OB/GYN

Antepartum Bleeding — Differential

OB/GYN

Antepartum Bleeding — Differential

Placenta previa vs abruption vs uterine rupture vs vasa previa.

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◆Quick differentiator rules

•Painful bleeding = mom's problem (abruption, rupture)
•Painless bleeding = baby's problem (previa, vasa previa)
•Contractions present? Yes → abruption; No → rupture or previa
•Loss of fetal station → uterine rupture until proven otherwise
•Bleeding right after ROM + fetal bradycardia + stable mom → vasa previa

◆Placenta previa management

•Confirm with transabdominal US
•NEVER digital cervical exam (risk of severe hemorrhage)
•Pelvic rest (no intercourse)
•Scheduled C-section at 36–37 weeks
•If actively bleeding hemodynamically unstable → emergent C-section

◆Placental abruption management

•Stabilize mother (IV fluids, transfusion as needed)
•Continuous fetal monitoring
•Delivery if maternal/fetal instability — vaginal if stable, C/S if not
•DIC workup (fibrinogen, platelets, PT/PTT)

◆Uterine rupture management

•Emergent ex-lap + C-section (NO time for imaging)
•Strongest RF: prior cesarean (especially classical incision)
•TOLAC carries small but real rupture risk

◆Vasa previa management

•If diagnosed antenatally on US/Doppler: scheduled C-section at 34–37 weeks
•If ROM occurs + bleeding: emergent crash C-section
•Fetal exsanguination within minutes

◆Placental adherence (accreta spectrum)

•Accreta: adherent to myometrium
•Increta: invades myometrium
•Percreta: invades through into bladder
•RFs: prior C/S + previa overlying scar
•Manage with planned cesarean hysterectomy

Antepartum bleeding patterns

Condition	Pain	Bleeding	Uterus	Contractions	Key clue
Placenta previa	PAINLESS	Bright red	Soft	Absent	Painless bleeding + soft uterus + previa on US
Placental abruption	PAINFUL	Variable (often dark)	RIGID/tetanic	Present	HTN, cocaine, trauma; risk of DIC
Uterine rupture	PAINFUL	Variable	Variable	Contractions CEASE	Prior C/S + loss of fetal station
Vasa previa	PAINLESS (after ROM)	Fetal blood	Soft	—	Bleeding immediately after ROM + sudden fetal bradycardia, mom stable

High-yield pearls

◆Loss of fetal station during labor = uterine rupture
◆Painful + rigid uterus + cocaine/HTN = abruption
◆Painless bright-red + soft uterus = previa (NEVER do digital exam)
◆After ROM + fetal bradycardia + stable mom = vasa previa

Quick check

5-question quiz on this note

Test yourself before moving on. ~1 min.

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