Differential diagnosis of vaginal bleeding after 20 weeks of gestation

Etiology of bleeding	Clinical findings						Diagnosis
Etiology of bleeding	Volume of vaginal bleeding	Abdominal/ uterine pain	Uterine tone	Uterine contractions	Fetal heart rate	Ultrasound findings	Diagnosis
Placental abruption	Light to heavy. Bleeding may be retained in the uterus behind the placenta.	May be absent with a small degree of placental separation, but moderate pain is common with more extensive separation.	May be normal, but increased tone is common with more extensive separation. Uterus can become rigid if a substantial volume of blood extravasates into the myometrium.	Present in one-third of cases.	Normal with mild separation. An abnormal heart rate is a sign of extensive separation.	May show a retroplacental hematoma.	Acute abruption is a clinical diagnosis based on abrupt onset of vaginal bleeding (any) plus abdominal and/or back pain and contractions, especially when associated with uterine tenderness and increased uterine tone. In patients with these classic symptoms, fetal heart rate abnormalities or fetal demise and/or maternal coagulopathy strongly support the diagnosis and indicate extensive placental separation. Sonographic identification of a retroplacental hematoma strongly supports the clinical diagnosis.
Placenta previa	Light to heavy	Usually absent	Normal	Usually absent, but there may be mild intermittent contractions.	Usually normal	Placenta covers the cervical os, partially or completely.	The diagnosis is based on sonographic identification of placental tissue extending over the internal cervical os, preferably using transvaginal ultrasound. The distance (millimeters) that the placenta extends over the os should be described in the diagnostic report.
Uterine rupture	Light to heavy	Sudden onset of abdominal pain is common. Pain ranges from minimal to severe.	Normal	Present if patient is in labor, which is a common predisposing factor.	Usually abnormal	May show disruption of the myometrium, a hematoma adjacent to a previous hysterotomy scar, extrauterine fluid-distended fetal membranes, free peritoneal fluid, anhydramnios, an empty uterus with fetal parts outside of the uterus, and/or fetal demise.	The diagnosis is based on identification of complete disruption of all uterine layers on imaging or at laparotomy.
Cervical or vaginal lesion	Usually light	Absent	Normal	Absent	Normal	Usually normal	The diagnosis is based on visual identification of the lesion on speculum examination.
Cervical insufficiency	Light	Absent	Normal	Absent or mild and irregular	Normal	Cervical length ≤25 mm before 24 weeks of gestation suggests cervical insufficiency. Cervical dilation and prolapsed fetal membranes may also be present.	The diagnosis is based on second trimester cervical dilation and effacement in the absence of contractions or in the presence of weak irregular contractions that appear inadequate to explain the cervical dilation and effacement. Fetal membranes may extend beyond the internal or external cervical os.
Bloody show	Light	Absent	Normal	Absent or mild and irregular	Normal	N/A	The diagnosis is based on passage of bloody mucus discharge that may precede the onset of preterm or term labor.
Labor	Light	Intermittent (occurs with each contraction)	Normal	Painful contractions of increasing frequency, intensity, and duration	Normal	N/A	The diagnosis is based on the presence of painful contractions of increasing frequency, intensity, and duration associated with cervical change.
Ruptured vasa previa	Light to heavy	Absent unless the patient is in labor	Normal	Present if the patient is in labor	Abnormal	Membranous fetal vessels passing across or in close proximity (within 2 cm) of the internal cervical os by transvaginal ultrasound with color Doppler. The membranous vessels may be associated with a velamentous umbilical cord or they may connect the lobes of a bilobed placenta or the placenta and a succenturiate lobe.	A positive Apt or Kleihauer-Betke test of blood in the vagina suggests a ruptured fetal blood vessel, especially in the setting of vasa previa and rupture of membranes; however, typically there is no time to wait for test results before performing an emergency cesarean birth for nonreassuring fetal heart rate pattern, thus these tests have limited practical role in diagnosis.

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Differential diagnosis of vaginal bleeding after 20 weeks of gestation