Vaginal Bleeding in

Late Pregnancy
Published August 2010

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 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

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 Causes of Late Pregnancy Bleeding

• Placenta Previa
• Abruption
Life-Threatening
• Uterine scar disruption
• Ruptured vasa previa
• Cervical polyp
• Bloody show
• Cervicitis or cervical ectropion
• Vaginal trauma
• Cervical cancer

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 Management of Significant Bleeding

• Same initial steps regardless of etiology

• Assess vital signs, circulatory stability
• Secure intravenous access, administer fluids
• Targeted history and physical exam

Gentle speculum exam is safe

NO digital vaginal exam unless placental location
known

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 Management, continued
• Continuous electronic fetal monitoring and toco
• Ultrasound for placenta location, clot, fetal position
• Baseline lab tests

Hematocrit

Platelet count

Fibrinogen level, fibrin degradation products, INR, PTT

Blood type and antibody screen
• Prepare for possible emergent cesarean delivery

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 Placenta Previa

Low-Lying: Marginal: Complete:

2 to 3.5 cm from os Within 2 cm Covers os

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 Prevalence of Placenta Previa

• Common finding on second trimester

ultrasound
• Previa occurs in approximately four percent
of pregnancies at 20 to 25 weeks, only 0.4
percent at term

If overlaps os by > 2.5 cm, then likely to persist
• No proven benefit to routine screening
ultrasound in late pregnancy

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 Risk Factors for Placenta Previa

• Chronic hypertension
• Multiparity
• Multiple gestation
• Increasing maternal age
• Previous cesarean delivery
• Previous uterine curettage
• Smoking

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 Morbidity with Placenta Previa

• Maternal hemorrhage
• Transfusion
• Cesarean delivery
• Placenta accreta, increta, or percreta

Increased risk of invasive placenta in women
with previa + prior cesarean

Evaluate with color flow Doppler US
• Prematurity

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Placenta Previa with Increta

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 Clinical Presentation - Previa

• Painless bleeding
 Second or third trimester, or at term
 Often following intercourse
 May have preterm contractions

• Suspect previa with persistent

malpresentation
• Diagnosis confirmed with ultrasound
localization of placenta

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 Ultrasound – Placenta Previa

• When previa seen on transabdominal US,

transvaginal scan should be performed

More accurate visalization of placental edge and
internal os
• Full bladder can create false appearance of
anterior previa
• Presenting part may overshadow posterior
previa

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Ultrasound – Placenta Previa

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 Management – Placenta Previa
• With no active bleeding  Expectant management

No intercourse or tampons in third trimester

Avoid digital exams
• With bleeding  Initial assessment in hospital

Overall status, circulatory stability

Full dose Rhogam if Rh neg

Consider maternal transfer if premature

May need corticosteroids, tocolysis, amniocentesis

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 Further Management
• May discharge home if stable after 72 hours
of inpatient observation
• Reduces stay in hospital by average of 14
days
• No increase in

Hemorrhage

Need for transfusion

Poor maternal or neonatal outcomes

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 Neonatal Morbidity from Placenta Previa

• Greatest morbidity and mortality related to

prematurity
• Tocolysis added 11 days to pregnancy, 320
grams to birth weight in one study

Allows for administration of corticosteroids

No increase in maternal or fetal complications
• Cervical cerclage decreased risk of birth before
34 weeks in meta-analysis

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 Delivery Decisions – Placenta Previa

• Low lying placenta or marginal previa, no bleeding 

Perform US at 36 weeks

If placenta > 2 cm from internal os, expect vaginal delivery

If 1 to 2 cm from os, may attempt vaginal delivery in setting
with immediate surgical backup
• Perform cesarean delivery for:

complete previa

fetal head not engaged, non-reassuring tracing, brisk or
persistent bleeding
• Regional anesthesia is safe, less blood loss

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 Placental Abruption

• Occurs in one percent of pregnancies

• Premature separation of placenta from
uterine wall

Partial or complete
• Apparent increase in incidence

Increased diagnosis (ultrasound) vs. increased
risk factors (hypertension)

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 Risk Factors for Abruption

• Hypertensive disorders of pregnancy

Treating preeclampsia with MgSO4 decreases risk by 27
percent
• Trauma

Blunt abdominal trauma or rapid deceleration without direct
trauma
• Tobacco, cocaine, stimulants
• Thrombophilias
• Chorioamnionitis
• Oligiohydramnios, PROM
• Abruption in previous pregnancy

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 Clinical Presentation - Abruption

• Pain = hallmark symptom

Varies from mild cramping to severe pain

Back pain – think posterior abruption
• Vaginal bleeding or bloody amniotic fluid

Differentiate from exuberant bloody show
• Concealed bleeding in 20 to 63 percent of
cases

Visible bleeding may not reflect amount of blood
loss

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 Evaluation - Abruption

• Check vital signs for circulatory instability

• Palpate maternal abdomen

Location of tenderness

Tetanic contractions
• Monitor FHR and contractions

Continuous FECG, consider amniotomy and IUPC
• Ultrasound or fundal height and Leopold’s

Estimated fetal weight, fetal lie

Evaluate placenta

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 Diagnosis - Abruption
Abruption is a clinical diagnosis!

