Third trimester bleeding - Revision history

Danbot: Formatting: removed bold

2026-03-19T16:15:32Z

Formatting: removed bold

← Older revision		Revision as of 16:15, 19 March 2026
Line 61:		Line 61:
	==Evaluation==		==Evaluation==
	===Workup===		===Workup===
	*~~'''~~Primary survey and maternal stabilization~~'''~~		*Primary survey and maternal stabilization
	**ABCs; two large-bore IVs, crystalloid resuscitation<ref name="muench"/>		**ABCs; two large-bore IVs, crystalloid resuscitation<ref name="muench"/>
	**Continuous maternal vital sign monitoring		**Continuous maternal vital sign monitoring
	**Left lateral uterine displacement		**Left lateral uterine displacement
	*~~'''~~Laboratory studies~~'''~~		*Laboratory studies
	**CBC (serial hematocrit)		**CBC (serial hematocrit)
	**Type and crossmatch (or at minimum type and screen)		**Type and crossmatch (or at minimum type and screen)
Line 72:		Line 72:
	**Metabolic panel		**Metabolic panel
	**[[Kleihauer-Betke test]] — especially if Rh-negative to calculate RhoGAM dosing		**[[Kleihauer-Betke test]] — especially if Rh-negative to calculate RhoGAM dosing
	*~~'''~~Fetal assessment~~'''~~		*Fetal assessment
	**Continuous electronic fetal heart rate monitoring and tocometry		**Continuous electronic fetal heart rate monitoring and tocometry
	**Category III fetal heart rate tracings (absent variability with recurrent late/variable decelerations, bradycardia, or sinusoidal pattern) warrant emergent delivery		**Category III fetal heart rate tracings (absent variability with recurrent late/variable decelerations, bradycardia, or sinusoidal pattern) warrant emergent delivery
	*~~'''~~Imaging~~'''~~		*Imaging
	**Transabdominal ultrasound to assess:		**Transabdominal ultrasound to assess:
	***Placental location (rule out previa before any digital vaginal exam)		***Placental location (rule out previa before any digital vaginal exam)
Line 83:		Line 83:

	===Diagnosis===		===Diagnosis===
	*~~'''~~Placental abruption~~'''~~ is primarily a '''clinical diagnosis'''; ultrasound has poor sensitivity (25–50%) because acute hemorrhage may be isoechoic to placental tissue<ref name="brandt"/>		*Placental abruption is primarily a '''clinical diagnosis'''; ultrasound has poor sensitivity (25–50%) because acute hemorrhage may be isoechoic to placental tissue<ref name="brandt"/>
	*~~'''~~Placenta previa~~'''~~ is diagnosed on ultrasound (transabdominal or transvaginal)		*Placenta previa is diagnosed on ultrasound (transabdominal or transvaginal)
	*~~'''~~Vasa previa~~'''~~ is diagnosed by transvaginal ultrasound with color Doppler demonstrating fetal vessels over the internal os, confirmed with pulse-wave Doppler showing fetal heart rate waveform<ref name="oyelese"/>		*Vasa previa is diagnosed by transvaginal ultrasound with color Doppler demonstrating fetal vessels over the internal os, confirmed with pulse-wave Doppler showing fetal heart rate waveform<ref name="oyelese"/>
	*~~'''~~Uterine rupture~~'''~~ is a clinical diagnosis; ultrasound may show free fluid, abnormal fetal lie, or absent myometrium, but operative findings are often required for confirmation<ref name="patel"/>		*Uterine rupture is a clinical diagnosis; ultrasound may show free fluid, abnormal fetal lie, or absent myometrium, but operative findings are often required for confirmation<ref name="patel"/>
	*~~'''~~Apt test~~'''~~ (alkali denaturation test) can distinguish fetal from maternal blood when the source of bleeding is uncertain; fetal hemoglobin (HbF) resists alkali denaturation and remains pink, while adult hemoglobin (HbA) denatures and turns brown		*Apt test (alkali denaturation test) can distinguish fetal from maternal blood when the source of bleeding is uncertain; fetal hemoglobin (HbF) resists alkali denaturation and remains pink, while adult hemoglobin (HbA) denatures and turns brown

