Third Trimester Bleeding,
Preterm labor, and
Premature rupture of
membranes
Melissa Zahnd, APN, CNP, CDE
Maternal Fetal Medicine
Third Trimester
Bleeding
Definition
• Bleeding/Spotting in pregnancy during the 3rd Trimester-28
weeks and beyond
Etiologies
• Placenta Previa
• Placental Abruption
• Vasa previa
• Bloody show (PTL)
• Cervicitis
• Genital
lacerations/Trauma
• Foreign Body
• Genital
Lacerations/Trauma
• Foreign Body
• Cervical/Vaginal
Cancer
Evaluation
• VS
• Labs (anemia/DIC)
• KB
• RH status
• Fetal evaluation
• US
• Confirm placental
location
• Avoid digital exam
Placental Abruption
• Placenta separates
from uterine wall
• 1: 100 births
• 30% of cases (TTB)
• 25% recurrence risk
• Risk factors:
•
•
•
•
Hypertension
Cocaine use
Abdominal trauma
Sudden uterine
decompression
(PROM)
• PROM
Clinical Presentation
• Frequent uterine
contractions
• Hypertonicity
• Vaginal bleeding
• NRFHR
• Low Fibrinogen
• DIC in 10-20% of
severe cases
Placenta Previa
• Placenta completely or
partially covers cervical os
• Marginal, complete, or
partial
• Low Lying placenta
• 1:20 pregnancies previa
persists beyond 20 weeks
• By 40 weeks, 1:200
• 20% cases TTB
Risk factors
• Prior C/S
• History of
myomectomy
• D&C, repetitive
• Multiples
• Increased parity
• AMA
• Smoking
Symptoms
• Painless vaginal
bleeding
• Vasa Previa
• Fetal vessels of
velamentous cord
insertion covering os
• Multiple gestations
Treatment
• Delivery
• Volume replacement
• Monitor
blood/coagulation
• Indications for
Transfusion
• Acute blood loss 3050%
• Chronic blood loss hgb
<6, or <10 with comorbidities
• Abnormal coagluation
studies
•
•
•
•
Fibrinogen <150
Prolonged PTT
Platelets <20,000
Platelets <50,000 + C/S
Preterm Labor
Diagnosis
• Regular contractions and cervical change-dilation, effacement,
or both or initial presentation of regular contractions and
cervical dilation of at least 2 cm between 20 weeks 0 days and
36 weeks 6 days.
Risk Factors
• Prior History of PTB
• African American
• Low Pre-pregnancy
BMI
• Preterm contractions
• PROM
• Incompetent cervix
• Short cx on US
• Infections
• Urinary
• BV
• Intra-Amniotic
• Excessive uterine size
• Uterine Distortion
• Myomas
• Septate, Didelphis
• Placental
abnormalities
Risk Factors
• Maternal Smoking
(PROM)
• Substance abuse
• Inflammation (oral)
• Decidual hemorrhage
• Pathologic uterine
distention
Symptoms
• Menstrual like
cramps
• Low, dull backache
• Abdominal pressure
• Pelvic Pressure
• Abdominal cramping
(w/wo diarrhea)
• Increase or change in
vaginal discharge
• Uterine contractions
• Sometimes painless
Evaluation
• Fetal status
• Maternal status
• Rule out other
possible etiologies
• Labs
• UA/Culture
• Vaginal cultures/wet
mount
• Assessment of cervix
• US
• Fetal Fibronectin
Treatment
• Underlying cause
• Treat Infections
• BV
• Nifedipine
• Terbutaline
• Indomethacin
• Steroids
• Magnesium
• NICU consult
Preterm Rupture of
Membranes
Definition
• Premature ROM: Amniorrhexis (SROM) Prior to the onset of
labor at any gestation (PROM)
• Preterm ROM: PROM prior to 37 weeks gestation
• Use PPROM/PROM
Definitions
• Latency Period: time interval between ROM and onset of
labor
• Expectant management: management of patients with the
goal of prolonging gestation (“watchful waiting” until delivery
indication arises)
Incidence-Preterm ROM
• Complicates up to
3.5% of all
pregnancies
• 30-40% of Preterm
births
• PPROM ~25% cases of
all PROM
Garite (2007), Santaloya-Forgas et al., (2007), Svigos, Robinson, et Vigneswaran,
2007)
Risk Factors
• Chorioamnionitis
• Vaginal infections
• Cervical abnormalities
• Vascular pathology
(incl. abruptio)
• Smoking
• 1st, 2nd, 3rd, or
multiple trimester
bleeding
• Previous preterm
delivery (PPROM)
• AA ethnicity
• Acquired or
congenital connective
tissue disorder
• Nutritional
deficiencies (Vit.C,
copper, zinc)
The Patient
• Vaginal discharge
• Gush of fluid
• Leaking of fluid
• Oligo/Anhydramnios
• Cramping
• Contractions
• Back pain
Diagnosis
• Sterile Speculum exam (Pooling)
• SSE-Free flow of fluid from cervical os
• Nitrizine testing
• Microscopic Fern testing
• Fetal Fibronectin
• AmniSure
• Ultrasonography
• Transabdominal Indigo dye injection
Why not do a digital vaginal
exam?
