Snapshot A 30-year-old, G1P0, female at 36 weeks gestation presents to the emergency room with sudden onset of severe back pain which has lasted for 2 hours. Thirty minutes prior to presentation she noted bright red vaginal bleeding. She has had no prenatal care. On physical exam she is afebrile; her blood pressure is 30/80 mmHg, pulse is 106/min, and respirations are 18/min. Abdominal palpation reveals a gravid hypertonic uterus and palpable uterine contractions. You observe blood in the vaginal vault. Results of transabdominal ultrasound are shown. Introduction Clinical definition premature separation of a normally implanted placenta placenta abruptio and placenta previa are the two most common causes of third trimester bleeding Epidemiology incidence 1% of all pregnancies demographics more common in African-American women risk factors trauma (e.g., motor vehicle accident) prior placental abruption maternal smoking cocaine use hypertensive disorders of pregnancy such as eclampsia preeclampsia premature rupture of membrane hyperhomocystinemia Pathophysiology rupture of maternal vessels results in bleeding into the decidual-placental interface that leads to placental separation from the uterine wall Associated conditions may be associated with cardiovascular disease Prognosis mother prompt intervention decreases the incidence of maternal mortality fetus increased mortality rate Presentation Symptoms abrupt third trimester vaginal bleeding abdominal and/or back pain uterine contractions Physical exam gravid hypertonic uterus blood/clots may be observed in the vaginal vault fetal distress is present Imaging Ultrasound indications used to rule out placenta previa to find a retroplacental hematoma which is classic for placental abruption Studies Diagnostic criteria a clinical diagnosis that can be confirmed with pathologic placental evaluation Differential Placenta previa presents as painless vaginal bleeding Uterine rupture Normal or pre-term labor Treatment Conservative expectant management with continuous fetal monitoring indications when both the mother and fetus are stable and the fetus is < 34 weeks gestation vaginal delivery indications in cases where the fetus is ≥ 36 weeks gestation, vaginal delivery is preferrable if there are no indications to cesarean delivery if the patient is not in active labor then amniotomy and oxytocin administration can be used Operative immediate delivery indications in cases of non-reassuring fetal status in cases of hemodynamic instability in the mother when the fetus is 34-36 weeks gestation; however, this is dependent on patient specific factors balancing risk and benefit Complications Complications disseminated intravascular coagulation (DIC) hemorrhagic shock recurrence risk in future pregnancies 3-15% have a recurrence fetal anemia