	====Critical Rule====		====Critical Rule====
Line 94:		Line 94:

	==Management==		==Management==
	*~~'''~~Resuscitation~~'''~~		*Resuscitation
	**IV access with two large-bore (16–18 gauge) catheters		**IV access with two large-bore (16–18 gauge) catheters
	**Aggressive crystalloid resuscitation; initiate massive transfusion protocol if hemodynamically unstable		**Aggressive crystalloid resuscitation; initiate massive transfusion protocol if hemodynamically unstable
	**Correct coagulopathy with blood products (pRBCs, FFP, cryoprecipitate, platelets) as indicated		**Correct coagulopathy with blood products (pRBCs, FFP, cryoprecipitate, platelets) as indicated
	*~~'''~~Rh immunoglobulin~~'''~~		*Rh immunoglobulin
	**Administer [[RhoGAM]] (300 mcg) to all Rh-negative mothers		**Administer [[RhoGAM]] (300 mcg) to all Rh-negative mothers
	**Additional doses guided by Kleihauer-Betke quantification		**Additional doses guided by Kleihauer-Betke quantification
	*~~'''~~Fetal monitoring~~'''~~		*Fetal monitoring
	**Continuous electronic fetal monitoring; ensure immediate operative delivery capability		**Continuous electronic fetal monitoring; ensure immediate operative delivery capability
	*~~'''~~Condition-specific management~~'''~~		*Condition-specific management
	**~~'''~~Placental abruption~~'''~~		**Placental abruption
	***Mild, with reassuring fetal status and preterm gestation: close inpatient observation, serial labs, consider antenatal corticosteroids if < 37 weeks		***Mild, with reassuring fetal status and preterm gestation: close inpatient observation, serial labs, consider antenatal corticosteroids if < 37 weeks
	***Moderate-to-severe abruption, maternal instability, or nonreassuring fetal status: emergent delivery<ref name="brandt"/>		***Moderate-to-severe abruption, maternal instability, or nonreassuring fetal status: emergent delivery<ref name="brandt"/>
	***If fetal demise has occurred, vaginal delivery is generally preferred to minimize maternal surgical morbidity<ref name="sakornbut"/>		***If fetal demise has occurred, vaginal delivery is generally preferred to minimize maternal surgical morbidity<ref name="sakornbut"/>
	***DIC: correct coagulopathy aggressively; target fibrinogen > 150–200 mg/dL		***DIC: correct coagulopathy aggressively; target fibrinogen > 150–200 mg/dL
	**~~'''~~Placenta previa~~'''~~		**Placenta previa
	***If stable, not actively hemorrhaging, and preterm: inpatient observation, antenatal corticosteroids, plan for cesarean delivery at 36–37 weeks<ref name="sakornbut"/>		***If stable, not actively hemorrhaging, and preterm: inpatient observation, antenatal corticosteroids, plan for cesarean delivery at 36–37 weeks<ref name="sakornbut"/>
	***Active hemorrhage or maternal/fetal instability: emergent cesarean delivery		***Active hemorrhage or maternal/fetal instability: emergent cesarean delivery
	***Tocolysis may be considered cautiously if preterm with contractions contributing to bleeding<ref name="sakornbut"/>		***Tocolysis may be considered cautiously if preterm with contractions contributing to bleeding<ref name="sakornbut"/>
	**~~'''~~Vasa previa~~'''~~		**Vasa previa
	***Known diagnosis: planned cesarean delivery at 34–37 weeks of gestation<ref name="smfm">Society for Maternal-Fetal Medicine (SMFM); Sinkey RG, Odibo AO, Dashe JS. #37: Diagnosis and management of vasa previa. ''Am J Obstet Gynecol''. 2015;213(5):615-619. PMID 26292048.</ref>		***Known diagnosis: planned cesarean delivery at 34–37 weeks of gestation<ref name="smfm">Society for Maternal-Fetal Medicine (SMFM); Sinkey RG, Odibo AO, Dashe JS. #37: Diagnosis and management of vasa previa. ''Am J Obstet Gynecol''. 2015;213(5):615-619. PMID 26292048.</ref>
	***Acute bleeding with rupture of fetal vessels: emergent cesarean delivery and preparation for neonatal transfusion		***Acute bleeding with rupture of fetal vessels: emergent cesarean delivery and preparation for neonatal transfusion
	**~~'''~~Uterine rupture~~'''~~		**Uterine rupture
	***Emergent cesarean delivery/laparotomy<ref name="patel"/>		***Emergent cesarean delivery/laparotomy<ref name="patel"/>
	***Uterine repair versus hysterectomy depending on extent of injury, hemodynamic stability, and future fertility desires		***Uterine repair versus hysterectomy depending on extent of injury, hemodynamic stability, and future fertility desires
	***Aggressive resuscitation and blood product administration		***Aggressive resuscitation and blood product administration
	*~~'''~~Antenatal corticosteroids~~'''~~		*Antenatal corticosteroids
	**Administer betamethasone or dexamethasone for fetal lung maturity if 23–36+6 weeks gestation and delivery is anticipated, but do not delay emergent delivery for steroid administration<ref name="gyamfi">Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period. ''Am J Obstet Gynecol''. 2018;218(1):B2-B8.</ref>		**Administer betamethasone or dexamethasone for fetal lung maturity if 23–36+6 weeks gestation and delivery is anticipated, but do not delay emergent delivery for steroid administration<ref name="gyamfi">Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period. ''Am J Obstet Gynecol''. 2018;218(1):B2-B8.</ref>
	*~~'''~~MgSO4 for neuroprotection~~'''~~		*MgSO4 for neuroprotection
	**Consider magnesium sulfate for fetal neuroprotection if < 32 weeks gestation and delivery is imminent		**Consider magnesium sulfate for fetal neuroprotection if < 32 weeks gestation and delivery is imminent

