gestations are described in the table ( table 1 ) [ 5 ]. Smoking is one of the few modifiable risk factors for abruption: it is associated with a 2.5-fold increased risk of abruption severe enough to result in fetal death and the risk increases by 40 percent for each pack per day smoked [ 35 ]. The combination of cigarette smoking and hypertension has a synergistic effect on risk of abruption [ 36 ]. Hypertensive women have a five-fold increased risk of severe abruption compared to normotensive women, and antihypertensive therapy does not appear to reduce the risk of placental abruption among women with chronic hypertension [ 37 ].
Two studies have reported an increased risk of abruption in women with elevated thyroperoxidase antibodies in early pregnancy [ 38,39 ]. However, most women with abruption do not have these antibodies, a positive value is not highly predictive of abruption, and there is no evidence that treatment will reduce the risk of abruption.
A modest increase in the risk of abruption has also been noted in women with asthma (adjusted OR 1.22, 95% CI 1.09-1.36) [ 40 ].
Prior to 20 weeks of gestation
Evaluation — The evaluation of pregnant women with vaginal bleeding prior to 20 weeks is similar to that in the first trimester (see above); however, ectopic pregnancy is less of a concern because over 95 percent of ectopic pregnancies occur in the fallopian tube and virtually all tubal ectopic pregnancies will have been diagnosed by this time. Although abdominal, heterotopic, cervical, cornual, and cesarean scar ectopic pregnancies often present at more advanced gestations than tubal ectopics, these types of ectopic pregnancy are rare.
The first step in the evaluation is to determine the extent of bleeding and whether bleeding is accompanied by pain. The presence of only light, intermittent, painless bleeding suggests bloody show from cervical insufficiency, a small marginal placental separation, or a cervical or vaginal lesion (eg, polyp, infection, cancer). Heavier bleeding, particularly when associated with pain, is more consistent with impending miscarriage or a larger placental separation (ie, abruption).
As discussed above, loss of a previously detected fetal heart beat should raise suspicion that fetal demise has occurred, but inability to detect the fetal heart by Doppler is subject to physician error and should always be confirmed by ultrasound examination. On the other hand, Doppler confirmation of fetal cardiac activity is reassuring.
An abdominal examination is performed to assess for pain or other abnormalities and uterine size. At 16 weeks of gestation, the uterine fundus is palpable about midway between the symphysis pubis and umbilicus, while at 20 weeks it is palpable at about the level of the umbilicus. After the abdominal examination, the patient is placed in the lithotomy position. The external genitalia are examined and then a speculum is inserted into the vagina. As discussed above, physical examination may reveal a nonpregnancy-related source of bleeding, such as cervical ectropion, an abnormal growth, a laceration, or sanguinous-purulent discharge.
Direct visualization of a dilated cervix or fetal membranes may be sufficient to diagnose impending miscarriage if contractions are present, or cervical insufficiency in the absence of contractions.
Transvaginal ultrasonography is also the cornerstone in the evaluation of bleeding in the second trimester. The primary goals are to determine whether the placenta is covering the cervical os (placenta previa), whether there is evidence of decidual hemorrhage causing placental separation (ie, abruptio placenta), and whether the cervix shows signs suggestive of cervical insufficiency (short length, dilated internal os, funneling of the fetal membranes). (See "Transvaginal ultrasound assessment of the cervix and prediction of spontaneous preterm birth" and "Cervical insufficiency" .)
Differential diagnosis
Miscarriage (see 'Threatened miscarriage' above and 'Inevitable miscarriage' above and 'Complete and incomplete miscarriage' above and 'Missed abortion' above)
Cervical, vaginal, or uterine pathology (see 'Vaginitis, trauma, cancer, warts, polyps, fibroids' above)
Cervical insufficiency — The diagnosis of cervical insufficiency is clinical; the classic presentation is cervical dilatation and effacement in the second trimester with fetal membranes visible at or beyond the external os in the absence of contractions. It may be asymptomatic or associated with one or more of the following: vaginal fullness or pressure; vaginal spotting or bleeding; an increased volume of watery, mucousy, or brown vaginal discharge; and vague discomfort in the lower abdomen or back. Sonographic findings of a short cervix, dilated internal cervical os, and/or funneling support the diagnosis. (See "Cervical insufficiency" .)