Ultrasound findings may

be supportive:
Retroplacental echolucency
Abnormal thickening of
placenta
“Torn” edge of placenta

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 Abruption severity

Mild: often identified at delivery with

retroplacental clot
Moderate to severe: Symptomatic, tender
abdomen
Severe with fetal demise:
- without coagulopathy (two thirds)
- with coagulopathy (one third)

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 Management - Severe Abruption

• Expeditious operative or vaginal delivery

Decision-to-delivery interval > 20 min increases incidence of
fetal death or cerebral palsy
• Maintain maternal circulation

Urine output > 30 cc/hr, hematocrit > 30 percent
• Prepare for neonatal resuscitation
• If fetal demise

Vaginal delivery preferred, unless severe hemorrhage

Check for coagulopathy

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 Coagulopathy with Abruption

• Occurs in one third of fetal demise

• Usually not seen if live fetus
• Etiologies: consumption, DIC
• Administer platelets, FFP
• Give Factor VIII if severe

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 Uterine Rupture

• Occult dehiscence vs. symptomatic rupture

• Rare in unscarred uterus

< 0.1 percent overall incidence

0.8 percent of women with uterine scar
• Previous cesarean incision most common
etiology

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 Risk Factors – Uterine Rupture
• Previous cesarean incision (most common)
• Other uterine surgery involving full thickness
myometrium
• Inappropriate oxytocin usage
• Uterine over-distention
• Abnormal placental attachment, difficult
removal
• Uterine or fetal anomaly
• Gestational trophoblastic neoplasia
• Adenomyosis

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 Morbidity with Uterine Rupture

• Maternal

hemorrhage with anemia (most common)

bladder rupture

hysterectomy

maternal death
• Fetal

respiratory distress

hypoxia

acidemia

neonatal death

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 Clinical Findings – Uterine Rupture

• Sudden deterioration of FHR pattern is most

frequent initial sign
• Vaginal bleeding
• Pain
• “Stair step” decrease or cessation of contractions
• Loss of station
• Palpable fetal parts through maternal abdomen
• Profound maternal tachycardia and hypotension

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 Management – Uterine Rupture

• Asymptomatic scar disruption

Expectant management

• Symptomatic rupture

Emergent cesarean delivery

Outcome good if decision to incision to delivery
time under 18 minutes in one study

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 Vasa Previa
• Fetal vessels run in membranes between cervix and
presenting part
• Rarest cause of hemorrhage
• Rapid intervention essential for fetal survival

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 Vasa Previa – Associated Conditions

In vitro fertilization

Low-lying placenta or
previa in second or
third trimester

Bilobed and
succenturiate lobe
placentas

Velamentous
insertion of the cord
Bi-lobed placenta with
Velamentous Insertion

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 Vasa Previa – Clinical Presentation

• Potential for ante partum detection

Palpate vessels during cervical examination

Color-flow Doppler ultrasound
• Typically, first sign is bleeding with membrane
rupture
• Blood loss is fetal

Fetal circulation = 250 ml total

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 Intrapartum Management –
Vasa Previa

• Tests for fetal hgb have limited usefulness

Apt test insensitive

Kleihauer-Betke or hgb electrophoresis slow
• Immediate cesarean delivery if fetal heart
rate non-reassuring
• Administer normal saline 10 to 20 cc/kg bolus
to newborn if in shock after delivery

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 Antepartum Diagnosis – Vasa Previa

• Critical for fetal survival as allows planned

cesarean delivery

97 percent survival when detected antenatally

44 percent survival without antenatal diagnosis
• If placenta previa on second trimester US 

Perform follow-up US with color-flow Doppler to
rule out vasa previa
• If persistent vasa previa 

Corticosteriods, delivery at 35 to 36 weeks

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 Summary
• Late pregnancy bleeding may herald diagnoses with
significant morbidity/ mortality
• Rapid clinical diagnosis is imperative
• Sterile speculum exam is safe, but avoid vaginal
exam until placental location is known!
• Ultrasound has a supportive role in determining the
cause of bleeding
• When antenatal US identifies placenta previa, color
flow Doppler study is recommended to evaluate for
placenta accreta and vasa previa

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