Ostermayer: Created page with "==Background== Third trimester bleeding (also termed antepartum hemorrhage) refers to vaginal bleeding occurring after 28 weeks gestational age through deliverySakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. ''Am Fam Physician''. 2007;75(8):1199-1206. Complicates 2–5% of all pregnancies *Is an obstetric emergency associated with significant maternal and fetal morbidity and mortalityGand..."

2026-03-12T15:18:00Z

Created page with "==Background== *Third trimester bleeding (also termed antepartum hemorrhage) refers to vaginal bleeding occurring after 28 weeks gestational age through delivery<ref name="sakornbut">Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. ''Am Fam Physician''. 2007;75(8):1199-1206.</ref> *Complicates 2–5% of all pregnancies<ref name="sakornbut"/> *Is an obstetric emergency associated with significant maternal and fetal morbidity and mortality<ref name="gandhi">Gand..."

New page

==Background==
*Third trimester bleeding (also termed antepartum hemorrhage) refers to vaginal bleeding occurring after 28 weeks gestational age through delivery<ref name="sakornbut">Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. ''Am Fam Physician''. 2007;75(8):1199-1206.</ref>
*Complicates 2–5% of all pregnancies<ref name="sakornbut"/>
*Is an obstetric emergency associated with significant maternal and fetal morbidity and mortality<ref name="gandhi">Gandhi M, Guo W. Prompt evaluation and treatment of third-trimester bleeding. ''Clin Obstet Gynecol''. 2020;63(4):751-760. PMID 33332831.</ref>
*The two most common causes — [[Placental Abruption|placental abruption]] and [[Placenta Previa|placenta previa]] — account for approximately half of all cases<ref name="gandhi"/>
*The remaining cases are attributable to less common etiologies (vasa previa, uterine rupture, cervical pathology) or remain unexplained
*The physiologic hypervolemia of pregnancy (30–50% increase in blood volume) may mask early signs of hemorrhagic shock, and clinicians should be aware that significant blood loss can occur before vital sign derangements appear<ref name="muench">Muench MV, Canterino JC. Vaginal bleeding in late pregnancy. ''Emerg Med Clin North Am''. 2019;37(2):251-264. PMID 30940370.</ref>

