Third Trimester Bleeding and Management

Third trimester bleeding and
management
Aleks Finderle
12th Turkish Congress of Gynaelcology &

Obstetrics and 6th FGOM Congress
Differential Diagnosis of Third
Trimester Bleeding
Placenta Previa Coagulation Disorder

Vaginal Lesion/Injury
Placental Abruption
Cervical Lesion/Injury
Uterine Rupture
Neoplasia
Vasa Previa
Early labor Bloody Show
Hemorrhoids
Epidemiology of Third Trimester Bleeding
• About 3.8 % of third trimester pregnancies

– placenta previa - 22%; placental abruption - 31%
• Serious problem in pregnancy associated
with maternal and fetal risks
• Require urgent initial assessment and,
occasionaly, only partial diagnostic
procedures
Oyelese Y, Smulian JC. Placenta Previa, Placenta Accreta, and Vasa Previa. Obstet Gynecol. 2006;107:927-941
Placenta Previa
• Defined as the abnormal implantation of the
placenta in the lower uterine segment
Placenta Previa
• Bleeding results from small disruptions in
the placental attachment during normal
development and thinning of the lower
uterine segment
• The degree of placenta previa cannot
alone predict the clinical course
accurately, nor can it serve as the sole
guide for management decisions
• As a consequence the importance of
presented classifications has diminished
Placenta previa - Epidemiology
• 4 percent of ultrasound studies performed at 20 to 24
weeks
• 0,4% at term
• The diagnosis of placenta previa is common before the

third trimester, but up to 95% resolve before delivery
• Placental migration ?
Placenta Previa
• The length by which the placenta overlaps the
internal os at 18 to 23 weeks is highly predictive for
the persistence of placenta previa
• Overlap less than 1.5 cm at 18 to 23 weeks, placenta
previa typically resolves
• Overlap 2.5 cm or greater at 20 to 23 weeks,
persistence to term is likely
Becker RH, Vonk R, Mende BC, Ragosch V, Entezami M. The relevance of placental location at 20–23 gestational weeks for prediction of placenta previa at
delivery: evaluation of 8650 cases. Ultrasound Obstet Gynecol. 2001;17:496–501.
Placenta Previa - Risk Factors
• Previous CS • Smoking
• Previous uterine • Multiple gestation
instrumentation • Prior placenta previa
• Multiparity • Uterine fibroids
• Advanced maternal age
Placenta Previa - Risk Factors
• 4.8‰
• Risk of recurrent placenta previa is 4% to 8%

• Risk of placenta previa increases with the
number of prior cesarean sections, rising to
10% with four or more
• For woman older than 40 years risk is 2%
Placenta Previa - Clinical presentation
• Episode of bleeding has a peak incidence at
about the 34th week of pregnancy
• One-third of cases become symptomatic
before the 30th week and one-third after the
36th week
• Approximately 10% of cases, bleeding begins
only with the onset of labor
Placenta Previa - Diagnosis
• Transabdominal sonography
• Transvaginal sonography
• Translabial sonography
• Magnetic resonance imaging

Warshak, Carri R. MD; Eskander, Ramez MD; Hull, Andrew D. MD; Scioscia, Angela L. MD; Mattrey, Robert F. MD; Benirschke, Kurt MD;
Resnik, Robert MD
Placenta Previa - Morbidity and Mortality
• Placenta Previa is rarely a cause of life-threatening maternal

hemorrhage unless instrumentation or digital exam is
performed
• The most common morbidity with this problem is the

necessity for operative delivery and the risks associated with
surgical intervention
• Perinatal morbidity and mortality are primarily related to the

complications of prematurity, because the hemorrhage is
maternal.
• Reduction in both maternal and perinatal

mortality rates over the past 40 years
• Expectant management approach and the
liberal use of cesarean section rather than
vaginal delivery
• Maternal mortality rate has fallen from
between 25% and 30% to less than 1%.
• Total perinatal mortality rate has fallen from
between 60% and 70% to under 10%
• Goal is to obtain the maximum fetal

