Third Trimester

Bleeding
Whitney Brantley
Most Common Causes
● Labor
● Placenta previa
● Placenta abruption
● Uterine rupture
● Vasa previa
● Polyps, fibroids
 ● Also called “Bloody show” is a normal sign of

Labor ●
progression of labor
Cause: cervix which is highly vascular can
bleed easily as it dilates, so when it becomes
effaced or thin and the mucus plug falls out, it

vaginal discharge of mucus can be tinged with blood

● Associated symptoms: menstrual-like
(mucus plug) that is slightly cramping, mild, irregular/regular contractions,
bloody pressure in pelvis
● Management: maternal and fetal monitoring;
cervical exam to determine dilation,
effacement and station, expectant
management if candidate for admittance
○ Admit: >4-5cm dilated, >80% effaced
with contractions

Placenta previa
complete or partial covering of
the internal os of the cervix with
the placenta
● 90% of cases are found on US in 1st half of
●
pregnancy
Symptoms: painless vaginal bleeding in 2nd
or 3rd trimester
● Risk Factors: previous placenta previa,
previous c-section, multiple gestation,
advanced maternal age
○ Smoking, cocaine use, assisted reproductive
technology, history of suction and curettage
● Diagnostic tests: TVUS; speculum exam
● Management: scheduled c-section at 36-37
weeks if asymptomatic
○ Monitor inpatient for episodes of bleeding
○ Continuous bleeding should deliver via c-
section regardless of gestational age
● Complications: preterm birth, postpartum
hemorrhage, low birth weight, higher risk
for placenta accreta spectrum

Placenta abruption
Early separation of the placenta
from the lining of the uterus
● Symptoms: vaginal bleeding with abdominal
●
and/or back pain
Risk Factors: prior placenta abruption,
smoking, cocaine use, advanced maternal age,
HTN, multiparity, trauma
● Complications: hemorrhage, preterm birth,
low birth weight, stillbirth
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 Uterine rupture
Disruption of the uterine layers, leading to
changes in maternal or fetal status
● Symptoms: sudden onset of pain, vaginal
bleeding, loss of fetal station, abnormal
fetal heart rate (bradycardia)
● Risk Factors: previous c-section, TOLAC,
trauma
● Management: stabilize patient, emergent
c-section, perform repair vs hysterectomy
● Complications: transfusion related
complications, hysterectomy, maternal
death, fetal death
 Vasa previa ●
●
Usually found on US by second trimester
Symptoms: rapid bleeding following
rupture of membranes, leading to
maternal hypotension and fetal heart
fetal blood vessels present in rate abnormalities

the membranes covering the ● Risk Factors: velamentous umbilical cord

insertion, placenta previa, bilobed
internal cervical os ●
placenta, multiple gestation, IVF
Management:
○ Betamethasone at 28-32 weeks
○ Daily NSTs at 30-34 weeks
○ C-section at 34-35 weeks
● Complications: hemorrhage, preterm
delivery, fetal growth restrictions, fetal
distress
 Fibroids
benign neoplasms arising from
the myometrium of the uterus
● Symptoms: abnormal uterine bleeding,
pelvic or abdominal pressure,
●
bowel/bladder dysfunction
Risk Factors: nulliparity, early menarche,
Black race, age 40-50yrs, history of
dysmenorrhea, family history of fibroids
● Management: hysteroscopic
myomectomy, hysterectomy, uterine
artery embolization
● Complications: miscarriage, preterm
labor, fetal malpresentation
A 23-year-old G2P1 at 36 weeks gestation presents with her third episode of heavy vaginal
bleeding. She has normal prenatal labs and a known placenta previa. She denies uterine
contractions or abdominal pain and reports good fetal movement. Her vital signs are: BP
100/60, HR 110. She is afebrile. Her abdomen and uterus are non-tender. Fundal height
measures 35cm, and fetal heart tones reveal 140 beats/minute and are reassuring. Pelvic
ultrasound confirms a placenta previa, and the fetus is in the cephalic presentation.
Hematocrit is 29%. Which of the following is the most appropriate next step in the
management of this patient?

A. Tocolysis
B. Induction of labor
C. Cesarean delivery
D. Amniocentesis
E. Administer steroids
A 23-year-old G2P1 at 36 weeks gestation presents with her third episode of heavy vaginal
bleeding. She has normal prenatal labs and a known placenta previa. She denies uterine
contractions or abdominal pain and reports good fetal movement. Her vital signs are: BP
100/60, HR 110. She is afebrile. Her abdomen and uterus are non-tender. Fundal height
measures 35cm, and fetal heart tones reveal 140 beats/minute and are reassuring. Pelvic
ultrasound confirms a placenta previa, and the fetus is in the cephalic presentation.
Hematocrit is 29%. Which of the following is the most appropriate next step in the
management of this patient?

A. Tocolysis
B. Induction of labor
C. Cesarean delivery
D. Amniocentesis
E. Administer steroids
C) Cesarean delivery: This patient is near term with her third episode of active bleeding from
a known placenta previa. Although the patient is not yet term, delivery is appropriate due the
heavy bleeding near term. Cesarean delivery is always indicated when there is evidence of
placenta previa.

