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 • Foreign Body
• Placental Abruption • Genital
• Vasa previa Lacerations/Trauma
• Bloody show (PTL) • Foreign Body
• Cervicitis • Cervical/Vaginal
• Genital Cancer
lacerations/Trauma
Evaluation
• VS
• Labs (anemia/DIC)
• KB
• RH status
• Fetal evaluation
• US
• Confirm placental
location
• Avoid digital exam
Placental Abruption
• Placenta separates • Risk factors:
from uterine wall • Hypertension
• 1: 100 births • Cocaine use
• 30% of cases (TTB) • Abdominal trauma
• Sudden uterine
• 25% recurrence risk 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 • Vasa Previa
bleeding • Fetal vessels of
velamentous cord
insertion covering os
• Multiple gestations
Treatment
• Indications for
• Delivery Transfusion
• Volume replacement • Acute blood loss 30-
50%
• Monitor
• Chronic blood loss hgb
blood/coagulation <6, or <10 with co-
morbidities
• 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 • Infections
• African American • Urinary
• Low Pre-pregnancy • BV
BMI • Intra-Amniotic

• Preterm contractions • Excessive uterine size

• PROM • Uterine Distortion
• Myomas
• Incompetent cervix
• Septate, Didelphis
• Short cx on US
• Placental
abnormalities
Risk Factors
• Maternal Smoking
(PROM)
• Substance abuse
• Inflammation (oral)
• Decidual hemorrhage
• Pathologic uterine
distention
Symptoms
• Menstrual like • Uterine contractions
cramps • Sometimes painless
• Low, dull backache
• Abdominal pressure
• Pelvic Pressure
• Abdominal cramping
(w/wo diarrhea)
• Increase or change in
vaginal discharge
Evaluation
• Fetal status • Assessment of cervix
• Maternal status • US
• Rule out other • Fetal Fibronectin
possible etiologies
• Labs
• UA/Culture
• Vaginal cultures/wet
mount
Treatment
• Underlying cause • Steroids
• Treat Infections • Magnesium
• BV • NICU consult
• Nifedipine
• Terbutaline
• Indomethacin
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 • Previous preterm
• Vaginal infections delivery (PPROM)
• Cervical abnormalities • AA ethnicity
• Vascular pathology • Acquired or
(incl. abruptio) congenital connective
• Smoking tissue disorder
• 1st, 2nd, 3rd, or • Nutritional
multiple trimester deficiencies (Vit.C,
bleeding 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
• Sterile
• No lubricating jelly
• Pooling of fluid in
Assess for

posterior fornix
• Free flow of fluid from
cervix
• Cervical dilation
• Nitrazine
• Collect slide for fern Consider need to collect other
(dry 10 mins) 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 5-
10 mins
have
passed.

Place Swab 2-3 Discard swab and

in. into vaginal place test stick into
canal x 1 min. 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 decidua-
chorionic 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, utero-
placental 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 30-
60 mins after
procedure
How would I manage this
patient?
• Gestational age • Active distress
• Availability of NICU (maternal/fetal)
• Fetal presentation • Is she in labor?
• FHR pattern • 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 Benefits
• Abruption • Mature lung profile
• Chorioamnionitis • Advancing GA
• Cord Prolapse (reducing risks
associated with PTB)
• Pulmonary
Hypoplasia (<19
weeks PPROM
• Skeletal Deformities

• Endometritis (1/3)
Risks-Benefits Profile of
Pre-term Birth
Risks Benefits

• Assoc. w/ PTB • Elimination of risks of

• NEC expectant
• IVH/CP management
• RDS
• Cesarean Delivery
• Endometritis (1/3)
Outcomes
• 1/3 develop • Neonatal outcomes
intraamniotic dependent on GA
infections, and indication for
endometritis, or delivery
septicemia
References
• Duff, Patrick, MD. “Preterm premature rupture of membranes.”
UpToDate. Ed. Charles J Lockwood, MD and Vanessa A Barss, MD. 1-
16. 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.