This is from Current Ob&Gyn talking about bleeding in third trimester There are 2 principles that must be followed in investigation of third-trimester hemorrhage:
(1) Any woman experiencing vaginal bleeding in late pregnancy must be evaluated in a hospita
l capable of dealing with maternal hemorrhage and a compromised perinate.
(2) A vaginal or rectal examination must not be performed
until placenta previa has been ruled out and until preparations are complete for management of massive hemorrhage and maternal or perinatal complications. (Vaginal or rectal examination is extremely hazardous because of the possibility of provoking an uncontrollable, catastrophic hemorrhage.)
Then we see if it's life threatening bleeding or not, each has a different management. We look for signs of hypovolemic shock.
A. HISTORY AND ABDOMINAL EXAMINATION
Once the patient is evaluated and found to be hemodynamically stable, the cause of bleeding must be quickly identifed. After a brief history is obtained, the patient's abdomen should be examined and a bedside ultrasound performed to evaluate the location of the placenta and the fetal status.
If ultrasound is not immediately available, fetal heart tones should be obtained and the fundal height marked on the abdomen with a ballpoint or other indelible pen. This aids in determining gestational age, and later in ascertaining if the uterus is rapidly expanding from concealed hemorrhage due to abruptio placentae. Leopold's maneuvers assist in determination of fetal size, presentation, position, and engagement. It is crucial to determine whether the presenting part is well engaged in the pelvis. When there is engagement, total placenta previa is unlikely. Palpation for uterine contractions, tone, and tenderness should be conducted. Hemodynamic status can change after initial assessment and therefore should be continuously reevaluated.
B. LABORATORY EVALUATION
Laboratory evaluation should include: blood type and cross-match (give 2?6 units, depending on the hemodynamic status) as well as a complete blood count with platelets and baseline coagulation status (prothrombin time and partial thromboplastin time). D-Dimer or fibrin split products are useful when abruptio placentae is suspected. These are the most sensitive tests to confirm coagulopathy; however, they are qualitative studies and give little information about the severity of abruption. Recent literature has demonstrated a correlation between elevated CA-125 levels and abruption. This assay has little clinical utility, as it usually requires a long turnaround time. A Kleihauer-Betke test may be useful in the Rh-negative patient. The results are useful in calculating the appropriate dose of Rh immune globulin.
C. VAGINAL EXAMINATION
Neither a vaginal examination nor a rectal examination should be performed until placenta previa has been excluded. Once this has been achieved, both a speculum and a manual vaginal examination should be performed to evaluate for the presence of either a nonobstetric etiology or labor. When other causes have been excluded, placental abruption (including marginal sinus bleed) becomes the assumed diagnosis.
D. ULTRASOUND EXAMINATION
The most accurate way to confirm a diagnosis of placenta previa is by ultrasound. A translabial study may better assess the placental location for a posterior placenta than a transabdominal scan. Transvaginal ultrasound is the most accurate means to evaluate for placenta previa. It has been demonstrated to be safe in experienced hands. Finally, the addition of color flow Doppler to real-time ultrasound increases the sensitivity. It has limited sensitivity in diagnosing a retroplacental clot (caused by abruption), even in experienced hands. However, ultrasound may be useful for diagnosis of a concealed hemorrhage when a combination of abnormal findings coexist sonographically.
Ultrasound evaluation should be performed in the labor and delivery suite if possible. Fetal heart rate monitoring should continue at regular intervals throughout the study. Assessment of amniotic fluid volume and confirmation of fetal age should be obtained at time of ultrasound. In addition, an amniocentesis for fetal lung maturity should be performed if indicated.
E. MANAGEMENT OF BLEEDING
At this point, findings regarding the status of the mother, fetus, and placenta and evaluation of labor should be combined to provide a diagnosis and to plan the course of management. The 3 general management options are immediate delivery, continued labor, or expectant management, depending on the diagnosis.
If the fetus is immature, the patient should be treated expectantly unless additional complications appear (eg, continuing bleeding, fetal distress, labor, or spontaneous rupture of the membranes). In about 90% of cases, third-trimester bleeding will subside within 24 hours. If placental studies signify a high placental implantation and bleeding stops, vaginal examination is indicated prior to discharge of the patient to exclude nonobstetric causes of bleeding.
In the past, a ?double setup examination? was frequently employed for diagnosis of third-trimester bleeding. All preparations were made for cesarean section, except for administering the anesthetic. A careful vaginal examination with a speculum was then conducted. If the placenta was not visualized, it was thought that placenta previa could be ruled out. This proved to be a highly inaccurate, dangerous method of diagnosis as compared with ultrasonic localization of the placenta and cesarean delivery without vaginal examination for placenta previa. Therefore, the double setup examination has largely been abandoned.
Nonobstetric causes of bleeding in late pregnancy usually result only in spotting that does not increase with activity. There are no uterine contractions, and the definitive diagnosis is usually made by speculum examination, Papanicolaou smear, culture, or colposcopy. Only in advanced cancer is there a poor maternal prognosis. Vaginal lacerations and varices may require repair but have a good prognosis. Most infections causing bleeding clear readily when treated with appropriate agents. Benign neoplasias and eversions require simple treatment and have a good prognosis.