Late Pregnancy Bleeding

Aka: Late Pregnancy Bleeding, Second Trimester Bleeding, Third Trimester Bleeding, Vaginal Bleeding Late in Pregnancy

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II. Epidemiology

  1. Late Pregnancy Bleeding complicates 4% of pregnancies

III. Causes

  1. Major causes of bleeding
    1. Placenta Previa (20%)
      1. Painless bleeding after 18-20 weeks gestation
    2. Placental Abruption (30%)
      1. Painful bleeding
    3. Ruptured Vasa Previa
    4. Uterine Scar Disruption
  2. Other causes
    1. Cervicitis or other genital tract infection
    2. Bloody show (may indicated Preterm Labor)
    3. Cervical polyp
    4. Cervical Cancer
    5. Cervical Ectropion
    6. Vaginal Trauma

IV. History

  1. Bleeding characteristics
    1. Amount of blood (pads per day)
    2. Color of blood (dark or bright red)
  2. Associated factors
    1. Pelvic Pain, Abdominal Pain or back pain
    2. Contractions
    3. Foul Vaginal Discharge
    4. Rupture of Membranes
  3. Inciting factors
    1. Recent examination
    2. Abdominal or pelvic Trauma
    3. Intercourse
  4. Fetal movement
  5. Previous Ultrasounds

V. Exam

  1. Orthostatic Blood Pressure and pulse
    1. Vital Signs often normal despite significant bleeding or Hemorrhagic Shock (until 30% blood loss)
  2. Abdominal Exam
    1. Pain on palpation
    2. Palpable contractions
    3. Hypertonic Uterus
  3. Pregnancy Monitoring
    1. External Fetal monitor for Fetal Heart Tones
    2. Tocometry for contraction monitoring
  4. Pelvic examination (if no Placenta Previa)
    1. Bimanual exam if placental location known
    2. Do not use speculum if suspicion of Placenta Previa

VI. Labs: Evaluation

  1. Vaginal Discharge
    1. AmniSure ROM Test (PAMG-1 Protein Marker Test) or
    2. Nitrazine and Ferning
  2. Gonorrhea Culture
  3. Chlamydia culture
  4. Saline preparation (Wet Prep)
  5. Bloody fluid for Apt Test

VII. Labs: Emergent (if indicated under management below)

  1. Complete Blood Count
  2. Type and cross 2 to 6 units Packed Red Blood Cells (or O negative if active Hemorrhage)
  3. Type and cross for Platelet Transfusion
  4. Coagulation studies (if indicated)
    1. ProTime (PT)
    2. Partial Thromboplastin Time (PTT)
    3. Fibrin split products (Fibrin Degradation Products)
    4. Fibrinogen

VIII. Radiology: Transvaginal Ultrasound

  1. Placental location (e.g. Placenta Previa)
  2. Placental Abruption (inconsistently identifiable)

IX. Management: General

  1. Evaluate for Vasa Previa if amniotic fluid present
    1. Modified Apt Test
  2. Maternal blood Rh Negative and large antepartum bleed
    1. Administer RhoGAM 300 mcg IV/IM
    2. Screen with sheep rosette test
    3. If sheep rosette test, then Kleihauer-Betke Test
      1. RhoGAM dose based on Kleihauer-Betke Test

X. Management: Emergency

  1. Indications
    1. Brisk Vaginal Bleeding
    2. Unstable Vital Signs
    3. Fetal Distress
  2. Immediate interventions
    1. Oxygen
    2. Trendelenburg position (or left lateral decubitus if Vital Signs stable)
    3. Obtain immediate Intravenous Access
      1. Two large bore IV (16-18 gauge)
      2. Initiate Isotonic crystalloid bolus
        1. Normal Saline
        2. Lactated Ringers
    4. Type, cross and transfuse pRBC as needed
    5. Call for immediate Obstetric and neonatal support

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