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. Definitions

  1. Late Pregnancy Bleeding
    1. Vaginal Bleeding after 20 weeks gestation

IV. 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 gynecologic causes
    1. Cervicitis (e.g. GC, Chlamydia, Trichomoniasis) or other genital tract infection
    2. Bloody show (may indicate labor or Preterm Labor)
    3. Cervical polyp
    4. Cervical Cancer
    5. Cervical Ectropion
    6. Vaginal Trauma
    7. Postcoital bleeding
  3. Non-gynecologic causes
    1. Gastrointestinal Bleeding (Rectal Bleeding, Hemorrhoids)
    2. Urinary tract bleeding (e.g. Ureterolithiasis, hemorrhagic cystitis)
    3. Coagulopathy

V. 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. Uterine Contractions
    3. Foul Vaginal Discharge
    4. Rupture of Membranes
  3. Inciting factors
    1. Recent examination
    2. Abdominal or pelvic Trauma
    3. Recent Intercourse
    4. Hypertension history
  4. Fetal movement
  5. Previous Ultrasounds
    1. Placental position
    2. Known placental previa

VI. Exam

  1. Vital Signs
    1. Vital Signs often normal despite significant bleeding or Hemorrhagic Shock (until 30% blood loss)
    2. Orthostatic Blood Pressure and pulse
  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. Sterile speculum exam may safely be used even if placental position is not know

VII. 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
  6. Urinalysis

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

  1. Complete Blood Count
  2. Comprehensive Metabolic Panel
  3. Type and cross 2 to 6 units Packed Red Blood Cells (or O negative if active Hemorrhage)
  4. Type and cross for Platelet Transfusion
  5. Kleihauer-Betke Test (if Rh Negative)
  6. Coagulation studies (if indicated)
    1. Prothrombin Time (INR, ProTime, PT)
    2. Partial Thromboplastin Time (PTT)
    3. Fibrin split products (Fibrin Degradation Products)
    4. Fibrinogen

IX. Imaging: Transvaginal Ultrasound

  1. Fetal Presentation
  2. Placental location (e.g. Placenta Previa)
  3. Placental Abruption (inconsistently identifiable)
  4. Vasa Previa
  5. Uterine Rupture

X. Precautions

  1. Serious bleeding causes (e.g. Placenta Previa) may present with initial minimal bleeding

XI. 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

XII. Management: Emergency

  1. Indications
    1. Brisk Vaginal Bleeding
    2. Unstable Vital Signs
    3. Fetal Distress
  2. Immediate interventions
    1. ABC Management
    2. Oxygen
    3. Trendelenburg position (or left lateral decubitus if Vital Signs stable)
    4. Obtain immediate Intravenous Access
      1. Two large bore IV (16-18 gauge)
      2. Initiate Isotonic crystalloid bolus (NS or LR)
    5. Type, cross and transfuse pRBC as needed
    6. Call for immediate Obstetric and neonatal support (and alert Anesthesia)
    7. Frequent Vital Signs, hemodynamic monitoring, Fetal Monitoring
    8. Consider antenatal Corticosteroids in preterm patients
    9. Consider higher level of care if stable enough for transfer

XIII. Complications

  1. Cesarean Delivery
  2. Preterm Birth
  3. Intrauterine Fetal Demise

XIV. References

  1. Rucker (2025) Crit Dec Emerg Med 39(9): 4-12
  2. Gyamfi-Bannerman (2018) Am J Obstet Gynecol 218(1): B2-8 [PubMed]
  3. Yonke (2025) Am Fam Physician 112(6): 638-45 [PubMed]

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