==Clinical Features==
===General===
*Vaginal bleeding — ranges from light spotting to massive hemorrhage; may be bright red, dark, or mixed with amniotic fluid
*Bleeding may be partially or completely concealed (e.g. in abruption)
*Abdominal or pelvic pain, uterine tenderness, or contractions may be present depending on etiology
*Signs of hemodynamic instability (tachycardia, hypotension, pallor, altered mental status) in severe cases
*Abnormal fetal heart rate patterns

===By Etiology===
====[[Placental Abruption]]====
*Most common cause of painful third trimester bleeding
*Classic triad: vaginal bleeding, abdominal/uterine pain, uterine contractions<ref name="brandt">Brandt JS, Ananth CV. Placental abruption at near-term and term gestations: pathophysiology, epidemiology, diagnosis, and management. ''Am J Obstet Gynecol''. 2023;228(5S):S1313-S1329. PMID 37164498.</ref>
*Uterus often tender and hypertonic ("woody" or "board-like")
*Concealed hemorrhage may present without vaginal bleeding but with pain, uterine irritability, and fetal distress<ref name="brandt"/>
*May be complicated by [[Disseminated intravascular coagulation|DIC]] in ~10% of cases (more common with fetal death)<ref name="sakornbut"/>
*Risk factors: hypertension/[[Preeclampsia|preeclampsia]], trauma, cocaine use, tobacco use, prior abruption, PPROM, advanced maternal age, multiparity

====[[Placenta Previa]]====
*Classic presentation is painless, bright red vaginal bleeding
*May have an initial "sentinel bleed" that is not immediately life-threatening<ref name="sakornbut"/>
*Bleeding may become profuse without warning
*Uterus is typically soft and non-tender
*Risk factors: prior cesarean delivery, prior previa, multiparity, advanced maternal age, smoking, IVF, multiple gestation

====[[Vasa Previa]]====
*Rare (~1 per 2,500 deliveries) but carries very high fetal mortality when undiagnosed<ref name="oyelese">Oyelese Y, Javinani A, Shamshirsaz AA. Vasa previa. ''Obstet Gynecol''. 2023;142(3):503-518. PMID 37590981.</ref>
*Onset of vaginal bleeding typically coincides with rupture of membranes
*Bleeding is of fetal origin; even small-volume blood loss can cause rapid fetal exsanguination
*Fetal heart rate tracing may show sinusoidal pattern or acute bradycardia
*Risk factors: velamentous cord insertion, bilobed/succenturiate placenta, low-lying placenta, IVF, multiple gestation<ref name="oyelese"/>

====[[Uterine Rupture]]====
*Most commonly occurs in women with prior uterine surgery (especially prior cesarean section) during trial of labor<ref name="tanos">Tanos V, Toney ZA. Uterine scar rupture – Prediction, prevention, diagnosis, and management. ''Best Pract Res Clin Obstet Gynaecol''. 2019;59:115-131.</ref>
*Presentation may include sudden severe abdominal pain, vaginal bleeding, loss of fetal station, cessation of contractions, and maternal hemodynamic instability
*Fetal bradycardia is often the earliest and most consistent sign<ref name="patel">Patel RM, Kaler M, Al-Soufi S, et al. Diagnosis and management of uterine rupture in the third trimester of pregnancy: a case series and literature review. ''Cureus''. 2023;15(6):e40060. PMID 37431303.</ref>
*Fetal parts may become palpable through the abdomen
*Risk factors: prior cesarean section (especially classical incision), myomectomy, uterine instrumentation, labor induction/augmentation, grand multiparity

