1. 8th Edition APGO Objectives for Medical Students
Third Trimester Bleeding

2. Rationale
Bleeding in the third trimester requires immediate patient evaluation. Thoughtful, prompt evaluation and management is necessary to reduce the threat to the lives of the mother and fetus.

3. Objectives The student will be able to:
Describe the approach to the patient with third-trimester bleeding
Compare symptoms, physical findings and diagnostic methods that differentiate patients with placenta previa, abruptio placenta and other causes of third-trimester bleeding
Describe complications of placenta previa and abruptio placenta
Describe immediate management of shock secondary to third-trimester bleeding
Describe components of the various blood products and indications for their use

4. Placental abruption Definition
separation of placenta from uterine wall
Incidence
1% of all pregnancies
20% of all third-trimester bleeders
Recurrence risk
10% in first pregnancy
25% in second pregnancy

5. Placental abruption Risk factors Chronic hypertension Cocaine
Abdominal trauma
Smoking
Uterine decompression
Prolonged PROM
High parity
Prior abruption

6. Placental abruption
Symptoms
Vaginal bleeding
Abdominal or back pain

7. Placental abruption Physical findings Uterine contractions Hypertonus
Tetany
Vaginal bleeding
Concealed hemorrhage
Fetal distress

8. Placental abruption Laboratory findings
Anemia - may be out of proportion to observed blood loss
DIC in 10% (30% if severe abruption)
First, increase in FSP
Followed by decrease in fibrinogen

9. Placental abruption Diagnosis Clinical scenario
Ultrasound - not good, except to rule out placenta previa

10. Placental abruption Treatment Continuous electronic fetal monitoring
Ultrasound to confirm viability, gestational age, no previa, fetal lie
Expectant care and vaginal delivery, if fetal tracing reassuring
Available anesthesia, OR team for stat cesarean delivery

11. Placenta previa
Definition
placental tissue covers cervical os

12. Placenta previa Types Central/total - complete covers os
Partial - partially covers internal os
Marginal - placental edge at margin of internal os
Lateral/low-lying - placenta approaches os

13. Placenta previa Incidence ~ 1:20 at 24 wk. 1:200 at 40 wk.
Nulliparous - 0.2%
Multiparous - 0.5%

14. Placenta previa Risk factors Prior cesarean delivery/myomectomy
Previous abortion
Increased parity
Multifetal gestation
Advanced maternal age
Abnormal presentation
Smoking

15. Placenta previa Symptom - painless vaginal bleeding Spontaneous
After coitus

16. Placenta previa Physical findings Abnormal lie
If significant bleeding:
Tachycardia
Postural hypertension

17. Placenta previa
Diagnosis
ultrasound

18. Placenta previa Management Admit to hospital Observe in L&D IV access
Electronic fetal monitoring

19. Placenta previa Management (con’t)
Less than 36 wk gestation - expectant management
Bed rest
No vaginal exams
Steroids for lung maturation
Greater than 36 wk gestation - schedule cesarean delivery with hysterectomy backup

20. Vasa previa Definition
In cases of velamentous cord insertion fetal vessels cover cervical os

21. Vasa previa Incidence 0.1-1.0% Singleton - 0.2% Twins - 6-11%
Triplets - 95%

22. Vasa previa Diagnosis Painless vaginal bleeding Fetal bleeding
Positive Kleihauer Betke test
Positive APT test

23. Vasa previa
Treatment
Emergent cesarean delivery

24. Other causes of third-trimester bleeding
Cervicitis
Cervical erosion
Trauma
Cervical cancer
Foreign body
Bloody show

25. Perinatal mortality and morbidity
Previa - 40%
Abruption - 0.4%; if severe abruption, approaches 50%
Vasa previa - about 50%

26. Perinatal mortality and morbidity
Prematurity
Fetal asphyxia
Exsanguination (rare)
Congenital malformations

27. Maternal mortality and morbidity
Mortality - rare
Morbidity
Anemia
Hemorrhage
Shock
DIC (coagulopathies)
Couvelaire uterus
Placenta accreta

