95
Vaginal Bleeding in Late Pregnancy

Vaginal Bleeding in Late Pregnancykho-health.mui.ac.ir/sites/kho-health.mui.ac.ir/files/kargah/allame... · Identify major causes of vaginal bleeding in the second half of pregnancy

Embed Size (px)

Citation preview

Vaginal Bleeding

in

Late Pregnancy

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

Vasa previa

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.

CLINICAL FEATURES

Ultrasound presentation and course

Bleeding

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