STUDENT PROBLEM-BASED LEARNING SESSION
Third Trimester Bleeding
Clinical Case:
A 25-year-old G 2 P 1 female at 32 weeks gestation is brought to labor and delivery by her husband. About an hour before, she was watching television when she noted a sudden gush of bright red blood vaginally. The bleeding was heavy and soaked through her clothes, and she has continued to bleed since then. She denies any cramps or abdominal pain. She says that her last sexual intercourse was a week ago. A review of her prenatal chart finds nothing remarkable other than a borderline high blood pressure from her first prenatal visit that has not required medication. There is no mention of bleeding prior to this episode. She had an ultrasound to confirm pregnancy at 14 weeks, but none since.
Physical examination reveals an extremely pale woman whose blood pressure is 98/60, pulse 130, respirations 30, temperature 99 ° F. Her abdomen is soft without guarding or rebound to palpation, and the uterus is nontender and firm, but not rigid. Fundal height is 33cm. Fetal heart tones are in the 140s with good variability. The external monitor reveals uterine irritability, but no discrete contractions are seen. There is a steady stream of bright red blood coming from her vagina.
Discussion questions:
- What is your differential diagnosis for potential causes of bleeding for this patient?
- What steps would you take to evaluate this patient and determine the etiology of the bleeding?
- What signs and symptoms would help you differentiate the potential causes of the bleeding?
- What steps would you take to manage the low blood pressure and tachycardia that the patient is displaying?
References:
- Obstetrics and Gynecology by Beckmann 5 th Edition, 2006; Chapter 20 Third-Trimester Bleeding. Pages 209-215.
- Essentials of Obstetrics and Gynecology by Hacker and Moore 4 th Edition, 2004; Chapter 11 Obstetric Hemorrhage and Puerperal Sepsis. Pages 146-150.
Bleeding in the third trimester requires immediate patient evaluation. Thoughtful, prompt evaluation and management is necessary to reduce the threat to the lives of the mother and fetus.
The APGO Educational Objectives related to this topic are the following:
- List the causes of third trimester bleeding*
- Describe the initial evaluation of a patient with third trimester bleeding
- Differentiate the signs and symptoms of third trimester bleeding*
- State the maternal and fetal complications of third trimester bleeding
- Describe the initial management for shock secondary to acute blood loss*
- List the indications and potential complications of blood products
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8 th Edition