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Vaginal Bleeding During Late Pregnancy

By

Emily E. Bunce

, MD, Wake Forest Baptist Health;


Robert P. Heine

, MD, Wake Forest School of Medicine

Last full review/revision Dec 2020| Content last modified Dec 2020
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Bleeding during late pregnancy ( 20 weeks gestation, but before birth) occurs in 3 to 4% of pregnancies.

Pathophysiology

Some disorders can cause substantial blood loss, occasionally enough to cause hemorrhagic shock or disseminated intravascular coagulation.

Etiology

The most common cause of bleeding during late pregnancy is

  • Bloody show of labor

Bloody show heralds onset of labor, is scant and mixed with mucus, and results from tearing of small veins as the cervix dilates and effaces at the start of labor.

More serious but less common causes (see table Some Causes of Bleeding During Late Pregnancy) include

Abruptio placentae is premature separation of a normally implanted placenta from the uterine wall. The mechanism is unclear, but it is probably a late consequence of chronic uteroplacental vascular insufficiency. Some cases follow trauma (eg, assault, motor vehicle crash). Because some or most of the bleeding may be concealed between the placenta and uterine wall, the amount of external (ie, vaginal) bleeding does not necessarily reflect the extent of blood loss or placental separation. Abruptio placentae is the most common life-threatening cause of bleeding during late pregnancy, accounting for about 30% of cases. It may occur at any time but is most common during the 3rd trimester.

Placenta previa is abnormal implantation of the placenta over or near the internal cervical os. It results from various risk factors. Bleeding may be spontaneous or triggered by digital examination or by onset of labor. Placenta previa accounts for about 20% of bleeding during late pregnancy and is most common during the 3rd trimester.

In vasa previa, the fetal blood vessels connecting the cord and placenta overlie the internal cervical os and are in front of the fetal presenting part. Usually, this abnormal connection occurs when vessels from the cord run through part of the chorionic membrane rather than directly into the placenta (velamentous insertion). The mechanical forces of labor can disrupt these small blood vessels, causing them to rupture. Because of the relatively small fetal blood volume, even a small blood loss due to vasa previa can represent catastrophic hemorrhage for the fetus and cause fetal death.

Uterine rupture may occur during labor—almost always in women who have had scarring of the uterus (eg, due to cesarean delivery, uterine surgery, or uterine infection)—or after severe abdominal trauma.

Bleeding may also result from nonobstetric disorders.

Table
icon

Some Causes of Bleeding During Late Pregnancy

Cause

Suggestive Findings

Diagnostic Approach

Passage of blood-tinged mucus plug, not active bleeding

Painful, regular uterine contractions with cervical dilation and effacement

Normal fetal and maternal signs

Diagnosis of exclusion

Painful, tender uterus, often tense with contractions

Dark, clotted, or bright red blood; in some women, slight or absent bleeding before delivery

Sometimes maternal hypotension

Signs of fetal distress (eg, bradycardia or prolonged deceleration, repetitive late decelerations, sinusoidal pattern)

Clinical suspicion

Often, ultrasonography, although it is not very sensitive

Sudden onset of painless vaginal bleeding with bright red blood and minimal or no uterine tenderness

Sometimes suspected based on findings during routine screening ultrasonography

Transvaginal ultrasonography

Painless vaginal bleeding with fetal instability but normal maternal signs

Often, symptoms of labor

Sometimes suspected based on findings during routine screening ultrasonography

Transvaginal ultrasonography with color Doppler studies

Severe abdominal pain, tenderness, cessation of contractions, often loss of uterine tone

Mild to moderate vaginal bleeding

Fetal bradycardia or loss of heart sounds

Maternal tachycardia

Loss of fetal station

Clinical suspicion, usually history of prior uterine surgery

Laparotomy

Evaluation

The evaluation of patients with vaginal bleeding during late pregnancy aims to exclude potentially serious causes of bleeding (abruptio placentae, placenta previa, vasa previa, uterine rupture). Bloody show of labor and abruptio placentae are diagnoses of exclusion.

