BLEEDING DURING THE THIRD

TRIMESTER
 CAUSES OF BLEEDING DURING THE
THIRD TRIMESTER

• Bloody Show • Abruptio Placentae

• Having an intercourse • Placenta Previa
• An internal exam • Preterm Labor
• Disease or infections of • Uterine Rupture
the vagina or cervix • Vasa Previa
• Uterine fibroids or
cervical growths or
polyps
 BLOODY SHOW

• a sign that labor is starting.

• most common cause of bleeding during late
pregnancy
• heralds onset of labor, is scant and mixed with
mucus, and results from tearing of small veins as
the cervix dilates and effaces at the start of labor.
 ABRUPTIO PLACENTAE

• Definition: premature separation of a normally implanted

placenta from the uterine wall
• Related Factors: Hypertension, blunt force trauma,
cocaine use, previous abruption
• Symptoms: Sharp Abdominal Pain, firm and tender uterus,
vaginal bleeding, signs of maternal shock, fetal distress
• FHT: Bradycardia, late decelerations
 ABRUPTIO PLACENTAE

• Difficult to pick up on sono, but done to rule out vasa previa

• Cautions: Disseminated intravascular coagulation associated
with condition
• Management:
• Maternal/fetal jeopardy – Emergent C-section
• Term and Stable – Vaginal Delivery
• Preterm and Stable – Admit and Observe
 PLACENTA PREVIA

• Definition: common condition in which the placenta lies in the

lower segment of the Uterus
• As the lower segment begins to stretch at 28 weeks, the placenta
may avulse from the uterine wall resulting the bleeding.
• Related Factors: Previous placenta previa, Multiple gestation,
Artificial Reproductive Techniques
• Symptoms: Painless bleeding from the vagina at the beginning
of cervical dilation, bright red
 PLACENTA PREVIA

• Types
• Marginal (placenta is in lower segment, but not
at cervical os)
• Partial (placenta partially covers cervical os)
• Complete (placenta completely covers cervical
os)
 PLACENTA PREVIA

• Presentation: Painless uterine bleeding; dx on sono

• Cautions: No vaginal examinations to minimize placental trauma
• Management: DO NOT DO A VAGINAL EXAM
• Maternal/fetal jeopardy – Emergent C-section
• Term and marginal os > 2cm – Vaginal Delivery
• Preterm and Stable – Admit and Observe, deliver at 36 weeks
• Term and Stable; <2cm – Scheduled C-section
 PRETERM LABOR

• Many possible etiologic factors such as trauma, substance

abuse, pregnancy induced hypertension or cervicitis;
increased chance in multiple gestation, maternal illness
• Symptoms: Show (pink-stained vaginal discharge)
accompanied by uterine contractions becoming regular and
effective
• Preterm labor may be halted if the cervix is less than 4 cm
dilated and the membranes are intact. Corticosteroids are
administered to aid fetal lung maturity.
 UTERINE RUPTURE

• Definition: complete separation of the wall of the uterus

• Most commonly associated with uterine scarring from a
classical (vertical) caesarean incision
• Related Factors: Uterine Scarring, hx myomectomy,
excessive uterine stimulation, uterine anomalies, hx
invasive molar pregnancy, hx placenta perceta/increta,
malpresention, fetal anomaly, cocaine abuse
 UTERINE RUPTURE

• Symptoms: Tearing uterine pain, “popping sensation”,

painful late pregnancy bleeding, cessation or
abnormalities of contractions, loss of fetal sensation
• Most reliable sx of the uterine rupture is fetal
distress (late decels)
• Management:
• Emergent C-section with repair or hysterectomy
 VASA PREVIA

• Definition: very rare condition in which the fetal

placental vessels cross the internal cervical os
• Related Factors: Velamentous cord, accessory
(succenturiate) placental lobe, multiple gestation
• May easily be diagnosed via sonography w/ color
doppler
 VASA PREVIA

• Presentation: AROM > bright red painless

bleeding > fetal bradycardia
• Management:
• Emergent C-section
• Complications:
• Fetal death due to exsanguination
 SUMMARY

Bleeding Blood Dx Complications

Abruptio Painful Maternal Sono, FHT DIC, maternal
Placentae shock/death
Uterine Painful Maternal Loss of station, Hysterectomy
Rupture abnormal UCs,
FHT
Placenta Previa Painless Maternal Sono, FHT High risk fetal
death
Vasa Previa Painless Fetal Sono w/ doppler, Hysterectomy,
bright red blood, maternal
FHT shock/death
 MAJOR RISK FACTORS

• Uterine scarring - Abnormal placentation

• Multiple Gestation, ART - Placenta previa
• Classical incision, overstimulation - Uterine rupture
• Hypertension, trauma - Abruptio placentae
• Multiple gestation, succenturiate lobe, villametous cord -Vasa previa