Bleeding in later pregnancy

Obstetrics

OB triage, 20 weeks and beyond

The first question

Where is the placenta, and is anyone bleeding to death?

Two patients: the gestational age and the maternal stability first, then the fetal status.

01
Maternal stability
Two large cannulas, bloods, crossmatch. Concealed abruption hides its volume.
02
Fetal status
Continuous monitoring; an abnormal tracing with a tender uterus is abruption.
03
Placental location before any examination
The anatomy scan report, or an ultrasound now. No digital examination until praevia is excluded.
04
Decide
Major or unstable: deliver. Minor and stable: admit, observe, steroids if preterm, anti-D if Rh negative.

Where it is

Each opens the structure on the 3D pelvis.

Diagnosis	Favours	Against	Urgency
Placenta praevia	Painless bright bleeding, soft uterus, known low placenta, prior caesarean	Placenta clearly fundal on a recent scan	emergent
Abruption	Pain, hard tender uterus, hypertension, trauma, cocaine, abnormal tracing	Painless with a soft uterus	emergent
Vasa praevia	Bleeding at rupture of membranes with sudden fetal compromise, velamentous cord or low placenta	Intact membranes	emergent
Show, cervical change	Mucousy blood-stained loss with contractions	Volume beyond a few millilitres	routine
Cervical cause (ectropion, polyp, cervicitis, cancer)	Postcoital spotting, a visible source on speculum	Bleeding from the os	routine
Uterine rupture	Prior caesarean in labour, sudden pain, loss of station, fetal bradycardia	Unscarred uterus, not in labour	emergent

Pitfalls this pathway refuses