maturation possible while minimizing the risk
to both the fetus and the mother
• In a significant proportion of cases delivery

may be safely delayed to a more advanced
stage of maturity
Placenta Previa - Management
• It is reasonable to hospitalize women in the
situation of acute bleeding episode or uterine
contractions
• Women who present with bleeding in the
second half of pregnancy should have a
sonographic examination for placental
location prior to any attempt to perform a
digital examination
• Wide-bore intravenous cannulas
• Blood count and type and screen
• At least 4 units of compatible packed red
blood cells and coagulation factors at short
notice
• Rh immune globulin to Rh-negative women
• Kleihauer-Bettke test for quantification of
fetal-maternal transfusion in Rh-negative
women
• Steroids should be administered in women
between 24 and 34 weeks of gestation
• Before 32 weeks of gestation, with no
maternal or fetal compromise blood
transfusions should be considered
• Tocolysis ?
• Cerclage ?
• When the patient has had no further bleeding
for 48 hours, she may be considered for
discharge
• Women who are stable and asymptomatic,
and who are reliable and have quick access to
hospital, may be considered for outpatient
management
Placenta Previa - Delivery
• Cesarean delivery at 36-37 weeks of gestation
- documentation of fetal lung maturity by
amniocentesis
• Placental edge is 2 cm or more from the
internal os at term - good chances to deliver
vaginally
• Regional anesthesia - less blood loss and
requirements for blood transfusion
Placental Abruption
• Defined as the premature
separation of the placental from
the uterine wall
• Occurs in 0,9%
• Neonatal death incidence of 10 to
30%.
Placental Abruption - Patophysiology
• Source of the bleeding is small arterial vessels in the
basal layer of the decidua
• Compression by the expanding hematoma leads to
obliteration of the overlying inter-villous space
• Destruction of the placental tissue in the involved
area - loss of surface area for exchange of respiratory
gases and nutrients
Placental Abruption - Patophysiology
• Extravasation into the myometrium
and through to the peritoneal
surface - Couvelaire uterus
• Access to the vagina through the
cervix - no reliable indication of the
severity of the condition.
• Through the membranes into the
amniotic sac - port wine
discoloration
Placental Abruption - Risk Factors
• Hypertensive Disease of • Polyhydramnios
Pregnancy • Previous abruption
• Smoking • Unexplained elevation
• Substance abuse of MSAFP
• Trauma • Maternal age and parity
• Short umbilical cord or • Inferior vena cava
uterine anomaly compression
Preeclampsia screening
Placental Abruption - Clinical
presentation
• Vaginal bleeding, abdominal pain, uterine

contractions, and uterine tenderness
• The amount of external bleeding may not

accurately reflect the amount of blood loss.
Placental Abruption - Diagnosis
• Ultrssonography - exclude placenta previa
• Sensitivity of ultrasonography in diagnosis of
placental abruption is approximately 25%
• Doppler flow changes
• Thrombomodulin - a marker of endothelial
cell damage
• Clinical diagnosis !!
Placental Abruption - Management
• Vital signs – RR!  Underlying hypertensive
condition
• IV line – large bore  Blood samples
• Diagnostic procedures  Ultrasound
• Plan for delivery  The method and timing of
delivery depend on the
condition and gestational
age of the fetus, the
condition of the mother,
and status of cervix
Uterine rupture
• Reported in 0.03-0.08% of all delivering women,
but 0.3-1.7% among women with a history of a
uterine scar
• 13% of all uterine ruptures occur outside the
hospital
• Morbidity is hemorrhage and subsequent
anemia, requiring transfusion
• Fetal morbidity is more common with extrusion
and includes respiratory distress, hypoxia,
acidemia, and neonatal death
Uterine Rupture Presentation
• Vaginal bleeding
• Pain
• Cessation of contractions
• Absence/ deterioration of fetal heart rate
• Loss of station
• Easily palpable fetal parts
• Profound maternal tachycardia and hypotension
Risk Factors for Uterine Rupture
• Excessive uterine • Multiparity