==Differential Diagnosis==
*[[Placental Abruption]]
*[[Placenta Previa]]
*[[Vasa Previa]]
*[[Uterine Rupture]]
*[[Cervicitis]] / cervical lesion (polyp, ectropion, cancer)
*Bloody show / normal labor onset
*[[Chorioamnionitis]]
*Cervical or vaginal trauma
*Coagulopathy (inherited or acquired)
*[[Intrauterine fetal demise]]
*Marginal sinus rupture
*Placenta accreta spectrum

==Evaluation==
===Workup===
*'''Primary survey and maternal stabilization'''
**ABCs; two large-bore IVs, crystalloid resuscitation<ref name="muench"/>
**Continuous maternal vital sign monitoring
**Left lateral uterine displacement
*'''Laboratory studies'''
**CBC (serial hematocrit)
**Type and crossmatch (or at minimum type and screen)
**Coagulation panel: PT/INR, PTT, fibrinogen — screen for [[Disseminated Intravascular Coagulation|DIC]]
***Fibrinogen < 200 mg/dL is concerning for consumptive coagulopathy
**Metabolic panel
**[[Kleihauer-Betke test]] — especially if Rh-negative to calculate RhoGAM dosing
*'''Fetal assessment'''
**Continuous electronic fetal heart rate monitoring and tocometry
**Category III fetal heart rate tracings (absent variability with recurrent late/variable decelerations, bradycardia, or sinusoidal pattern) warrant emergent delivery
*'''Imaging'''
**Transabdominal ultrasound to assess:
***Placental location (rule out previa before any digital vaginal exam)
***Retroplacental hematoma (though sensitivity for abruption is limited)
***Fetal presentation, viability, and amniotic fluid volume
**Transvaginal ultrasound with color Doppler if vasa previa suspected<ref name="oyelese"/>

===Diagnosis===
*'''Placental abruption''' is primarily a '''clinical diagnosis'''; ultrasound has poor sensitivity (25–50%) because acute hemorrhage may be isoechoic to placental tissue<ref name="brandt"/>
*'''Placenta previa''' is diagnosed on ultrasound (transabdominal or transvaginal)
*'''Vasa previa''' is diagnosed by transvaginal ultrasound with color Doppler demonstrating fetal vessels over the internal os, confirmed with pulse-wave Doppler showing fetal heart rate waveform<ref name="oyelese"/>
*'''Uterine rupture''' is a clinical diagnosis; ultrasound may show free fluid, abnormal fetal lie, or absent myometrium, but operative findings are often required for confirmation<ref name="patel"/>
*'''Apt test''' (alkali denaturation test) can distinguish fetal from maternal blood when the source of bleeding is uncertain; fetal hemoglobin (HbF) resists alkali denaturation and remains pink, while adult hemoglobin (HbA) denatures and turns brown

====Critical Rule====
*'''Do NOT perform a digital vaginal examination until placenta previa has been excluded''' by ultrasound — digital exam in the setting of previa can precipitate catastrophic hemorrhage<ref name="sakornbut"/>
*Sterile speculum exam may be performed to evaluate the cervix and assess the source/quantity of bleeding