A) The patient is not experiencing contractions, so tocolysis is not necessary. Also, tocolytics
are contraindicated with heavy vaginal bleeding.

B) Vaginal delivery can cause catastrophic bleeding as the cervix dilates; therefore, cesarean
delivery is indicated.

D) Amniocentesis is not indicated as the mother is afebrile with a nontender uterus, and fetal
heart tones are reassuring.

E) Steroids is not indicated because the patient is >34 weeks and is needing urgent delivery.
A 28-year-old G2P1 at 36 weeks gestation presents in active labor. Her prior pregnancy was a
cesarean delivery for a breech presentation. Prenatal care and labs have been unremarkable.
Anatomy ultrasound showed a posterior placenta. Her vital signs are normal and she is
afebrile. Fundal height is 36cm. Cervical examination is 5cm, 100% effaced, and -2 station. At
the time of amniotomy, brisk vaginal bleeding is noted. Concomitantly there is fetal
tachycardia to 180 beats/minute followed by decelerations and bradycardia. What is the most
likely diagnosis that explains the bleeding in this patient?

A. Uterine rupture
B. Placental abruption
C. Placenta previa
D. Placenta accreta
E. Vasa previa
A 28-year-old G2P1 at 36 weeks gestation presents in active labor. Her prior pregnancy was a
cesarean delivery for a breech presentation. Prenatal care and labs have been unremarkable.
Anatomy ultrasound showed a posterior placenta. Her vital signs are normal and she is
afebrile. Fundal height is 36cm. Cervical examination is 5cm, 100% effaced, and -2 station. At
the time of amniotomy, brisk vaginal bleeding is noted. Concomitantly there is fetal
tachycardia to 180 beats/minute followed by decelerations and bradycardia. What is the
most likely diagnosis that explains the bleeding in this patient?

A. Uterine rupture
B. Placental abruption
C. Placenta previa
D. Placenta accreta
E. Vasa previa
E) This is the classic presentation for vasa previa. In this rare condition the umbilical cord
inserts into the membranes and the exposed vessels are over the cervix. Upon amniotomy,
there is an abrupt onset of bleeding from the fetal circulation and fetal tachycardia followed by
decelerations and bradycardia.

A) Risk of uterine rupture is low in a patient with one prior cesarean delivery. There was also no
mention of sudden onset of pain or loss of fetal station which are classic signs of uterine
rupture.

B) Risk of placenta abruption is low in this patient. Her prenatal care and labs have been
unremarkable, ruling out major risk factors such as hypertension, smoking, cocaine use.

C) This patient’s anatomy scan showed a posterior placenta, making placenta previa unlikely.

D) Placenta accreta is unlikely. Although this patient has a history of one prior cesarean delivery
the anatomy scan showed a posterior placenta. If not seen on ultrasound, clinical symptoms of
placenta accreta usually occur when attempting to separate the placenta from the uterus.
A 32-year-old G3P2 presents at 40 weeks gestation because of regular uterine contractions
every 5 minutes for the last two hours. Her prenatal course was unremarkable except for
ASCUS pap test with a negative test for high-risk HPV. She states that baby is moving, but she
has had bright red, bloody mucous discharge for the last 30 minutes. She does not believe she
has ruptured her membranes. Vital signs are: BP 120/70, HR 80, and afebrile. Her abdomen is
soft and she has regular contractions of moderate intensity. Fetal heart tones have a baseline
of 130 beats/minute. Pelvic ultrasound reveals a fundal placenta and cephalic presentation of
the fetus. Cervical examination is 5cm, 100% effaced. What is the source of the bleeding?

A. Placenta abruption
B. Cervical Cancer
C. Placenta previa
D. Bloody show
E. Cervicitis
A 32-year-old G3P2 presents at 40 weeks gestation because of regular uterine contractions
every 5 minutes for the last two hours. Her prenatal course was unremarkable except for
ASCUS pap test with a negative test for high-risk HPV. She states that baby is moving, but she
has had bright red, bloody mucous discharge for the last 30 minutes. She does not believe
she has ruptured her membranes. Vital signs are: BP 120/70, HR 80, and afebrile. Her abdomen
is soft and she has regular contractions of moderate intensity. Fetal heart tones have a baseline
of 130 beats/minute. Pelvic ultrasound reveals a fundal placenta and cephalic presentation of
the fetus. Cervical examination is 5cm, 100% effaced. What is the source of the bleeding?

A. Placenta abruption
B. Cervical Cancer
C. Placenta previa
D. Bloody show
E. Cervicitis
D) Bloody Show: During pregnancy, the cervix is extremely vascular, so with dilation a small
amount of bleeding may occur. This is called bloody show and is not of clinical significance
but a common symptom of normal labor.

A) Risk of placenta abruption is low in this patient. Her current vitals and prenatal care are
unremarkable, ruling out major risk factors such as hypertension, smoking, cocaine use.

B) Although her pap test was abnormal, the high-risk HPV typing was negative, making
cervical cancer unlikely.

C) Ultrasound showed fundal placenta, making placenta previa very unlikely.

E) Cervicitis is unlikely in this patient because her prenatal care was unremarkable and her
cervical exam did not note cervical discharge or friability at the cervical os.