stimulation • Non-vertex fetal
• Previous C/S presentation
• Trauma • Shoulder dystocia
• Prior rupture • Forceps delivery
• Previous uterine
surgery
Uterine Rupture Management
• In the case of sudden change in fetal baseline heart
rate or the onset of severe decelerations, the
provider should initiate intrauterine resuscitation
with maternal position change, IVF hydration,
discontinuation of oxitocin, O2 administration by re-
breather mask
• If the measures are ineffective, emergent

laparotomy is indicated
Vasa Previa
• Rarely reported condition in which
the fetal vessels from the placenta
cross the entrance to the birth canal
• Reported incidence varies, but most resources note
occurrence in 1:2500 pregnancies
• Associated with a high fetal mortality rate (50-95%)
which can be attributed to rapid fetal
exsanguination resulting from the vessels tearing
during labor
Risk Factors for Vasa Previa
• Bilobed and • Pregnancies resulting

succenturiate placentas from in vitro
• Velamentous insertion fertilization
of the cord • Palpable vessel on
• Low-lying placenta vaginal exam
and/or placenta previa • Maternal history of
• Multiple gestation uterine surgery
Vasa Previa - Management
• When vasa previa is detected prior to labor, the baby
has a much greater chance of surviving
• It can be detected during pregnancy with use of

transvaginal sonography, preferably in combination
with color Doppler
• Some researchers have suggested screening color

Doppler in the second trimesters of patients with risk
factors present on routine 20 week ultrasound
Vasa Previa - Management
• When vasa previa is diagnosed prior to labor,
elective caesarian delivery can save the baby’s life
• The International Vasa Previa Foundation

recommends hospitalization in the third trimester,
delivery by 35 weeks, and immediate blood
transfusion of the infant in the event of a rupture
Color Doppler of Vasa Previa
Vasa Previa - Diagnosis in the Acute Setting
• Clinical scenarios suggesting vasa previa:
-significant bleeding at the time of membrane

rupture
-fetal heart rate abnormalities associated with vaginal

bleeding
-palpable vessels on vaginal examination

Tests for Fetal Blood in Acute Setting
• There are many tests available for determining
whether bleeding in the peripartum period is fetal or
maternal in origin.
• Among existing tests are:
-Apt test
-Ogita test
-Londersloot test
-Kleihauer-Bettke test
-Hemoglobin electrophoresis
Take-home message
• Development of clinical guidelines and
protocols designed to provide early diagnosis
of patients at risk for major obstetric hemorrhage
and efficient care in emergency situations

Take-home message
• Multidisciplinary team capable to perform all
diagnostics procedures and management
including emergency peripartum
hysterectomy is essential

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Third trimester bleeding and

12th Turkish Congress of Gynaelcology &

Placenta Previa Coagulation Disorder

• About 3.8 % of third trimester pregnancies

• The diagnosis of placenta previa is common before the

• Risk of recurrent placenta previa is 4% to 8%

• Magnetic resonance imaging

• Placenta Previa is rarely a cause of life-threatening maternal

• The most common morbidity with this problem is the

• Perinatal morbidity and mortality are primarily related to the

• Reduction in both maternal and perinatal

• Goal is to obtain the maximum fetal

• In a significant proportion of cases delivery

• Vaginal bleeding, abdominal pain, uterine

• The amount of external bleeding may not

• Excessive uterine • Multiparity

• If the measures are ineffective, emergent

• Bilobed and • Pregnancies resulting

• It can be detected during pregnancy with use of

• Some researchers have suggested screening color

• The International Vasa Previa Foundation

-significant bleeding at the time of membrane

-fetal heart rate abnormalities associated with vaginal

-palpable vessels on vaginal examination

protocols designed to provide early diagnosis

of patients at risk for major obstetric hemorrhage

and efficient care in emergency situations

diagnostics procedures and management

including emergency peripartum

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