Latest SMFM Guidelines: Third Trimester Bleeding Between 34w0d and 36w6d Gestation
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. State the timing of delivery in the late preterm period for placenta accreta, vasa previa, placenta previa and placental abruption 2. Discuss use of antenatal corticosteroids when faced with hemorrhage in the late preterm period
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 1/31/2017 through 1/25/2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
No clinical trials regarding ideal timing for delivery
Stable with high clinical index of suspicion: Delivery in late preterm or early term (expert opinion)
Diagnosis unclear, minimal bleeding, both mother and fetus stable: Delivery may be delayed with close surveillance and ongoing fetal testing
Active bleeding: Delivery as with any other active hemorrhage case
If patient actively bleeding, delivery is indicated if the following are present
Significant vaginal bleeding
Abnormal laboratory results including such as acute anemia or coagulopathy
Abnormal fetal heart tracing
Maternal status unstable
If actively hemorrhaging, do not delay delivery for purpose of administering antenatal corticosteroids (Grade 1B)
Do not perform fetal lung maturity testing in late preterm period to guide management if there is an indication for delivery (Grade 1B)
Administer antenatal corticosteroids if (Grade 1A)
Delivery expected within 7 days
Gestational age is between 34w0d to 36w6d
Antenatal corticosteroids have not previously been administered
Cesarean section for placenta previa, vasa previa or accreta
For other clinical scenarios, vaginal delivery may be appropriate if
No contraindication for vaginal delivery
Fetal status is stable
Small amount of late preterm bleeding that has resolved by the time the patient presents may be treated expectantly if the following conditions met (no evidence-based recommendations currently available)
Both mother and fetus stable
Absence of active bleeding or contractions
Patient lives close to the hospital
Perform ultrasound exam to evaluate placental location prior to digital vaginal exam
Placental previa: Use transvaginal ultrasound
Vasa previa: Pulsed-wave Doppler may help identify a fetal arterial vessel (with FH rate) or fetal vessels with venous flow
Placenta accreta: Ultrasound can be used, but sensitivity (89 to 92%) and specificity (92 to 97%) less than that of placenta previa and vasa previa
Placental abruption: Use clinical suspicion/judgement to determine management as ultrasound can miss this diagnosis in 20 to 50% of the cases
MRI in women who are actively bleeding is not recommended
Depends on clinical status and may include
CBC and platelets
Type and cross
Coag studies: PT/PPT/INR/fibrinogen
If transfusion likely: BUN, Cr and lytes
Wall clot test
Place blood in plain (red top) tube
Normal expectation is clot within 6 min
Rh negative patient
Assess maternal-fetal hemorrhage
Quantitative rosette test
Qualitative Kleihauer-Betke stain
Administer standard Rh immunoglobulin dose of 300 μg
Increase as needed based on quantitative testing
Initial Stabilization for Delivery
2 large-bore intravenous lines
Obtain results from lab testing above, especially blood type
O-neg blood may need to be identified and prepared in the interim
Crossmatch for an initial 2 to 4 U of blood
Utilize hemorrhage protocol in units where available
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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