What are the key questions to ask and steps to take when evaluating and managing pregnancy bleeding?

Key Questions and Management Steps for Pregnancy Bleeding

When evaluating pregnancy bleeding, a systematic approach focusing on specific questions and management steps is essential to identify potentially life-threatening conditions and optimize maternal and fetal outcomes.

Initial Assessment Questions

• Timing and characteristics of bleeding:

  • When did the bleeding start? 1
  • What is the amount of bleeding (light spotting vs. heavy flow)? 1
  • Is the bleeding associated with pain? 1
  • Is there passage of tissue or clots? 1

• Pregnancy history:

  • Gestational age (trimester-specific causes differ significantly) 1
  • Previous episodes of bleeding in this pregnancy 1
  • Previous pregnancy complications (especially prior placenta previa or accreta) 1
  • History of cesarean deliveries or uterine surgeries 1

• Risk factors assessment:

  • History of bleeding disorders 1
  • Fibrinogen levels if relevant 1
  • Previous pregnancy losses 1
  • Multiple gestations 1

Physical Examination Considerations

• Vital signs monitoring to assess hemodynamic stability 1

  • Blood pressure, pulse, respiratory rate, temperature
  • Signs of hypovolemic shock

• Abdominal examination:

  • Uterine tenderness or rigidity (may indicate abruption) 1
  • Fundal height assessment 1

• Important: Avoid digital pelvic examination until placenta previa, low-lying placenta, and vasa previa have been excluded by ultrasound 1

Immediate Management Steps

• Establish IV access and draw blood for laboratory studies 1

  • Complete blood count
  • Blood type and Rh status
  • Coagulation studies (particularly important with heavy bleeding)
  • Fibrinogen levels (especially in patients with known fibrinogen disorders) 1

• Fetal assessment:

  • Fetal heart rate monitoring 1
  • Ultrasound evaluation 1

• Fluid resuscitation if hemodynamically unstable 1

Imaging Studies

• Transabdominal ultrasound to assess:

  • Fetal viability 1
  • Placental location 1
  • Evidence of abruption 1
  • Presence of subchorionic hemorrhage 1

• Transvaginal ultrasound for:

  • Precise placental localization in suspected previa 1
  • Assessment of cervical length 1
  • Evaluation for vasa previa 1

• Doppler studies when vasa previa is suspected 1

Trimester-Specific Management

Second and Third Trimester Bleeding

• For placenta previa:

  • Assess distance from placental edge to internal cervical os 1
  • Hospitalization may be necessary, especially after an episode of bleeding 1
  • Plan for delivery timing (typically 34-36 weeks for stable patients with placenta previa) 1

• For suspected placental abruption:

  • Continuous fetal monitoring 1
  • Assessment of maternal coagulation status 1
  • Preparation for possible emergency delivery 1

• For vasa previa:

  • Planned cesarean delivery before labor onset 1
  • Consider hospitalization from 30-32 weeks 1

• For patients with fibrinogen disorders and vaginal bleeding:

  • Target fibrinogen replacement to levels ≥1.5 g/L until bleeding cessation 1
  • Consider tranexamic acid administration based on thrombotic risk 1

Special Considerations

• For suspected placenta accreta spectrum:

  • Multidisciplinary team involvement (maternal-fetal medicine, anesthesiology, blood bank) 1
  • Preparation for possible massive transfusion 1
  • Consideration of planned cesarean hysterectomy 1

• For unexpected intraoperative recognition of placenta accreta:

  • Temporarily pause the case if possible 1
  • Alert anesthesia team and consider general anesthesia 1
  • Obtain additional IV access and order blood products 1

Postpartum Hemorrhage Management

• For patients with bleeding disorders:

  • Close clinical monitoring for 72 hours postpartum 1
  • Early fibrinogen replacement targeting levels >1.5 g/L 1
  • Consider tranexamic acid administration 1

• For all patients with significant postpartum bleeding:

  • Keep patient warm (temperature >36°C) 1
  • Avoid acidosis 1
  • Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1
  • Consider fixed ratio transfusion of packed red cells, fresh frozen plasma, and platelets for massive hemorrhage 1

The systematic evaluation of pregnancy bleeding requires immediate assessment of maternal and fetal status, appropriate imaging studies, and condition-specific management to optimize outcomes and reduce morbidity and mortality.