Third Trimester Bleeding

CASE: 25yo G2P1 at 32 weeks is brought to the ED. An hour ago, she was watching tv when
she noticed a bright red gush of blood coming from her vaginal region. The bleeding was
heavy and soaked through her clothes and has continued to bleed since then. She had an
ultrasound at 14 weeks to confirm pregnancy but none since.
How would you evaluate the patient?
Assess maternal hemodynamic status
-vital signs
-heme studies to assess for acute anemia and DIC
Confirm placental location
-avoid digital cervical exam until placenta previa is excluded
-ultrasound to evaluate placental location
Differential?
-placental abruption
-placenta previa
-vasa previa
-genital lacerations and/or trauma
-cervical/vaginal cancer
-bloody show
Placental Abruption:
-separation of placenta from uterine wall due to hemorrhage into decidua
-accounts for 30% of 3rd trimester bleeding
-25% recurrence risk in a subsequent pregnancy
Clinical presentation:
-frequent contractions, painful vaginal bleeding & uterine tenderness
-non-reassuring fetal heart rate tracing
-low fibrinogen

Risk factors: HTN, cocaine

use, smoking, abdominal
trauma, sudden uterine
decompression (ROM)

Placenta previa:
-placental tissue is covering cervical os
-20% cases of 3rd trimester bleeding
Clinical presentation:
-painless vaginal bleeding & may occur after intercourse
-may present with contractions, thus ultrasound is critical to differentiate
from abruption
Vasa previa:
-fetal vessels of a velamentous cord insertion cover cervical os
-less than 1% of all pregnancies

Risk factors: prior

cesarean, myomectomy,
increased parity, multiple
gestations, advanced
maternal age

Risk factors: up to 11% in twins and up to 95% in triplets

Clinical presentation: painless vaginal bleeding in the absence of evidence of
placental previa or abruption
Bloody show/cervical insufficiency:
-small amount of blood with mucus discharge that may precede the onset of
labor by as much as 72 hours
cervical, vaginal, uterine pathology
non-tubal ectopic pregnancies
Initial treatment:
-continuously assess vitals and assess O2 sat. ABCs.
-establish IV access and resuscitation with crystalloids. May require blood if symptomatic or
coags are extremely low. Type and cross patient.
-Rhogam!!!

-monitor CBC, platelet counts, PT, PTT, fibrinogen

-if the fetus is mature, can deliver after mother is hemodynamically stable.
-cesarean delivery is required for all cases of previa and vasa previa