28. Management of shock Stabilize mother Monitor urine output
Large-bore IV x 2
Place patient in Trendelenburg position
Crossmatch for 4 units of blood
Rapidly infuse 5% dextrose in lactated Ringer’s
Monitor urine output

29. Management of shock Serial labs CBC and platelets
Prothrombin time (factors II, V, VII, X {extrinsic})
Partial thromboplastin time (factors II, V, XIII, IX, X, XI {intrinsic})

30. Management of shock Transfusion products Product Content Volume
Whole blood
RBCs, 2,3 DPG, coagulation factors (50 V, VIII), plasma proteins
500 cc
Packed RBCs
RBCs
240cc
Platelets
55 x 106 platelets/unit
50cc
Fresh frozen plasma
Clotting factors V, VIII, fibrinogen cc
Cryoprecipitate
Factor VIII; 25% fibrinogen, von Willebrand’s factor
10-40cc

31. Management of shock Risks of blood transfusion Infectious disease
Risk Factor
Hepatitis B
1/200,000
Hepatitis C
1/3,300
HIV
1/225,000
CMV
1/20
MTLV-1/11
1/50,000

32. Management of shock Risks of blood transfusion Immunologic reactions
Fever - 1/100
Hemolysis - 1/25,000
Fatal hemolytic reaction - 1/1,000,000

33. Management of shock Delivery
Vaginally unless other obstetrical indication, i.e. fetal distress, herpes, etc.
Best to stabilize mother before initiating labor or going to delivery

34. References
Baron F, Hill WC. “Placenta previa, placenta abruption”, Clinical Obstetrics and Gynecology, Sep (3) pp
Benedetti T. Obstetric hemorrhage, in obstetrics: normal and problem pregnancies, Gabbe S, Niebyl J, Simpson J, 3rd ed. New York: Churchill Livingston 1996, pp
Hertzberg B. “Ultrasound evaluation of third trimester bleeding,” The Radiologist, July (4) pp
Sheiner E, Shohan-Vardi I. “Placenta previa: obstetric risk factors and pregnancy outcome,” Journal of Maternal-Fetal Medicine, December (6) pp
Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997.

35. Third Trimester Bleeding
Clinical Case
Third Trimester Bleeding

36. Objectives
At the conclusion of this exercise, the student will be able to
Describe the approach to the patient with third trimester bleeding
Compare symptoms, physical findings and diagnostic methods to differentiate between placenta previa, placental abruption and other causes of 3rd trimester bleeding
Describe immediate management of shock due to 3rd trimester bleeding
Understand complications of placental abruption and placenta previa

37. Patient presentation
Joanne is a 25-year-old G2P1 female at 32 weeks gestation. About an hour before arrival in labor and delivery, she was watching television when she noted a sudden gush of bright red blood vaginally. The bleeding was heavy and soaked through her clothes, though it has decreased since then. She denies any cramps or abdominal pain. She says that her last sexual intercourse was a week ago. A review of her prenatal chart finds nothing remarkable other than a borderline high blood pressure from her first prenatal visit that has not required medication. There is no mention of bleeding prior to this episode. She had an ultrasound to confirm pregnancy at 14 weeks, but none since.

38. Patient presentation
Physical examination reveals a very anxious woman whose blood pressure is 138/90, pulse 90, respirations 22, temperature 99 F. Her abdomen is soft without guarding or rebound to palpation, and the uterus is nontender and firm, but not rigid. Fundal height is 33cm. Fetal heart tones are in the 140s with good variability. The external monitor reveals uterine irritability, but no discrete contractions are seen. There is a small amount of dark blood on her underwear, but no active bleeding is seen. Vaginal examination is deferred pending an ultrasound evaluation of placental location.