Abruption — Bleeding and cramping are the signs and symptoms of placental separation due to hemorrhage into the decidual basalis. The diagnosis is one of exclusion since placental separation usually cannot be visualized on ultrasound examination. The presence of a subchorionic hematoma or placenta that covers the internal cervical os supports the diagnosis. (See "Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation", section on 'Ultrasonography' .)
Ectopic pregnancy — Ectopic pregnancy is rare at this gestational age. When an ectopic pregnancy is diagnosed after the first trimester, the location is likely to be nontubal (abdominal, cervical, cesarean scar, or cornual) or heterotopic (ie, coexistent intrauterine and extrauterine pregnancies). (See "Abdominal pregnancy, cesarean scar pregnancy, and heterotopic pregnancy" and "Cervical pregnancy" .)
Bleeding after 20 weeks of gestation — The term antepartum hemorrhage typically refers to uterine bleeding after 20 weeks of gestation that is unrelated to labor and delivery. Antepartum hemorrhage complicates 4 to 5 percent of pregnancies. The major causes are:
Placenta previa (20 percent)
Abruptio placenta (30 percent)
Uterine rupture (rare)
Vasa previa (rare)
Evaluation — In contrast to bleeding in the first half of pregnancy, digital examination of the cervix SHOULD BE AVOIDED in women presenting with bleeding in the second half of pregnancy until placenta previa has been excluded. Digital examination of a placenta previa can cause immediate, severe hemorrhage.
Differential diagnosis
Placenta previa — Placenta previa should be suspected in any woman who presents with vaginal bleeding in the second half of pregnancy. Classically, the absence of abdominal pain and uterine contractions was considered the clinical feature that distinguished between placenta previa and abruptio placenta, which is the other major cause of vaginal bleeding at this time. However, some women with placenta previa have uterine contractions in addition to bleeding; thus, the diagnosis of placenta previa must be determined by sonographic examination. (See "Clinical features, diagnosis, and course of placenta previa" .)
Abruptio placenta — Abruptio placenta refers to premature separation of a normally implanted placenta prior to delivery of the infant. The most common risk factors include prior placental abruption, trauma, smoking, cocaine use, hypertension, and preterm premature rupture of the membranes.
Clinically, placental abruption typically presents with vaginal bleeding (80 percent), uterine tenderness (70 percent), and uterine contractions (35 percent), with or without nonreassuring fetal testing. Uterine tenderness is caused by extravasation of blood into the myometrium (called a Couvelaire uterus when the blood penetrates all the way through the myometrium to the peritoneal cavity). The amount of vaginal bleeding may not be a reliable indicator of the severity of the hemorrhage since bleeding may be concealed (retained in the uterine cavity). Ultrasound may show placental separation, but this is uncommon (only 2 percent of abruptions can be visualized on ultrasound); the major purpose of ultrasound examination is to exclude placenta previa. Abruption ranges from mild to severe (life threatening) and may be acute or chronic. (See "Placental abruption: Clinical features and diagnosis" .)
The possibility of abruption should always be considered in women who are being evaluated for trauma (eg, motor vehicle crash, fall, domestic violence). (See "Trauma in pregnancy", section on 'Abruptio placentae' .)
Uterine rupture and vasa previa — Uterine rupture and vasa previa are rare causes of vaginal bleeding, and occur more often intrapartum than antepartum. Both may lead to fetal death. (See "Velamentous umbilical cord insertion and vasa previa" and "Choosing the route of delivery after cesarean birth" .)
Cervical, vaginal, or uterine pathology (see 'Vaginitis, trauma, cancer, warts, polyps, fibroids' above)
Prognosis — As with first trimester bleeding, episodes of second and third trimester bleeding are also associated with adverse pregnancy outcome, primarily preterm birth [ 22-24 ]. (See "Risk factors for preterm labor and delivery", section on 'Vaginal bleeding' .)
The risk of adverse outcome appears to depend on the degree of bleeding (worse outcome with heavier bleeding) and the cause (worse outcome with bleeding from nonprevia source) [ 25 ].
MANAGEMENT — The management of pregnant women with vaginal bleeding depends on the numerous factors, including the gestational age, the cause of bleeding, the severity of bleeding, and fetal status. Management is discussed in the individual topic reviews on the specific causes of vaginal bleeding. INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5 th to 6 th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to- read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
Basics topics (see "Patient information: Threatened miscarriage (The Basics)" )
SUMMARY AND RECOMMENDATIONS The clinician typically makes a provisional clinical diagnosis of the cause of vaginal bleeding based upon the patient's gestational age and the character of her bleeding (light or heavy, associated with pain or painless, intermittent or constant). Laboratory and imaging tests are then used to confirm or revise the initial diagnosis. (See 'Introduction' above.)
