Advanced Life Support in Obstetrics (ALSO): Vaginal Bleeding in Late Pregnancy

All that follows is from Chapter C in the Advanced Life Support in Obstetrics (ALSO) Course Manual, August 2010, Vaginal Bleeding in Late Pregnancy:


“The four conditions that account for most cases of serious or life-threatening hemorrhage are placenta previa, placental abruption [“Abruption is the most common cause of serious vaginal bleeding, occurring in one percent of pregnancies.], uterine scar disruption, and vasa previa. Nonemergent causes of bleeding include cervical dilatation during normal labor, which is commonly accompanied by a small amount of blood or blood tinged mucus (bloody show). Many pregnant women experience spotting or minor bleeding after sexual intercourse or a digital vaginal examination. cervicitis, cervical ectropion, cervical polyps, and cervical cancer are other possible causes of minor bleeding.”


“The initial management of significant bleeding in late pregnancy is similar regardless of the etiology. Determination of vital signs and assessment for circulatory instability are the first steps, along with establishing intravenous access and beginning prompt fluid resuscitation as indicated.”

“Baseline laboratory tests include hematocrit, platelet count, fibrinogen level, coagulation studies, blood type and antibody screen. In some instances it may be appropriate to obtain preeclampsia labs or a urine drug screen. Fibrinogen levels less than 250 mg/dL are abnormal and less than 150 mg/dL are diagnostic for coagulopathy. Protime and activated partial thromboplastin time may be abnormal and platelet levels may be low. Fibrin split products may be elevated, but the presence of fibrin D-dimer is poorly correlated with the diagnosis of abruption. . . . Women who are Rh negative should receive Rho(D) immune globulin (Rhogam); a Kleihauer-Betke test should be performed to determine the appropriate dose.” 

“Continuous fetal monitoring is recommended to determine if there is a need for urgent operative delivery. Fetal heart rate decelerations, tachycardia or loss of variability may resolve with adequate maternal resuscitation; however a persistently nonreassuring fetal heart rate tracing may require delivery before the etiology of the hemorrhages established.”

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