Vaginal Bleeding in Late Pregnancy

Vaginal Bleeding in Later Pregnancy

A critical red-flag presentation requiring urgent maternal and foetal evaluation.

Late pregnancy bleeding Abruptio placentae Placenta previa Preterm labour Cervical / vaginal lesions

Overview

Vaginal bleeding after the first trimester occurs in approximately 4% of pregnancies, and always warrants urgent clinical evaluation due to the potential risks to both mother and foetus.

      Key ED principle: All late-pregnancy bleeding should be treated as an obstetric emergency until
      proven otherwise.
    

Causes of Late Pregnancy Bleeding

Abruptio placentae.
Placenta previa.
Early or preterm labour (cervical dilation, “show”).
Cervical lesions (polyps, ectropion, malignancy).
Vaginal trauma or genital tract infections.
Non-obstetric perineal sources (e.g. haemorrhoids, fissures).

Correct identification of the bleeding source is essential for maternal stabilisation and determining urgency of delivery.

Second vs Third Trimester Bleeding

Second trimester bleeding (14–24 weeks):
- Carries a 33% fetal loss risk.
- Management is generally supportive and expectant due to foetal immaturity.
Third trimester bleeding:
- Often serious and may require urgent delivery depending on maternal stability and foetal status.
- Most commonly related to placenta previa or abruptio placentae.

      Red flags requiring immediate action: haemodynamic instability, abdominal pain + bleeding,
      abnormal foetal heart rate, suspected placental pathology.
    

Triage Indicators (ED Perspective)

Green – Lower Risk (Still Obstetric Review)

Minor spotting, no clots.
Maternal vitals normal, no abdominal pain.
Foetal movements normal (if viable).
No history of trauma or placental disease.

Yellow – Concerning, Urgent Review

Moderate bleeding, saturating pads but not exsanguinating.
Mild tachycardia, borderline blood pressure.
Mild abdominal discomfort or uterine tightenings.
Foetal heart present but needs monitoring.

Red – Emergency

Heavy bleeding or clots, rapidly soaking pads/linen.
Shock (tachycardia, hypotension, altered mental status).
Severe abdominal pain, “board-like” uterus or frequent contractions.
Absent or abnormal foetal heart / reduced foetal movement.

ED Decision-Making Algorithm

Triage & ABCs:

Immediate triage using Green/Yellow/Red indicators above.
Secure airway, give O₂, assess breathing.
Two large-bore IV lines; check vitals and level of consciousness.

Initial Investigations:

FBC, group & crossmatch, coagulation profile.
Baseline Hb and platelets.
Foetal heart with Doppler (if viable gestation).

Critical Safety Step:

Do NOT perform a digital vaginal exam until placenta previa is excluded with ultrasound.
Call obstetrics early for any late pregnancy bleeding.

Ultrasound & Differentiation:

Use ultrasound to assess placental location and foetal status.
Think: Placenta previa (painless, bright red bleeding, soft uterus) vs abruptio placentae (painful bleeding, tender/rigid uterus).

Disposition:

All but the mildest cases require admission under obstetrics.
Urgent delivery if:
- Maternal instability despite resuscitation, or
- Foetal distress in a viable foetus.

      Simple memory aid: “Mother first, baby always” – stabilise the mother, then address
      foetal needs with the obstetric team.
    

Clinical Importance

Late-pregnancy vaginal bleeding is a major obstetric emergency. ED clinicians must rapidly assess maternal haemodynamic status, evaluate foetal well-being, consider placental causes, avoid digital vaginal examination until placenta previa is excluded, and involve obstetrics early.