The four major causes of bleeding in early pregnancy are: ectopic pregnancy; threatened or impending miscarriage; physiologic (ie, related to implantation of the pregnancy), and cervical, vaginal, or uterine pathology. Transvaginal ultrasonography is the cornerstone of the evaluation of bleeding in early pregnancy. (See 'First trimester bleeding' above.)
An important goal in the evaluation of women with bleeding in early pregnancy is to exclude the possibility of ectopic pregnancy, since ruptured ectopic pregnancies can result in severe hemorrhage and death. (See 'Ectopic pregnancy' above.)
The major causes of bleeding in the second and third trimesters are: bloody show associated with cervical insufficiency or labor; placenta previa; abruptio placenta; and rarely uterine rupture or vasa previa. (See 'Second and third trimester bleeding' above.)
Digital examination of the cervix should be avoided in women presenting with bleeding in the second half of pregnancy until placenta previa has been excluded because digital examination of a placenta previa can cause immediate, severe hemorrhage. (See 'Bleeding after 20 weeks of gestation' above.)
For women with uterine bleeding who are Rh(D)-negative, we recommend anti-D immune globulin to protect against Rh(D) alloimmunization ( Grade 1B ). (See "Prevention of Rh(D) alloimmunization" .)
Treatment of disseminated intravascular coagulation — In women with DIC, we transfuse blood and blood products to achieve the following minimum levels:
Platelet count ≥50,000/microL
Fibrinogen ≥100 mg/dL
Prothrombin (PT) and partial thromboplastin time (PTT) less than 1.5 times control
Hematocrit 25 to 30 percent
The following actions potentially severe acute abruption:
Immediately initiate continuous fetal monitoring.
Secure intravenous access one, and preferably two, wide-bore intravenous lines. Closely monitor the mother's hemodynamic status (heart rate, blood pressure, urine output). Urine output should be maintained at above 30 mL/hour and monitored with a Foley catheter. Assessment of multiple parameters is important because normal blood pressure may mask hypovolemia if the mother was hypertensive/preeclamptic prior to the abruption.
Keep maternal oxygen saturation >95 percent and keep the patient warm.
Estimate the extent of blood loss by collection in a volumetric container and/or by weighing pads/towels used to absorb vaginal bleeding. In addition to the practical difficulties in determining the volume of blood passed from the vagina, actual blood loss may be far in excess of what is observed due to retd retroplacental hemorrhage.
Draw blood for a complete blood count, blood type and Rh, and coagulation studies. A crude clotting test can be performed at the bedside by placing 5 mL of the patient's blood in a tube with no anticoagulant for 10 minutes . Failure to clot within this time or dissolution of an initial clot implies impairment of coagulation, and is suggestive of a low fibrinogen level. Prolonged oozing from needle puncture sites also suggests coagulopathy.
Notify the blood bank so blood replacement products (red blood cells, fresh frozen plasma, cryoprecipitate, platelets) will be readily available, if needed. Blood products should be replaced aggressively, as required. If disseminated intravascular coagulation (DIC) is suspected, activate the institution’s massive transfusion protocol.
Notify the anesthesia team. Anesthesia-related issues in these patients include management of hemodynamic instability, technical issues related to bleeding diathesis, and the potential need for emergency cesarean delivery.
Treatment of disseminated intravascular coagulation — In women with DIC, we transfuse blood and blood products to achieve the following minimum levels: Platelet count ≥50,000/microL Fibrinogen ≥100 mg/dL Prothrombin (PT) and partial thromboplastin time (PTT) less than 1.5 times control Hematocrit 25 to 30 percent
Severe abruption at any gestational age and nonsevere abruption at >36 weeks — We recommend expeditious delivery for pregnancies at any gestational age complicated by severe abruption, which can be defined as an abruption where the mother is unstable (eg, significant coagulopathy, hypotension, and/or ongoing major blood loss) or the fetal heart rate tracing is nonreassuring. We also recommend delivery for pregnancies with nonsevere abruption at ≥36 weeks of gestation [ 1 ]. For nonsevere abruptions a