Third-trimester bleeding

Third-trimester bleeding is an obstetric emergency and is associated with significant maternal and fetal morbidity and mortality. Five to 10 percent of women have vaginal bleeding in late pregnancy. The clinician must distinguish between placental causes (placenta previa, placental abruption, vasa previa) and nonplacental causes (labor, infection, disorders of the lower genital tract, systemic disease). The approach to bleed­ing in late pregnancy depends on the underlying cause, the gestational age at presentation, the degree of blood loss, and the overall status of the mother and her fetus.

Management

The patient should initially be observed closely with con­tinuous fetal monitoring to assess for fetal distress. A com­plete blood count with platelets and a prothrombin time (INR) should be obtained and repeated serially if the bleed­ing continues. If hemorrhage is significant or if there is evidence of acute hypovolemia, the need for transfusion should be anticipated and an appropriate volume of red cells prepared with cross-matching. Ultrasound examina­tion should be performed to determine placental location. Digital pelvic examinations are done only after ultrasound examination has ruled out placenta previa. Administration of anti-D immune globulin may be required for women who are Rh negative.

Placenta Previa

Placenta previa occurs when the placenta implants over the internal cervical os. Risk factors for this condition include previous cesarean delivery, increasing maternal age, multi­parity, and smoking. If the diagnosis is initially made in the first or second trimester, the ultrasound should be repeated in the third trimester. Persistence of placenta previa at this point is an indication for cesarean as the route of delivery.

Painless vaginal bleeding is the characteristic symptom in placenta previa and can range from light spotting to profuse hemorrhage. Hospitalization for extended evalua­tion is the appropriate initial management approach. For pregnancies that have reached 37 weeks’ gestation or beyond with continued bleeding, cesarean delivery is generally indicated.

Pregnancies at 36 weeks or earlier are candidates for expectant management provided the bleeding is not prodigious, and a subset of these women can be discharged if the bleeding and contractions completely subside.

Morbidly Adherent Placenta

Morbidly adherent placenta is a general term describing an abnormally adherent placenta that has invaded into the uterus. The condition can be further classified depending on whether the depth of invasion is limited to the endome­trium (accreta), extends into the myometrium (increta), or invades beyond the uterine serosa (percreta). The most important risk factor for a morbidly adherent placenta is a prior uterine scar—typically from one or more prior cesar­ean deliveries.

The focus of invasion usually involves the scar itself, and placenta previa is commonly associated with morbid adherence. Of serious concern for the field of obstetrics, the incidence of these syndromes has increased dramatically over the last 50 years commensurate with the increasing cesarean delivery rate.

After delivery of the infant, the morbidly adherent placenta does not separate normally, and the bleeding that results can be torrential. Emergency hysterectomy is usually required to stop the hemorrhage, and transfusion requirements are often massive. Because of the consider­able increase in both maternal morbidity and mortality associated with this condition, careful preoperative plan­ning is imperative when the diagnosis is suspected ante­natally.

Ultrasound findings such as intraplacental lacunae, bridging vessels into the bladder, and loss of the retroplacental clear space suggest placental invasion in women who have placenta previa. Importantly, however, even if ultrasound findings are subtle, an abnormally adherent placenta should be suspected in any patient with one or more prior cesarean deliveries and an anterior pla­centa previa.

Ideally, delivery planning should involve a multidisciplinary team, and the surgery should take place at an institution with appropriate personnel and a blood bank equipped to handle patients requiring massive transfusion. It has been demonstrated that a systematic approach to management with a multidisciplinary team improves patient outcomes.

Evidence-based recommendations regarding delivery timing are lacking, but the goal is to have a planned, late-preterm cesarean delivery. As such, delivery at 34–36 weeks in a stable patient seems a reasonable approach.

Placental Abruption

Placental abruption is the premature separation of the placenta from its implantation site before delivery. Hypertension is a known risk factor for abruption. Other risk factors include multiparity, cocaine use, smoking, previous abrup­tion, and thrombophilias. Classic symptoms are vaginal bleeding, uterine tenderness, and frequent contractions, but the clinical presentation is highly variable. There is often concealed hemorrhage when the placenta abrupts, which causes increased pressure in the intervillous space.

Excess amounts of thromboplastin escape into the mater­nal circulation and defibrination occurs. Profound coagu­lopathy and acute hypovolemia from blood loss can occur and are more likely with an abruption severe enough to kill the fetus. Ultrasound may be helpful to exclude placenta previa, but failure to identify a retroplacental clot does not exclude abruption. In most cases, abruption is an indica­tion for immediate cesarean delivery because of the high risk of fetal death.

Testing

The tests should include the following:

• Ultrasonography
• Complete blood count (CBC) and type and screen
• Possibly Kleihauer-Betke testing

All women with bleeding during late pregnancy require ultrasonography, done at the bedside if the patient is unstable. Transvaginal ultrasonography should be considered if normal placentation has not been previously confirmed. A normal placenta and normal cord and vessel insertion exclude placenta previa and vasa previa. Although ultrasonography sometimes shows abruptio placentae, this test is not sufficiently reliable to distinguish abruptio placentae from uterine rupture. These diagnoses are made clinically, based on risk factors and examination findings (a tense uterus is more common in abruptio placentae; loss of tone is more common in rupture). Rupture is confirmed during laparotomy.

In addition, CBC and type and screen (blood typing and screening for abnormal antibodies) should be done. If bleeding is severe, if moderate to severe abruptio placentae is suspected, or if maternal hypotension is present, several units of blood are cross-matched and tests for disseminated intravascular coagulation (prothrombin time/partial thromboplastin time [PT/PTT], fibrinogen level, d-dimer level) are done.

The Kleihauer-Betke test can be done to measure the amount of fetal blood in the maternal circulation and determine the need for additional doses of Rho(D) immune globulin to prevent maternal sensitization.

Treatment

Treatment of vaginal bleeding during late pregnancy is aimed at the specific cause. Patients with signs of hypovolemia require IV fluid resuscitation, starting with 20 mL/kg of normal saline solution.

Blood transfusion should be considered for patients who have any of the following:

• No response to 2 L of saline,
• Abnormal vital signs or laboratory test results
• Continuing bleeding