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Some Causes of Bleeding During Late Pregnancy

Cause

Suggestive Findings

Diagnostic Approach*

Labor

Passage of blood-tinged mucus plug, not active bleeding

Painful, regular uterine contractions with cervical dilation and effacement

Maternal vital signs and serial pelvic examinations

Fetal heart rate monitoring

Placental abruption

Dark, clotted, or bright red blood, bleeding may be profuse; in some women, slight or absent bleeding before delivery (concealed abruption)

Painful, tender uterus, often tense with contractions

Sometimes, maternal hypotension

Signs of fetal distress (eg, bradycardia or prolonged deceleration, repetitive late decelerations, sinusoidal pattern)

Maternal vital signs and pelvic examination

Fetal heart rate monitoring

Complete blood count, coagulation tests

Often, ultrasonography, although it is not very sensitive

Placenta previa

Sudden onset of painless vaginal bleeding with bright red blood and minimal or no uterine tenderness

Often, a low-lying placenta detected earlier in pregnancy on routine screening ultrasonography

NOTE: DIGITAL CERVICAL EXAMINATION SHOULD NOT BE PERFORMED.

Complete blood count

Ultrasonography

Vasa previa

Painless vaginal bleeding with fetal instability but normal maternal signs

Often, symptoms of labor

Sometimes, suspected based on findings during routine screening ultrasonography

Transvaginal ultrasonography with color Doppler studies

Uterine rupture

Severe abdominal pain, tenderness, cessation of contractions, often loss of uterine tone

Mild to moderate vaginal bleeding

Fetal bradycardia or loss of heart sounds

Maternal tachycardia

Loss of fetal station

Usually, a history of prior cesarean delivery or other uterine surgery

Clinical suspicion, based on characteristic signs and symptoms

Emergency cesarean delivery

* Evaluation of concerning symptoms in all pregnant patients should include assessment of maternal vital signs, physical examination, and evaluation of fetal status with fetal heart rate monitoring or ultrasonography.