Can a 38-year-old female at 22 weeks gestation with approximately 1 cup of bright red bleeding and a normal pelvic ultrasound (US) have a normal pregnancy and go to term?

Prognosis of Second Trimester Bleeding with Normal Ultrasound

A 38-year-old woman at 22 weeks gestation with approximately 1 cup (240 mL) of bright red bleeding and a normal pelvic ultrasound can potentially continue to term, but faces significantly elevated risks of adverse pregnancy outcomes including preterm delivery, recurrent bleeding episodes, and placental complications that require intensive surveillance.

Immediate Clinical Context and Limitations

• The American College of Radiology emphasizes that ultrasound misses up to 50% of placental abruptions, meaning a normal ultrasound does not definitively exclude this life-threatening condition 1, 2, 3
• This volume of bleeding (approximately 240 mL) represents moderate hemorrhage at 22 weeks gestation, which is concerning even with reassuring imaging 1
• Digital cervical examination should only be performed after ultrasound has definitively excluded placenta previa, low-lying placenta, and vasa previa to avoid precipitating catastrophic hemorrhage 1, 2, 3

Risk Stratification and Prognosis

Likelihood of continuing to term:

• First and second trimester bleeding is associated with substantially increased risk of preterm delivery, with the magnitude of bleeding correlating with adverse outcomes 2
• Patients with significant bleeding episodes face increased risk of recurrent placental abruption later in pregnancy, even when initial ultrasound appears normal 2
• The risk of small for gestational age infants is elevated in pregnancies complicated by mid-trimester bleeding 2

Essential Surveillance Strategy

Immediate management priorities:

• Confirm fetal heart rate pattern shows Category 1 tracing (normal baseline, moderate variability, no decelerations) to assess current fetal well-being 1
• Document maternal vital signs and hemodynamic stability, as normal vital signs do not exclude significant placental pathology that can rapidly deteriorate 2
• Assess cervical length via transvaginal ultrasound, as short cervix identified with bleeding significantly increases preterm delivery risk 2

Ongoing monitoring requirements:

• Continue intensive antenatal surveillance with non-stress tests or biophysical profiles as clinically indicated throughout the remainder of pregnancy 1
• Schedule frequent outpatient follow-up (typically weekly initially) with assessment of maternal vital signs, fetal heart rate, and physical examination 1
• Instruct the patient to monitor daily for warning signs including increased bleeding, regular contractions, abdominal pain, decreased fetal movement, fever, or rupture of membranes 1

Critical Pitfalls to Avoid

• Never dismiss the significance of this bleeding volume: Even with normal ultrasound, placental abruption can present with minimal external bleeding but significant concealed hemorrhage 1
• Avoid false reassurance from single normal ultrasound: Up to 50% of abruptions are not visible on imaging, requiring ongoing clinical vigilance 1, 2
• Do not delay corticosteroids if preterm delivery risk increases: Benefit extends through 35+6 weeks gestation for fetal lung maturity 1
• Maintain high suspicion for recurrent bleeding: This initial episode increases risk of subsequent placental complications throughout the pregnancy 2

Delivery Planning Considerations

• If bleeding recurs or worsens, or if fetal status becomes non-reassuring at any point, expedited delivery may be necessary regardless of gestational age 1
• With stable clinical status and reassuring fetal surveillance, expectant management can continue, but delivery planning should account for the elevated preterm delivery risk 1
• The American College of Obstetricians and Gynecologists recommends considering delivery between 37-39 weeks in pregnancies complicated by significant bleeding episodes, balancing prematurity risks against ongoing placental concerns 1