Third Trimester Bleeding, Postpartum
Hemorrhage, & Shock Management
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Objectives for Third Trimester Bleeding
 List the causes of third trimester bleeding
 Describe the initial evaluation of a patient with third
trimester bleeding
 Differentiate the signs and symptoms of third trimester
bleeding
 Describe the maternal and fetal complications of placenta
previa and abruption placenta
 Describe the initial evaluation and management plan for
acute blood loss
 List the indications and potential complications of blood
product transfusion
Objectives for Postpartum Hemorrhage
 Identify the risk factors for postpartum hemorrhage
 Construct a differential diagnosis for immediate and
delayed postpartum hemorrhage
 Develop an evaluation and management plan for the
patient with postpartum hemorrhage
Rationale (why we care….)
 4-5% of pregnancies complicated by 3rd trimester
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bleeding
Immediate evaluation needed
Significant threat to mother & fetus (consider
physiologic increase in uterine blood flow)
Consider causes of maternal & fetal death
Priorities in management (triage!)
Vaginal Bleeding: Differential Diagnosis
 Common:
 Abruption, previa, preterm labor, labor
 Less common:
 Uterine rupture, fetal vessel rupture, lacerations/lesions,
cervical ectropion, polyps, vasa previa, bleeding disorders
 Unknown
 NOT vaginal bleeding!!!
 (happens more than you think!)
Initial Management for Third Trimester
Bleeding
 Stabilize patient – two large bore IVs if bleeding is heavy, EBL is
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significant or patient is clearly unstable
Auscultate fetal heart rate - Confirm reassuring pattern
Focused history
PE
 Vitals
 Brief inspection for petechiae, bruising
 Careful inspection of vulva
 Speculum exam of vagina and cervix – NO DIGITAL EXAM until r/o
previa
Labs – CBC, coag profile, type and cross match
Ultrasound exam to assess placental location and fetal condition
Placental Abruption: Definition
 Separation of placenta from uterine wall
 Incidence
 0.5-1.5% of all pregnancies
 Recurrence risk
 10% after 1st episode
 25% after 2nd episode
Placental abruption: Risk factors and
associations
 Cocaine
 Prolonged PROM
 Maternal hypertension
 Uterine decompression
 Abdominal trauma
 Short umbilical cord
 Smoking
 Chorioamnionitis
 Prior abruption
 Multiparity
 Preeclampsia
 Multiple gestation
Placental Abruption: Symptoms
 Vaginal bleeding
 Abdominal or back pain
 Uterine contractions
 Uterine tenderness
Placental Abruption: Physical Findings
 Vaginal bleeding
 Uterine contractions
 Hypertonus
 Tetanic contractions
 Non-reassuring fetal status or demise
 Can be concealed hemorrhage
Placental Abruption: Laboratory Findings
 Anemia
 May be out of proportion to observed blood loss
 DIC
 Can occur in up to 10% (30% if “severe”)
 First, increase in fibrin split products
 Followed by decrease in fibrinogen
Placental Abruption: Diagnosis
 Clinical scenario
 Physical exam
 NOT DIGITAL PELVIC EXAMS UNTIL RULE OUT PREVIA
 Careful speculum exam
 Ultrasound
 Can evaluate previa
 Not accurate to diagnose abruption
Placental Abruption: Management
 Physical exam
 Continuous electronic fetal monitoring
 Ultrasound
 Assess viability, gestational age, previa, fetal position/lie
 Expectant mgmt
 vaginal vs cesarean delivery
 Available anesthesia, OR team for stat cesarean
delivery
Placenta Previa: Definition
 Placental tissue covers cervical os
 Types:
 Complete - covers os
 Partial
 Marginal - placental edge at margin of internal os
 Low-lying
 placenta within 2 cm of os
Placenta Previa: Incidence
 Most common abnormal placentation
 Accounts for 20% of all antepartum hemorrhage
 Often resolves as uterus grows
 ~ 1:20 at 24 wk.
 1:200 at 40 wk.
 Nulliparous - 0.2%
 Multiparous - 0.5%
Placenta Previa: Risk factors and
associations
 Prior cesarean delivery/myomectomy
 Prior previa (4-8% recurrence risk)
 Previous abortion
 Increased parity
 Multifetal gestation
 Advanced maternal age
 Abnormal presentation
 Smoking
Placenta Previa: Symptoms
 Painless vaginal bleeding
 Spontaneous
 After coitus
 Contractions
 No symptoms
 Routine ultrasound finding
 Avg gestational age of 1st bleed, 30 wks
 1/3 before 30 weeks
Placenta Previa: Physical Findings
 Bleeding on speculum exam
 Cervical dilation
 Bleeding a sx related to PTL/normal labor
 Abnormal position/lie
 Non-reassuring fetal status
 If significant bleeding:
 Tachycardia
 Postural hypertension
 Shock
Placenta Previa: Diagnosis
 Ultrasound
 Abdominal 95% accurate to detect
 Transvaginal (TVUS) will detect almost all
 Consider what placental location a TVUS may find that was
missed on abdominal
 Physical/speculum exam
 remember: no digital exams unless previa RULED OUT!
Placenta Previa: Management
 Initial evaluation/diagnosis
 Observe/admit to L&D
 IV access, routine (maybe serial) labs
 Continuous electronic fetal monitoring
 Continuous at least initially
 May re-evaluate later if stable, no further bleeding
 Delivery???
Placenta Previa: Management
 Less than 36 wks gestation - expectant management if
stable, reassuring
 Bed rest (negotiable)
 No vaginal exams (not negotiable)
 Steroids for lung maturation (<32 wks)
 Possible mgmt at home after 1st bleed

