244  •  Third Trimester Bleeding

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THIRD TRIMESTER BLEEDING 244 

INTRODUCTION
Imaging: Ultrasonography (transabdominal) to determine placental
Description: Vaginal bleeding during the third trimester of preg- location and condition, fetal status.
nancy (generally >25–27 weeks gestation). Vaginal bleeding Special Tests: Kleihauer–Betke test for fetal–maternal transfusion,
should be seen as a symptom, rather than a diagnosis. Most often, clot tube to assess possibility of coagulopathy, Apt test to identify
the blood is of maternal origin. fetal blood loss (such as from a vasa previa).
Prevalence: Bleeding complicates 4%–5% of pregnancies. Diagnostic Procedures: History, ultrasonography. Pelvic examina-
Predominant Age: Reproductive age. tion is contraindicated until the location of the placenta can be
Genetics: No genetic pattern. ascertained.

ETIOLOGY AND PATHOGENESIS Pathologic Findings

Causes: Cervical dilation, premature separation of a part or all of Based on the cause.
the placenta, abnormal placentation (location or character).
Risk Factors: Trauma (including physical abuse), labor, multiparity, MANAGEMENT AND THERAPY
advanced maternal age, smoking, cocaine use, multiple gestation,
Nonpharmacologic
prior placenta previa and prior abortion.
General Measures: History, evaluation, hemodynamic stabilization
if bleeding is heavy, fetal assessment.
SIGNS AND SYMPTOMS Specific Measures: Based upon the etiology and severity of
• Painless vaginal bleeding after 25–27 weeks of gestation. bleeding.
• Uterine hyperactivity possibly present when associated with a Diet: Nothing by mouth if the bleeding is heavy or it is thought to
placental abnormality (20%). foreshadow labor.
• When bleeding is heavy—hypotension, tachycardia, orthostasis, Activity: Bed rest pending a working diagnosis.
syncope. Patient Education: American College of Obstetricians and Gyne-
cologists Patient Education Pamphlets AP038 (Bleeding During
DIAGNOSTIC APPROACH Pregnancy), AP006 (Cesarean Birth), and AP025 (Ultrasound
Exams).
Differential Diagnosis
• Labor (bloody show)
Drug(s) of Choice
• Placenta previa
• Abruptio placentae When bleeding is heavy, fluid and blood product replacement as
• Uterine rupture needed. Rh (D) immunoglobulin should be administered as
• Vasa previa indicated in mothers who are Rh negative. If tocolysis is required,
• Vaginal or cervical lacerations MgSO4 is preferred.
• Bleeding from other sources (hemorrhoids, vulva, vagina) Contraindications: Beta mimetic agents should not be used if there
Associated Conditions: Labor, prematurity, anemia, postpartum is significant maternal blood loss or hypotension.
hemorrhage, coagulopathy. Precautions: Vaginal examinations should not be performed until
a placenta previa has been ruled out.
Workup and Evaluation
Laboratory: Complete blood count. If bleeding is heavy, type and
cross-match blood products for possible replacement.

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 prolonged blood loss. Preterm delivery represents the greatest
source of morbidity for the fetus.
Expected Outcome: Good with most causes of bleeding, presum-
ing early recognition and prompt management of the underlying
cause.

MISCELLANEOUS
Pregnancy Considerations: No effect on pregnancy aside from
those imposed by the underlying cause of the symptom of
bleeding.
ICD-10-CM Codes: Based on the cause.

Whenever there is any significant bleeding during the third trimester of
pregnancy it is vital to establish the location and condition of the
placenta and fetus prior to any pelvic examination.
Figure 244.1  Ultrasound in third trimester bleeding
FOLLOW-UP
Patient Monitoring: Maternal—hemodynamic monitoring, direct
inspection of bleeding. Fetal—fetal heart rate and biometry as
indicated by obstetric considerations.
Prevention/Avoidance: None.
Possible Complications: Catastrophic maternal hemorrhage, fetal
anoxia. Coagulation defects may occur as a result of heavy or
REFERENCES
LEVEL II
Bhandari S, Raja EA, Shetty A, et al. Maternal and perinatal conse-
quences of antepartum haemorrhage of unknown origin. BJOG. 2014;
121:44.
Magann EF, Cummings JE, Niederhauser A, et al. Antepartum bleeding
of unknown origin in the second half of pregnancy: a review. Obstet
Gynecol Surv. 2005;60:741.
Towers CV, Pircon RA, Heppard M. Is tocolysis safe in the management
of third-trimester bleeding? Am J Obstet Gynecol. 1999;180:1572.
LEVEL III
American College of Obstetricians and Gynecologists. Ultrasonography
in pregnancy. ACOG Practice Bulletin No. 101. Obstet Gynecol. 2009;
113:451.

Téléchargé pour Mourad BENNANI (bennani.orthopedics@gmail.com) à Hospital Military Instruction Mohamed V à partir de ClinicalKey.fr par Elsevier sur février 29, 2020.
Pour un usage personnel seulement. Aucune autre utilisation n´est autorisée. Copyright ©2020. Elsevier Inc. Tous droits réservés.