Post on 09-Jun-2018
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
Ruptured vasa previa
Uterine scar disruption
Cervical polyp
Bloody show
Cervicitis or cervical ectropion
Vaginal trauma
Cervical cancer
Life-Threatening
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
Grade I
Grade II
Grade III with fetal demise
III A - without coagulopathy (2/3)
III B - with coagulopathy (1/3)
mild, often retroplacental
clot identified at delivery tense, tender abdomen and
live fetus
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
anomaly
Fetal anomaly
Uterine overdistension Vigorous uterine
pressure
Gestational trophoblastic
neoplasia
Difficult placental
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
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,
]: 12 -2include [
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,
]. Another 13 ,2,1the lower uterine cavity [
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.
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),
]. 37 -35percent) [ 67 to 50 and ≥four previous cesarean births (
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
). The diagnosis of placenta 1 image lower uterine segment to give the appearance of a previa (
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
]. 54 ,53,39transabdominal sonography for diagnosis of placenta previa [
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,
]. 55 percent, respectively [ 97.6 , 93.3
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
]. 56 canal [
Translabial (transperineal) ultrasound imaging is an alternative technique
]. The use of 57 that provides excellent images of the cervix and placenta [
]58 D) ultrasound may also improve accuracy [ 3dimensional (-three
). 2 image The placenta completely covers the internal os ( —Complete placenta previa
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
). 3 image internal os, but does not cover it (
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
]. 61 ,60previas [
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
].1 births) [
The majority of perinatal deaths (up to 77 percent) occur in
utero; deaths in the postnatal period are primarily related to
]. However, perinatal mortality 4 -1preterm delivery [
]. 1 associated with abruption appears to be decreasing [
INCIDENCE
— Placental abruption complicates 0.4
]. 7 -5percent of pregnancies [ 1 to
In one review, 40 to 60 percent of
abruptions occurred before 37 weeks of
gestation
].6 weeks [ 32 percent occurred before 14
gestational age-specific incidence rates vary
considerably depending on the etiology [
].10 ,9
The production of thrombin can lead to the following
clinical sequelae:
Uterine hypertonus and contractions, as thrombin is a potent, direct uterotonic agent [
]. 25
regulation of genes involved -], up23 Enhanced expression of matrix metalloproteinases [
], and induced expression of inflammatory cytokines (predominantly 24 in apoptosis [
interleukin-8), leading to tissue necrosis and degradation of extracellular matrix [
]. A vicious cycle then ensues, resulting in further vascular disruption, and often 27 ,26,24
). 1 algorithm leading to initiation of labor and rupture of membranes (
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
]. 32 -28placental separation [
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
]. This overwhelms hemostatic control mechanisms, 33 over a brief period of time [
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
]. 34 decidual cells, which initiates or contributes to uterine contractility [
Risk factors — The major risk factors for placental abruption in ]. 5 ) [ 1 table singleton and twin gestations are described in the table (
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
]. The combination of cigarette smoking and 35 per day smoked [ ]. 36 hypertension has a synergistic effect on risk of abruption [
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 ]. 37 chronic hypertension [
Two studies have reported an increased risk of abruption in women with ]. 39 ,38antibodies in early pregnancy [ thyroperoxidaseelevated
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 ]. 40 ) [ 1.36-1.09% CI 95, 1.22with asthma (adjusted OR
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
"Transvaginal ultrasound assessment of the cervix fetal membranes). (See
.) "Cervical insufficiency" and and prediction of spontaneous preterm birth"
Differential diagnosis
above and 'Inevitable miscarriage' above and 'Threatened miscarriage' (see Miscarriage
above) 'Missed abortion' above and 'Complete and incomplete miscarriage'
'Vaginitis, trauma, cancer, warts, polyps, fibroids' (see Cervical, vaginal, or uterine pathology
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
"Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnosis. (See
.) 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
"Abdominal pregnancy, cesarean scar pregnancy, and and extrauterine pregnancies). (See
.) "Cervical pregnancy" and heterotopic 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
"Clinical features, diagnosis, determined by sonographic examination. (See
.) 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
.) "Placental abruption: Clinical features and diagnosis" chronic. (See
The possibility of abruption should always be considered in women who are being
"Trauma evaluated for trauma (eg, motor vehicle crash, fall, domestic violence). (See
.) 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
and "Velamentous umbilical cord insertion and vasa previa" to fetal death. (See
.) "Choosing the route of delivery after cesarean birth"
'Vaginitis, trauma, cancer, warts, polyps, (see Cervical, vaginal, or uterine pathology
above) fibroids'
Prognosis — As with first trimester bleeding, episodes of
second and third trimester bleeding are also associated
with adverse pregnancy outcome, primarily preterm
"Risk factors for preterm labor and ]. (See 24 -22birth [
.) 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
]. 25 from nonprevia source) [
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.)
"Patient information: Threatened miscarriage Basics topics (see
) (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
above.) 'Introduction'
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
above.) 'First trimester bleeding' of the evaluation of bleeding in early pregnancy. (See
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
above.) 'Ectopic pregnancy' result in severe hemorrhage and death. (See
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
above.) 'Second and third trimester bleeding' rarely uterine rupture or vasa previa. (See
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
above.) weeks of gestation' 20 'Bleeding after
For women with uterine bleeding who are Rh(D)-negative, we recommend anti-D
). (See B 1Grade immune globulin to protect against Rh(D) alloimmunization (
.) "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
]. For nonsevere 1 gestation [
abruptions a