70% will have recurrent vaginal bleeding before 36
completed weeks requiring emergent cesarean
Placenta Previa: Management
 36+ weeks gestation
 Cesarean delivery if positive fetal lung maturity by
amniocentesis
 Delivery vs expectant mgmt if fetal lung immaturity
 Schedule cesarean delivery @ 37 weeks
 Discussion/counseling regarding cesarean hysterectomy

Note: given stable maternal and reassuring fetal
status, none of these management guidelines are
absolute (this is why OB is so much fun!)
Placenta Previa: Other considerations
 Placenta accreta, increta, percreta
 Cesarean delivery may be necessary
 History of uterine surgery increases risk
 Must consider these diagnoses if previa present
 Could require further evaluation, imaging (MRI
considered now)

NOT the delivery you want to do at 2 am
Vasa Previa: Definition
 In cases of velamentous cord insertion fetal vessels
cover cervical os
Vasa Previa: Incidence
 0.1-1.0%
 Greater in multiple gestations
 Singleton - 0.2%
 Twins - 6-11%
 Triplets - 95%
Vasa Previa:
Symptoms, Findings, Diagnosis
 Painless vaginal bleeding
 Fetal bleeding
 Positive Kleihauer Betke test
 Ultrasound
 Routine vs at time of symptoms
Vasa Previa: Management
 If bleeding, plan for emergent delivery
 If persistent bleeding, nonreassuring fetal status,
STAT cesarean… not a time for conservative
mgmt!
 Fetal blood loss NOT tolerated
Third Trimester Bleeding: Other Etiologies
 Cervicitis
 Infection
 Cervical erosion
 Trauma
 Cervical cancer
 Foreign body
 Bloody show/labor
Perinatal Morbidity and Mortality
 Previa
 Decreased mortality from 30% to 1% over last 60 years
 Now emergent cesarean delivery often possible
 Risk of preterm delivery
 Abruption
 Perinatal mortality rate 35%
 Accounts for 15% of 3rd trimester stillbirths
 Risk of preterm delivery
 Most common cause of DIC in pregnancy
 Massive hemorrhage --> risk of ARF, Sheehan’s, etc.
Postpartum Hemorrhage:
Definition and Differential Diagnosis
 EBL >500 cc, vaginal delivery
 EBL >1000 cc, cesarean delivery
 Differential Diagnosis:
 Uterine atony
 Lacerations
 Uterine inversion
 Amniotic fluid embolism
 Coagulopathy
Risk Factors for Postpartum Hemorrhage
 Prolonged labor
 Augmented labor
 Rapid labor
 h/o prior PPH
 Episiotomy
 Preeclampsia
 Overdistended uterus (macrosomia, twins, hydramnios)
 Operative delivery
 Asian or Hispanic ethnicity
 Chorioamnionitis
Uterine Atony
(same overall mgmt regardless of delivery type)
 Recognition
 Uterine exploration
 Uterine massage
 Medical mgmt:
 Pitocin (20-80 u in 1 L NS)
 Methergine (ergonovine maleate 0.2 mg IM)
 Not advised for use if hypertension
 Hemabate (prostaglandin F2 mg IM or intrauterine)
Uterine Atony
 B-lynch suture (to compress uterus)
 Uterine artery ligation
 Must understand anatomy
 Risk of ureteral injury
 Uterine artery embolization
 Typically an IR procedure
 Plan “ahead” and let them know you may need them
 Hysterectomy (last resort)
 Anesthesia involved
 Whether in L&D room or the OR!!!
Lacerations
 Recognition
 Perineal, vaginal, cervical
 All can be rather bloody!
 Assistance
 Lighting
 Appropriate repair
 Control of bleeding
 Identify apex for initial stitch placement
Uterine Inversion
 Uncommon, but can be serious, especially if
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unrecognized
Consider if difficult placental delivery
Consider if cannot recognize bleeding source
Consider… always!
Delayed recognition is bad news
Patient can have shock out of proportion to EBL
 (though not all sources will agree on this)
Uterine Inversion
