Society for Maternal-Fetal Medicine (SMFM) Consult Series | #44Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period
Section snippets
What are the etiologies of late preterm antepartum third-trimester bleeding?
The phrase, third-trimester bleeding, defines vaginal blood loss that occurs in the latter part of pregnancy and can range from spotting to obstetric hemorrhage. There is no universally agreed-upon definition of antepartum obstetric hemorrhage; however, the definition most frequently used is bleeding from the genital tract that occurs in the latter half of gestation.
The etiologies of third-trimester bleeding are varied and of differing acuity. The epidemiology of late preterm vaginal bleeding
Placenta previa
Placenta previa can cause late preterm third-trimester bleeding and is defined as placental implantation that overlies or abuts the internal cervical os. Classically, a patient presents with painless bleeding. Diagnosis is most accurately made by transvaginal ultrasound.1, 2 The incidence of placenta previa ranges from 5% to 20% with second-trimester transabdominal ultrasonography.3, 4, 5
Transvaginal ultrasound provides a more accurate diagnosis than transabdominal ultrasound, with estimates of
What is the evaluation of women who present with late preterm bleeding?
A detailed history and physical examination are important in the evaluation of bleeding in the late preterm period. Pertinent elements in the history include the amount and duration of bleeding as well as a review of the woman’s obstetric course, including any prior bleeding.
A history of cesarean delivery, myomectomy, or dilation and curettage is important because these are thought to increase the risk of placenta accreta.2, 47 Imaging results should be reviewed to evaluate reported
Timing of delivery
The management of women presenting with late preterm bleeding depends on the amount and duration of bleeding, maternal and fetal status, presence of preterm labor or ruptured membranes, and the patient’s proximity to the hospital. The decision for delivery is highly dependent on the degree and etiology of bleeding.
Stabilization and preparation for delivery is indicated in women with an active, ongoing hemorrhage in the late preterm period, regardless of etiology. Stabilization includes the
What are the neonatal sequelae of late preterm delivery?
The rate of late preterm delivery, defined as delivery between 34 0/7 weeks through 36 6/7 weeks of gestation, has declined consistently in the United States over the past several years.58, 59 Nevertheless, many indications for late preterm birth exist.8, 9 Guidance about appropriate indications for late preterm delivery is available but is based mainly on expert opinion. Furthermore, this guidance does not address management decisions in the face of the expected changes in clinical status that
What are the gaps in knowledge regarding late preterm bleeding?
The likelihood of the recurrence of bleeding that first presents in the late preterm period is ill defined. Rather, data on recurrence of bleeding are extrapolated from the likelihood to enter spontaneous labor, which would precipitate further bleeding from many of the conditions described. Diagnostic criteria that reliably predict placental abruption are needed. Placental abruption is often a diagnosis of exclusion when other known sources of vaginal bleeding, such as placenta previa and
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