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

ConditionPainBleedingUterusContractionsKey clue
Placenta previaPAINLESSBright redSoftAbsentPainless bleeding + soft uterus + previa on US
Placental abruptionPAINFULVariable (often dark)RIGID/tetanicPresentHTN, cocaine, trauma; risk of DIC
Uterine rupturePAINFULVariableVariableContractions CEASEPrior C/S + loss of fetal station
Vasa previaPAINLESS (after ROM)Fetal bloodSoft—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
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