 Management
 Call for help
 Manual replacement of uterus
 Uterotonics to necessary to relax uterus & allow
thorough manual exploration of uterine cavity
 IV nitroglycerin (100 g)
 Appropriate anesthesia to allow YOU to manually
explore uterine cavity
 Concern for shock… to be discussed (and managed by
the help you’ve called into the room!)
 Exploratory laparotomy may be necessary
Amniotic Fluid Embolism
 High index of suspicion
 Recognition
 Again… call for help!
 Supportive treatment
 Replete blood, coagulation factors as able
 Plan for delivery (if diagnose antepartum) if able to
stabilize mom first
Management of Shock
 Stabilize mother
 Large-bore IV x 2
 Place patient in Trendelenburg position
 Crossmatch for pRBCs (2, 4, more units)
 Rapidly infuse 5% dextrose in lactated Ringer’s
 Monitor urine output
 Ins/Outs very important
 (and often not well-recorded prior to emergency situation --
how many times did she really void while in labor??? How
dehydrated was she when presented???)
 By the way… get help (calling for help works quickly on
L&D!)
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})
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
200-250cc
Cryoprecipitate
Factor VIII; 25% fibrinogen, von
Willebrand’s factor
10-40cc
Indications for Transfusion
 No universally accepted guidelines for replacement of blood
components
 If lab data available, most providers will transfuse patients with
hemoglobin values less than 7.5 to 8 g/dL
 If no labs, it is reasonable to transfuse 2 units of packed red
blood cells (pRBCs) if hemodynamics do not improve after the
administration of 2 to 3 liters of normal saline and continued
bleeding is likely.
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
Management of Shock
 Risks of blood transfusion
 Immunologic reactions
 Fever - 1/100
 Hemolysis - 1/25,000
 Fatal hemolytic reaction - 1/1,000,000
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
Bottom Line Concepts
 Common causes of third trimester bleeding - Abruption,
previa, preterm labor, labor
 NO DIGITAL EXAMS until placenta previa has been ruled out
 Ultrasound – can use to evaluate previa but not accurate to
diagnose abruption
 Postpartum hemorrhage refers to EBL >500 cc, vaginal
delivery or EBL >1000 cc, cesarean delivery
 Most common cause of PPH – uterine atony
 No universal rule for when to transfuse – decision made with
clinical judgment and based on each patient’s individual
circumstance and presentation
References and Resources
 APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic
23, 27 (p48-49, 56-57).
 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB
Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas
W Laube, Roger P Smith. Chapter 12, 21 (p133-39, 207-11).
 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th
edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 10 (p128136).

Baron F, Hill WC. “Placenta previa, placenta abruption”, Clinical Obstetrics and
Gynecology, Sep 1998 41(3) pp527-532.

Benedetti T. Obstetric hemorrhage, in obstetrics: normal and problem pregnancies,
Gabbe S, Niebyl J, Simpson J, 3rd ed. New York: Churchill Livingston 1996, pp161-184.

Hertzberg B. “Ultrasound evaluation of third trimester bleeding,” The Radiologist, July
1997 4(4) pp227-234.

Sheiner E, Shohan-Vardi I. “Placenta previa: obstetric risk factors and pregnancy
outcome,” Journal of Maternal-Fetal Medicine, December 2001 10(6) pp414-418.

Jacobs, Allan J. “Management of postpartum hemorrhage at vaginal delivery.”
UpToDate. May 2011