Snap Shot
  •  A 33-year-old G4P3 presents at 29 weeks gestation by dates with painless vaginal bleeding. The bleeding began two hours ago and has delivered a substantial amount of blood with clots. She is having no uterine contractions and the fetal heart rate is 150. Her last pregnancy was delivered by emergency cesarean at 37 weeks due to double-footing breech presentation during labor.

  • Placenta Abrupto and Placenta Previa are the two most common causes of third trimester bleeding
  • In Placenta Previa, the placenta is implanted over internal cervical os
  • Classified as
    • total
    • partial
    • marginal
    • low lying
  • Incidence is 1/200
  •  Risk factors include
    • prior cesarean sections
    • grand multiparous
    • advanced maternal age
  • Symptoms
    • painless bright red bleeding at 29-30 weeks 
      • of note abruptio is painful
    • bleeding often stops in 1-2 hours with or without uterine contractions
    • usually no fetal distress (vs. vasa previa which normally presents with fetal heart deccelerations due to compression of umbilical vessels)
  • Transabdominal ultrasound to look for abnormally positioned placenta  
  • Vaginal exam and transvaginal ultrasound are contraindicated due to risk of placental disruption 
  •  Abruptio placentae
  • Stablize patient with premature fetus
    •  treatment
      • pelvic rest
      • tocolytics (magnesium sulfate)
      • amniocentesis to check fetal lung maturity
  • Proceed with delivery (Caesarean section) if
    • persistant labor
    • blood loss > 500 mL
    • coagulation defects
    • documented fetal lung maturity
      • L:S ratio > 2
    • > 36 weeks gestation
Prognosis, Prevention, and Complications
  • Associated with 2-fold increase in congenital malformations
  • Placenta accreta
  • Vasa previa
    • rupture of fetal vessels that cross the membranes covering the cervix
    • treat with C-section 
  • Increases risk of postpartum hemorrhage

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