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APGO educational topic number 23 third
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trimester bleeding bleeding in the third
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trimester of pregnancy can range from
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spotting to life-threatening hemorrhage
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remember that at term a woman’s total
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blood volume has increased by 40 percent
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and our cardiac output has increased by
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30 percent 20 percent of cardiac output
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goes to the gravid uterus so significant
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bleeding can be quickly catastrophic the
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objectives of this video are to list the
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causes of third trimester bleeding to
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describe the initial evaluation of a
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patient with third trimester bleeding
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differentiate the signs and symptoms
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with third trimester bleeding list the
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maternal and fetal complications of
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placenta previa and placental abruption
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describe the initial evaluation and
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management plan for acute blood loss
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lists the indications and potential
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complications of blood product
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transfusion the causes of third
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trimester bleeding include placenta
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previa placental abruption preterm labor
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uterine rupture and vaso previa as well
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as vaginal or cervical tear or
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laceration from intercourse cervical
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polyp or severe cervicitis
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we will focus on the first two on this
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list the Sun to previa & placental
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abruption in this video the first five
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causes can lead to serious neonatal and
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maternal morbidity and mortality the
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last three on this list are considered
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the benign causes of third trimester
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bleeding we are all familiar with the
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ABCs of cardiopulmonary resuscitation
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don’t forget in a pregnant third
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trimester patient with bleeding there
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needs to be another b4 baby remember to
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always assess fetal heart rate status as
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part of the initial evaluation of third
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trimester bleeding once you are assured
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that the patient is stable and that
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there is a reassuring fetal heart rate
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pattern then a careful history should be
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obtained here the PP qrst mnemonic is
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helpful to frame your questions P is
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there pain with the bleeding P placenta
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has she had a formal ultrasound during
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the pregnancy that assess for some –
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location Q quantity of bleeding are
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recreational drugs during this pregnancy
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s sex recently and T the timing of the
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bleeding then move on to the physical
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examination look at the maternal vital
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signs again remember to assess the fetal
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heart rate ensure that there is good IV
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access if you are concerned about heavy
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bleeding
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look at the skin carefully for petechiae
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I’ll pick the uterus to assess if it is
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soft hard or tender remember do not
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perform a cervical examination until the
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placental location has been confirmed a
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speculum examination can be performed to
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visually assess the cervix let’s now
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discuss placenta previa here is the
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uterus with the external off internal
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off and endometrial cavity a complete
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previa completely covers the AHS where
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as a marginal previa partially covers
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the AHS the classic presentation for
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placenta previa is painless vaginal
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bleeding the center previa is diagnosed
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by ultrasound remember that with a
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placenta praevia a digital cervical
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examination should not be performed for
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digital manipulation can cause bleeding
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if there is heavy bleeding volume
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resuscitation and possibly betamethasone
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for fetal lung maturity the management
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of placenta previa must balance the
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risks of prematurity with the risks to
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mom of heavy vaginal bleeding delivery
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where the placenta previa should be
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performed via caesarean section let’s
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now discuss potential complications with
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placenta previa there can be bleeding
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from the lower uterine segment where the
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placenta was abnormally attached in
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addition there can be abnormal extension
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of placental tissue placenta accreta
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involves extension of the central tissue
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into the superficial layer the
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myometrium in Krita involves extension
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further into the myometrium and percreta
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involves extension completely through
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the myometrium to the serosa and
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sometimes into adjacent viscera note
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that the depth of invasion corresponds
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to alphabetical order these three
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abnormal placental extensions are
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associated with significant bleeding and
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morbidity cesarean hysterectomies need
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to be performed for these three
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conditions let’s now discuss the central
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abruption this is an abnormal separation
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of the placenta and the classic
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presentation is vaginal bleeding with
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abdominal pain here is the placenta that
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is normally attached to the endometrial
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wall if this starts to separate with a
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placental abruption then there is
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usually painful vaginal bleeding note
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that there can be concealed bleeding if
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the blood is trapped behind the placenta
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and cannot exit the term Cavalleria
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uterus refers to the extrapolation of
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blood into the uterine musculature which
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causes the uterus to appear purple or
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blue risk factors for placental
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abruption include trauma
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such as a motor vehicle accident
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domestic violence or fall cocaine use
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hypertension and multiple gestation the
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diagnosis of placental abruption is by
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clinical examination the management of
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placental abruption involves monitoring
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of the vital signs fluid administration
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close monitoring of fetal heart rate
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pattern and delivery for severe
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hemorrhage
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note that abruption is the most common
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cause of coagulopathy and pregnancy
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let’s conclude this video by discussing
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evaluation and plan for managing acute
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blood loss obstetric hemorrhage is one
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of the leading causes of massive blood
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transfusion along with trauma ruptured
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abdominal aortic aneurysm and liver
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transplant massive blood transfusion is
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defined as a transfusion of greater than
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10 units of packed red blood cells and
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24 hours remember that one unit of
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packed red blood cells is approximately
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200 cc’s of red cells and should raise
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the hematocrit by approximately 3 to 4
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percent a key point to remember is that
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oxygen delivery is greater than four
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times oxygen consumption so there is
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always enormous reserve
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so if intravascular volume is maintained
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during bleeding and cardiovascular
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status is not impaired then oxygen
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delivery can be maintained until
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bleeding becomes too excessive this is
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why it is so important for anesthesia
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colleagues to aggressively give IV
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fluids during a hemorrhage in order to
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maintain this intravascular volume in
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cases of massive transfusion if only red
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blood cells and crystalloid volume are
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administered and they’ll be dilution of
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the plasma clotting proteins the one to
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one to one ratio reflects a ratio of 1
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unit of fresh frozen plasma to one unit
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of packed red blood cells to one unit of
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platelets let’s take a step back to
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discuss when do we decide to give a
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blood transfusion
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we have to consider the risks of
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transfusion and the desire to avoid an
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unnecessary transfusion in this
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discussion in cases of massive
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hemorrhage the need for transfusion is
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great in order to avoid significant
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morbidity and mortality in less acute
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situations the patient’s overall health
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status and blood counts will help with
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the decision-making in general when the
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hemoglobin is 6 to 7 a transfusion is
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recommended between 7 & 8 that a
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transfusion should be strongly
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considered and between 8 and 10
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transfusion is needed generally only if
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the patient has symptomatic anemia or
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acute coronary syndrome the risks of
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blood transfusion that must be
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considered are the risk of infection the
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risk of HIV is approximate
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one out of 450,000 to 650,000 the risk
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of allergy or immune reaction and risk
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of volume overload the final point to
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remember with third trimester bleeding
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is to remember to give rhogam to Rh
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negative mom’s this concludes the aapko
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video and third trimester bleeding we
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have discussed the causes evaluation and
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management of the most common causes a
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third trimester bleeding and the
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management of acute blood loss