History

History of present illness should include

  • The patient’s gravidity (number of confirmed pregnancies), parity (number of deliveries after 20 weeks), and number of abortions (spontaneous or induced)

  • Duration of bleeding

  • Amount and color (bright red vs dark) of blood

Important associated symptoms include abdominal pain and rupture of membranes. Clinicians should note whether these symptoms are present or not and describe them (eg, whether pain is intermittent and crampy, as in labor, or constant and severe, suggesting abruptio placentae or uterine rupture).

Review of systems should elicit any history of syncope or near syncope (suggesting major hemorrhage).

Past medical history should note risk factors for major causes of bleeding (see table Some Risk Factors for Major Causes of Bleeding During Late Pregnancy), particularly previous cesarean delivery. Clinicians should determine whether patients have a history of hypertension, cigarette smoking, in vitro fertilization, or any illicit drug use (particularly cocaine).

Table
icon

Some Risk Factors for Major Causes of Bleeding During Late Pregnancy

Cause

Risk Factors

Hypertension

Age > 35

Multiparity

Cigarette smoking

Cocaine

Previous abruptio placentae

Trauma

Previous cesarean delivery

Multiparity

Multiple gestations

Previous placenta previa

Age > 35

Cigarette smoking

In vitro fertilization

Low-lying placenta

Bilobed or succenturiate-lobed placenta

Multiple gestations

In vitro fertilization

Previous cesarean delivery

Any uterine surgery

Age > 30

History of uterine infection

Induction of labor

Trauma (eg, gunshot wound)

Grand multiparity (delivery of ≥ 5 viable fetuses)

Uterine abnormalities

Multifetal pregnancies

Short interpregnancy interval

Placenta accreta spectrum (including placenta increta, and perceta)

Physical examination

Examination starts with review of vital signs, particularly blood pressure, for signs of hypovolemia. Fetal heart rate is assessed, and continuous fetal monitoring is started if possible.

The abdomen is palpated for uterine size, tenderness, and tonicity (normal, increased, or decreased).

A digital cervical examination is contraindicated when bleeding occurs during late pregnancy until ultrasonography confirms normal placental and vessel location (and excludes placenta previa and vasa previa). Careful speculum examination can be done. If ultrasonography is normal, clinicians may proceed with a digital examination to determine cervical dilation and effacement.

Red flags

The following findings are of particular concern:

  • Hypotension

  • Tense, tender uterus

  • Fetal distress (loss of heart sounds, bradycardia, variable or late decelerations detected during monitoring)

  • Cessation of labor and atonic uterus

Vaginal bleeding may be mild despite maternal hypotension.

Interpretation of findings

If more than a few drops of blood are observed or there are signs of fetal distress, the more serious causes must be ruled out: abruptio placentae, placenta previa, vasa previa, and uterine rupture. However, some patients with abruptio placentae or uterine rupture have minimal visible bleeding despite major intra-abdominal or intrauterine hemorrhage.

Clinical findings help suggest a cause (see also table Some Causes of Bleeding During Late Pregnancy):

  • Light bleeding with mucus suggests bloody show of labor.

  • Sudden, painless bleeding with bright red blood suggests placenta previa or vasa previa.

  • Dark red clotted blood suggests abruptio placentae or uterine rupture.

  • A tense, contracted, tender uterus suggests abruptio placentae.

  • An atonic or abnormally shaped uterus with abdominal tenderness suggests uterine rupture.

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

Key Points

  • All patients with vaginal bleeding during late pregnancy require IV access for fluid or blood resuscitation, as well as continuous maternal and fetal monitoring.

  • A digital cervical examination is contraindicated in evaluation of bleeding during late pregnancy until placenta previa and vasa previa are excluded.

  • In abruptio placentae, vaginal bleeding may be absent if blood is concealed between the placenta and uterine wall.

  • Suspect uterine rupture in women with a history of cesarean delivery or other uterine surgery.

  • Vaginal bleeding may be mild despite maternal hypotension.

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