Evaluation
This mode of imaging is an important part of the initial evaluation for a patient with third trimester bleeding.
What is transvaginal ultrasound?
These 5 major causes of vaginal bleeding in the 2nd and 3rd trimesters
Labor (bloody show)/cervical insufficiency, placenta previa, placenta abruption, uterine rupture, vasa previa?
What are some less common causes of vaginal bleeding in the 2nd and 3rd trimester of pregnancy?
What are uterine, vaginal, or cervical polyps, inflammation/infection, non-tubal ectopic pregnancy, trophoblastic disease?
This is the definition of a low-lying placenta.
What is a placental edge < 2cm away from the internal cervical os?
This part of the physical exam should NOT be performed in a patient with 3rd trimester bleeding.
What is the digital cervical exam? *
*Not until placenta previa has been ruled out
This diagnosis should be ruled out in every pregnant patient presenting with vaginal bleeding in the second half of pregnancy
Bonus: A low-lying placenta or a placenta previa is less likely to "migrate" if this is present
What is placenta previa?
Bonus: What is a prior cesarean delivery scar?
These are the types of vasa previa.
Bonus: This is the definition of a succenturiate placenta
What is type 1 - vessels as part of a velamentous cord insertion, and type 2 - vessels spanning portions of a bilobate or succenturiate placenta?
Bonus: What is when 1 or more accessory lobes of placenta form, adjacent to the main placental body, with fetal vessels connecting them only supported by membranes?
True or False: In the setting of placenta previa, transvaginal ultrasonography is unsafe.
What is false?
These should be used to assess the severity of a patient presenting with 3rd trimester vaginal bleeding.
What are maternal/fetal vital signs, presence and intensity of associated pain, volume of bleeding, sterile speculum exam, and, for heavier bleeding, a CBC?
Bonus: This is the percentage of placental abruptions that can be visualized on ultrasound
What are: prior placental abruption, trauma, smoking, cocaine use, HTN, and PPROM? What are vaginal bleeding (80%), uterine tenderness (70%), and uterine contractions (35%)?
Bonus: What is 2%?
I.e. abdominal, cervical, cesarean scar, or even heterotopic
This is a frequent and serious complication of placenta previa due to implantation in the lower uterine segment.
What is morbidly adherent placenta aka placenta accreta?
This is the primary adverse outcome associated with vaginal bleeding in the 2nd and/or 3rd trimester.
What is pre-term birth?
This rare, but major cause of vaginal bleeding usually occurs either during labor or as a result of abdominal trauma, and is typically associated with severe abdominal pain, abnormal FHR, and maternal hemodynamic instability.
What is uterine rupture?
These symptoms and this sonographic finding support the clinical diagnosis of cervical insufficiency.
What are vaginal/pelvic pressure, vaginal bleeding/spotting, increased vaginal discharge, vague back/lower abdominal discomfort, and short cervix (< or equal to 25mm before 24 weeks)?
What is bloody show?
True or False: Any pregnancy with antepartum bleeding is at higher risk for adverse outcome even if the bleeding is stopped and placenta previa is sonographically excluded
What is: 1) Uterine body remodels to form the LUS; 2) Internal cervical os dilates, causing separation of implanted placenta, 3) LUS myometrial fibers inherently unable to contract to constrict disrupted vessels, 4) Lacerations from the friable cervix and LUS further contribute to bleeding
Patients with antepartum bleeding, respiratory symptoms, and/or neurologic symptoms, should be evaluated for this rare cause of vaginal bleeding.
What is choriocarcinoma?
Can occur in any trimester, resulting from vaginal metastasis or intrauterine tumor
This is a Couvelaire uterus.
What is widespread extravasation of blood into the uterine myometrium and beneath the uterine serosa in the setting of placental abruption?