==Management==
*'''Resuscitation'''
**IV access with two large-bore (16–18 gauge) catheters
**Aggressive crystalloid resuscitation; initiate massive transfusion protocol if hemodynamically unstable
**Correct coagulopathy with blood products (pRBCs, FFP, cryoprecipitate, platelets) as indicated
*'''Rh immunoglobulin'''
**Administer [[RhoGAM]] (300 mcg) to all Rh-negative mothers
**Additional doses guided by Kleihauer-Betke quantification
*'''Fetal monitoring'''
**Continuous electronic fetal monitoring; ensure immediate operative delivery capability
*'''Condition-specific management'''
**'''Placental abruption'''
***Mild, with reassuring fetal status and preterm gestation: close inpatient observation, serial labs, consider antenatal corticosteroids if < 37 weeks
***Moderate-to-severe abruption, maternal instability, or nonreassuring fetal status: emergent delivery<ref name="brandt"/>
***If fetal demise has occurred, vaginal delivery is generally preferred to minimize maternal surgical morbidity<ref name="sakornbut"/>
***DIC: correct coagulopathy aggressively; target fibrinogen > 150–200 mg/dL
**'''Placenta previa'''
***If stable, not actively hemorrhaging, and preterm: inpatient observation, antenatal corticosteroids, plan for cesarean delivery at 36–37 weeks<ref name="sakornbut"/>
***Active hemorrhage or maternal/fetal instability: emergent cesarean delivery
***Tocolysis may be considered cautiously if preterm with contractions contributing to bleeding<ref name="sakornbut"/>
**'''Vasa previa'''
***Known diagnosis: planned cesarean delivery at 34–37 weeks of gestation<ref name="smfm">Society for Maternal-Fetal Medicine (SMFM); Sinkey RG, Odibo AO, Dashe JS. #37: Diagnosis and management of vasa previa. ''Am J Obstet Gynecol''. 2015;213(5):615-619. PMID 26292048.</ref>
***Acute bleeding with rupture of fetal vessels: emergent cesarean delivery and preparation for neonatal transfusion
**'''Uterine rupture'''
***Emergent cesarean delivery/laparotomy<ref name="patel"/>
***Uterine repair versus hysterectomy depending on extent of injury, hemodynamic stability, and future fertility desires
***Aggressive resuscitation and blood product administration
*'''Antenatal corticosteroids'''
**Administer betamethasone or dexamethasone for fetal lung maturity if 23–36+6 weeks gestation and delivery is anticipated, but do not delay emergent delivery for steroid administration<ref name="gyamfi">Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period. ''Am J Obstet Gynecol''. 2018;218(1):B2-B8.</ref>
*'''MgSO4 for neuroprotection'''
**Consider magnesium sulfate for fetal neuroprotection if < 32 weeks gestation and delivery is imminent

==Disposition==
*All patients with third trimester bleeding require emergent OB consultation
*Admit for observation at minimum; most patients will require inpatient monitoring
*Indications for emergent delivery include:
**Maternal hemodynamic instability despite resuscitation
**Category III fetal heart rate tracing in a viable fetus
**Massive hemorrhage
**Suspected uterine rupture
**Ruptured vasa previa
*If at a facility without obstetric/surgical capability, stabilize and arrange emergent transfer
*Ensure neonatal resuscitation team (NICU) is available or on standby for all deliveries
*Social work and emotional support services as needed, particularly in cases of fetal demise

==See Also==
*[[Placental Abruption]]
*[[Placenta Previa]]
*[[Vasa Previa]]
*[[Uterine Rupture]]
*[[Intrauterine fetal demise]]
*[[Vaginal Bleeding (Pregnant)]]
*[[DIC]]
*[[Postpartum hemorrhage]]

==External Links==
*[https://pubmed.ncbi.nlm.nih.gov/33332831/ Prompt evaluation and treatment of third-trimester bleeding - Clin Obstet Gynecol 2020]
*[https://pubmed.ncbi.nlm.nih.gov/37164498/ Placental abruption at near-term and term gestations - Am J Obstet Gynecol 2023]
*[https://pubmed.ncbi.nlm.nih.gov/37590981/ Vasa Previa - Obstet Gynecol 2023]
*[https://pubmed.ncbi.nlm.nih.gov/26292048/ SMFM #37: Diagnosis and management of vasa previa - Am J Obstet Gynecol 2015]
*[https://pubmed.ncbi.nlm.nih.gov/30940370/ Vaginal bleeding in late pregnancy - Emerg Med Clin North Am 2019]

==References==
<references/>

[[Category:OBGYN]]