39. Patient presentation
Electrolytes, liver enzymes and coagulation profile are all within normal range. CBC reveals a hemoglobin of 8.0 gm/dl and a hematocrit of 24%; MCV, MCH and MCHC are all low normal. White blood cell and platelet counts are normal. Type and Rh confirm A negative blood type with negative antibody titer. Kleihauer-Betke test is negative for fetal blood.

40. Patient presentation
An ultrasound examination shows a singleton fetus in cephalic position. Biparietal diameter, head circumference and femur length are all consistent with gestational age. No gross anomalies are seen. Amniotic fluid volume is normal. The placenta is low lying and extends to, but does not appear to cover, the cervical os.

41. Diagnosis
Third trimester bleeding with low-lying placenta

42. Assessment/plan
After being observed for several hours in labor and delivery, Joanne is admitted to the antepartum floor for further observation. She is placed at strict bed rest with fetal heart monitoring each nursing shift. She is instructed to report any further bleeding. Blood has been typed and crossed for 4 units and a repeat CBC ordered for the morning. Nursing orders are to notify you of any orthostatic changes or complaints of dizziness or weakness.

43. Assessment/plan
After 24 hours, there has been no further bleeding and Joanne’s vital signs have remained normal. She is discharged to home on iron replacement, to follow-up at the next scheduled appointment next week. She is advised to avoid intercourse or strenuous physical activities, though she may to continue to do her regular work as an accountant.

44. Teaching points
There are several causes of third trimester bleeding. Placental abruption describes separation of the placenta from the uterine wall. It occurs in about 20% of all third trimester bleeders and has a 25% recurrence risk in a subsequent pregnancy. Risk factors for placental abruption include chronic hypertension, cocaine use, abdominal trauma, sudden uterine compression (as with rupture of membranes), and high parity. Physical findings include frequent uterine contractions or hypertonicity, vaginal bleeding (sometimes catastrophic), and fetal distress. Disseminated intravascular coagulation occurs in 10% of cases, in 30% if the bleeding is severe. If the fetal heart tracing is reassuring, expectant management and vaginal delivery may be considered. If there are signs of maternal or fetal deterioration, an immediate cesarean delivery is required. Perinatal mortality approaches 50% in severe cases.

45. Teaching points
Placenta previa occurs when placental tissue covers the cervical os. A central or total placenta previa covers the os completely; as its name implies, a partial placenta previa partially covers the os. In a marginal previa, the placental edge is at the margin of the internal os while, with a low-lying placenta, the placenta approaches the os, but is not at its edge. At 24 weeks, about 1 pregnancy in 20 will demonstrate ultrasound evidence of a placenta previa, while, at 40 weeks, the incidence decreases to 1 in 200. Risk factors include prior cesarean delivery, history of myomectomy, previous abortion, increased parity, multiple gestation, advanced maternal age and smoking. Bleeding is usually painless and may occur after intercourse. Management includes observation in labor and delivery, IV access, continuous fetal monitoring and steroids for fetal lung maturation if needed. Cesarean delivery is the method of choice with hysterectomy backup if intraoperative bleeding cannot be controlled. Perinatal mortality can read 40%

46. Teaching points
Vasa previa is a rare condition where the fetal vessels of a velamentous cord insertion cover the cervical os. The incidence is less than 1% of all pregnancies, though it is increased in multiple gestations: up to 11% in twins and up to 95% in triplets. The diagnosis is suggested by painless vaginal bleeding in the absence of evidence of placenta previa or abruption. Treatment is delivery by cesarean section.

47. Teaching points
Shock from blood loss is a very real possibility in 3rd trimester bleeding from any cause. Management includes 2 large bore IVs, crossmatch for 4 or more units of blood; 5% dextrose in lactated ringers or normal saline should be infused rapidly. Urine output must be monitored and is a gauge of renal failure from hypoperfusion. Serial CBC and platelet counts, prothrombin time and partial thromboplastin time are all followed. Transfusion products are given as needed: whole blood, packed red blood cells, platelets, fresh frozen plasma and cryoprecipitate.