• Latency period
• Infection
Sterile Speculum Exam
Assess for
• Sterile
• No lubricating jelly
• Pooling of fluid in
posterior fornix
• Free flow of fluid from
cervix
• Cervical dilation
• Nitrazine
• Collect slide for fern
(dry 10 mins)
Consider need to collect other
cervical tests/cultures such fetal
fibronectin while doing the SSE.
Nitrazine paper testing
• Vaginal pH (3.5-4.5)
• Turns blue in
presence of alkaline
Amniotic fluid
• 93.3% sensitivity
• False positive (1-17%)
for urine, blood,
semen, BV,
Trichomonas
Fern slide
Must allow slide to dry
thoroughly prior to
examination under
microscope. Assess for
arborization of fluid.
Cervical mucous has
broad, ferning pattern
that is different than the
fern of amniotic fluid.
AmniSure
•
•
•
•
•
•
Newer test
Point of Care test
Cost-up to $50 each
Sensitivity-98.7-98.9%
Specificity-87.5-100%
Awaiting further testing prior to recommendations
AmniSure
Remove swab
and rotate in
solvent x 1 min.
Read
results
after 510 mins
have
passed.
Place Swab 2-3
in. into vaginal
canal x 1 min.
Discard swab and
place test stick into
solvent.
Fetal Fibronectin
• fFn present in cervical
secretions <22 wks, >34
wks
• Used for assessment of
potential PTB
• Positive result (>50 ng/dl)
may be indicative of
PROM and represents
disruption of deciduachorionic interface
In PPROM, Sensitivity-98.2%, Specificity-26.8%.
Ultrasonography
• 50-70% of women with
PPROM have low AFV on
US
• Mild reduction requires
further investigation
• Rule out other causes
(Renal agenesis, uteroplacental insufficiency,
obstructive uropathy)
• Measure for pockets of
fluid and quantitate AFV
into AFI
Ultrasound showing 7 cm pocket of fluid
Transabdominal Injection of
Dye
• Amniocentesis
• Collect Fluid samples
• Inject dye (Indigo
Carmine)
• Tampon placed in
vagina and checked
for blue staining 3060 mins after
procedure
How would I manage this
patient?
• Gestational age
• Availability of NICU
• Fetal presentation
• FHR pattern
• Active distress
(maternal/fetal)
• Is she in labor?
• Cervical assessment
Delivery Indication
• Maternal-Fetal
Distress
• Infection
• Abruption
• Cord Prolapse
Expectant Management
•
•
•
•
•
•
•
Typical for GA 32 weeks or less (32 weeks, document FLM)
Steroids
Tocolysis if indicated for lung maturity
Antibiotics (Ampicillin/EES-Azithro)
Fetal Surveillance
Majority Inpatient Observation
Assess for Chorioamnionitis
Goal: Mature Lung Profile, reduction of PTB risks!
Expectant Management
Risks
• Abruption
• Chorioamnionitis
• Cord Prolapse
• Pulmonary
Hypoplasia (<19
weeks PPROM
• Skeletal Deformities
• Endometritis (1/3)
Benefits
• Mature lung profile
• Advancing GA
(reducing risks
associated with PTB)
Risks-Benefits Profile of
Pre-term Birth
Risks
• Assoc. w/ PTB
• NEC
• IVH/CP
• RDS
• Cesarean Delivery
• Endometritis (1/3)
Benefits
• Elimination of risks of
expectant
management
Outcomes
• 1/3 develop
intraamniotic
infections,
endometritis, or
septicemia
• Neonatal outcomes
dependent on GA
and indication for
delivery
References
• Duff, Patrick, MD. “Preterm premature rupture of membranes.”
UpToDate. Ed. Charles J Lockwood, MD and Vanessa A Barss, MD. 116. 27 June 2008 <http://utdol.com>.
• Garite, Thomas J, MD. “Premature Rupture of the Membranes.”
Clinics in Perinatalogy. N.p.: n.p., n.d. 723-736.
• Hacker, and Moore. Essentials of Obstetrics and Gynecology. 4th ed.
N.p.: n.p., 2004.
• Santolaya-Forgas, Joaquin, et al. “Prelabor rupture of the
membranes.” Clinical Obstetrics-Handbook: The Fetus and Mother.
By E Albert Reece and John Hobbins. N.p.: n.p., 2007. 1130-1173.
• Svigos, John Micheal, Jeffrey S Robinson, and Rasniah Vigneswaran.
“Prelabor Rupture of Membranes.” High-Risk Pregnancy. N.p.: n.p.,
n.d. 1321-1330.