Society for Maternal-Fetal Medicine (SMFM) Consult Series | #44
Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period

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Third-trimester bleeding is a common complication arising from a variety of etiologies, some of which may initially present in the late preterm period. Previous management recommendations have not been specific to this gestational age window, which carries a potentially lower threshold for delivery. The purpose of this document is to provide guidance on management of late preterm (34 0/7–36 6/7 weeks of gestation) vaginal bleeding. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend delivery at 36–37 6/7 weeks of gestation for stable women with placenta previa without bleeding or other obstetric complications (GRADE 1B); (2) we do not recommend routine cervical length screening for women with placenta previa in the late preterm period due to a lack of data on an appropriate management strategy (GRADE 2C); (3) we recommend delivery between 34 and 37 weeks of gestation for stable women with placenta accreta (GRADE 1B); (4) we recommend delivery between 34 and 37 weeks of gestation for stable women with vasa previa (GRADE 1B); (5) we recommend that in women with active hemorrhage in the late preterm period, delivery should not be delayed for the purpose of administering antenatal corticosteroids (GRADE 1B); (6) we recommend that fetal lung maturity testing should not be used to guide management in the late preterm period when an indication for delivery is present (GRADE 1B); and (7) we recommend that antenatal corticosteroids should be administered to women who are eligible and are managed expectantly if delivery is likely within 7 days, the gestational age is between 34 0/7 and 36 6/7 weeks of gestation, and antenatal corticosteroids have not previously been administered (GRADE 1A).

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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    The authors report no conflict of interest.

    All authors and committee members have filed a conflict of interest disclosure delineating personal, professional, and/or business interests that might be perceived as a real or potential conflict of interest in relation to this publication. Any conflicts have been resolved through a process approved by the Executive Board.

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    This document has undergone an internal peer review through a multilevel committee process within the Society for Maternal-Fetal Medicine (SMFM). This review involves critique and feedback from the SMFM Publications and Document Review Committees and final approval by the SMFM Executive Committee. SMFM accepts sole responsibility for document content. SMFM publications do not undergo editorial and peer review by the American Journal of Obstetrics & Gynecology. The SMFM Publications Committee reviews publications every 18-24 months and issues updates as needed. Further details regarding SMFM Publications can be found at www.smfm.org/publications.

    All questions or comments regarding the document should be referred to the SMFM Publications Committee at [email protected].

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