Second and Third Trimester Vaginal Bleeding

Variant: 1 Second and third trimester vaginal bleeding. Painless bleeding. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler pelvis	Usually Appropriate	O
US pregnant uterus transabdominal	Usually Appropriate	O
US pregnant uterus transvaginal	Usually Appropriate	O
US cervix transperineal	May Be Appropriate	O

Variant: 2 Second and third trimester vaginal bleeding. Painful bleeding. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler pelvis	Usually Appropriate	O
US pregnant uterus transabdominal	Usually Appropriate	O
US pregnant uterus transvaginal	Usually Appropriate	O
US cervix transperineal	May Be Appropriate	O

Variant: 3 Second and third trimester vaginal bleeding. Suspicion of or known placental previa, low-lying placental, or vasa previa. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler pelvis	Usually Appropriate	O
US pregnant uterus transabdominal	Usually Appropriate	O
US pregnant uterus transvaginal	Usually Appropriate	O
US cervix transperineal	Usually Not Appropriate	O

Panel Members

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (ie, only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (ie, more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Second and third trimester vaginal bleeding. Painless bleeding. Initial imaging.

Variant 1: Second and third trimester vaginal bleeding. Painless bleeding. Initial imaging.
A. US Cervix Transperineal

Variant 1: Second and third trimester vaginal bleeding. Painless bleeding. Initial imaging.
B. US Duplex Doppler Pelvis

Variant 1: Second and third trimester vaginal bleeding. Painless bleeding. Initial imaging.
C. US Pregnant Uterus Transabdominal

Variant 1: Second and third trimester vaginal bleeding. Painless bleeding. Initial imaging.
D. US Pregnant Uterus Transvaginal

Variant 2: Second and third trimester vaginal bleeding. Painful bleeding. Initial imaging.

Variant 2: Second and third trimester vaginal bleeding. Painful bleeding. Initial imaging.
A. US Cervix Transperineal

Variant 2: Second and third trimester vaginal bleeding. Painful bleeding. Initial imaging.
B. US Duplex Doppler Pelvis

Variant 2: Second and third trimester vaginal bleeding. Painful bleeding. Initial imaging.
C. US Pregnant Uterus Transabdominal

Variant 2: Second and third trimester vaginal bleeding. Painful bleeding. Initial imaging.
D. US Pregnant Uterus Transvaginal

Variant 3: Second and third trimester vaginal bleeding. Suspicion of or known placental previa, low-lying placental, or vasa previa. Initial imaging.

Variant 3: Second and third trimester vaginal bleeding. Suspicion of or known placental previa, low-lying placental, or vasa previa. Initial imaging.
A. US Cervix Transperineal

Variant 3: Second and third trimester vaginal bleeding. Suspicion of or known placental previa, low-lying placental, or vasa previa. Initial imaging.
B. US Duplex Doppler Pelvis

Variant 3: Second and third trimester vaginal bleeding. Suspicion of or known placental previa, low-lying placental, or vasa previa. Initial imaging.
C. US Pregnant Uterus Transabdominal

Variant 3: Second and third trimester vaginal bleeding. Suspicion of or known placental previa, low-lying placental, or vasa previa. Initial imaging.
D. US Pregnant Uterus Transvaginal

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Safety Considerations in Pregnant Patients

Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and risk. For further information and guidance, see the following ACR documents:

· ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)

· ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation

· ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound

· ACR Manual on Contrast Media

· ACR Manual on MR Safety

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Norwitz ER, Park JS. Overview of the etiology and evaluation of vaginal bleeding in pregnant women. Available at: https://www.uptodate.com/contents/overview-of-the-etiology-and-evaluation-of-vaginal-bleeding-in-pregnant-women.
2.	Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period. Am J Obstet Gynecol. 218(1):B2-B8, 2018 01.
3.	Yang J, Hartmann KE, Savitz DA, et al. Vaginal bleeding during pregnancy and preterm birth. Am J Epidemiol. 2004; 160(2):118-125.
4.	Vahanian SA, Vintzileos AM. Placental implantation abnormalities: a modern approach. [Review]. Curr Opin Obstet Gynecol. 28(6):477-484, 2016 Dec.
5.	Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006; 108(4):1005-1016.
6.	Nkwabong E, Tiomela Goula G. Placenta abruption surface and perinatal outcome. J Matern Fetal Neonatal Med. 30(12):1456-1459, 2017 Jun.
7.	Reddy UM, Abuhamad AZ, Levine D, Saade GR, Fetal Imaging Workshop Invited Participants. Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging workshop. Obstet Gynecol. 123(5):1070-82, 2014 May.
8.	Silver RM.. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. [Review]. Obstet Gynecol. 126(3):654-68, 2015 Sep.
9.	Baumfeld Y, Gutvirtz G, Shoham I, Sheiner E. Fetal heart rate patterns of pregnancies with vasa previa and velamentous cord insertion. Arch Gynecol Obstet. 293(2):361-7, 2016 Feb.
10.	Society of Maternal-Fetal (SMFM) Publications Committee, Sinkey RG, Odibo AO, Dashe JS. #37: Diagnosis and management of vasa previa. Am J Obstet Gynecol. 213(5):615-9, 2015 Nov.
11.	American College of Radiology. ACR Appropriateness Criteria®: Suspected Placenta Accreta Spectrum Disorder. Available at: https://acsearch.acr.org/docs/3102403/Narrative/.
12.	Leerentveld RA, Gilberts EC, Arnold MJ, Wladimiroff JW. Accuracy and safety of transvaginal sonographic placental localization. Obstet Gynecol. 1990; 76(5 Pt 1):759-762.
13.	Oppenheimer LW, Farine D, Ritchie JW, Lewinsky RM, Telford J, Fairbanks LA. What is a low-lying placenta? Am J Obstet Gynecol. 1991; 165(4 Pt 1):1036-1038.
14.	Timor-Tritsch IE, Monteagudo A. Diagnosis of placenta previa by transvaginal sonography. Ann Med. 1993; 25(3):279-283.
15.	American College of Radiology. ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=23+&releaseId=2.
16.	Hertzberg BS, Bowie JD, Carroll BA, Kliewer MA, Weber TM. Diagnosis of placenta previa during the third trimester: role of transperineal sonography. AJR. 1992; 159(1):83-87.
17.	Vintzileos AM, Ananth CV, Smulian JC. Using ultrasound in the clinical management of placental implantation abnormalities. [Review]. Am J Obstet Gynecol. 213(4 Suppl):S70-7, 2015 Oct.
18.	American College of Radiology. ACR Appropriateness Criteria®: Assessment of Gravid Cervix. Available at: https://acsearch.acr.org/docs/69464/Narrative/. Accessed September, 12, 2019.
19.	Carlan SJ, Richmond LB, O'Brien WF. Randomized trial of endovaginal ultrasound in preterm premature rupture of membranes. Obstet Gynecol. 1997;89(3):458-461.
20.	Timor-Tritsch IE, Monteagudo A, Rebarber A, Goldstein SR, Tsymbal T. Transrectal scanning: an alternative when transvaginal scanning is not feasible. Ultrasound Obstet Gynecol. 21(5):473-9, 2003 May.
21.	Wachsberg RH.. Transrectal ultrasonography for problem solving after transvaginal ultrasonography of the female internal reproductive tract. J Ultrasound Med. 22(12):1349-56, 2003 Dec.
22.	Nomiyama M, Toyota Y, Kawano H. Antenatal diagnosis of velamentous umbilical cord insertion and vasa previa with color Doppler imaging. Ultrasound Obstet Gynecol. 1998; 12(6):426-429
23.	D'Antonio F, Bhide A. Ultrasound in placental disorders. [Review]. Best Pract Res Clin Obstet Gynaecol. 28(3):429-42, 2014 Apr.
24.	Quant HS, Friedman AM, Wang E, Parry S, Schwartz N. Transabdominal ultrasonography as a screening test for second-trimester placenta previa. Obstet Gynecol. 123(3):628-33, 2014 Mar.
25.	Taipale P, Hiilesmaa V, Ylostalo P. Transvaginal ultrasonography at 18-23 weeks in predicting placenta previa at delivery. Ultrasound Obstet Gynecol. 1998; 12(6):422-425.
26.	Becker RH, Vonk R, Mende BC, Ragosch V, Entezami M. The relevance of placental location at 20-23 gestational weeks for prediction of placenta previa at delivery: evaluation of 8650 cases. Ultrasound Obstet Gynecol. 2001; 17(6):496-501.
27.	Morales-Rosello J, Khalil A, Akhoundova F, et al. Fetal cerebral and umbilical Doppler in pregnancies complicated by late-onset placental abruption. J Matern Fetal Neonatal Med. 30(11):1320-1324, 2017 Jun.
28.	Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment of placental abruption. J Ultrasound Med. 2002; 21(8):837-840.
29.	Uharcek P, Brestansky A, Ravinger J, Manova A, Zajacova M. Sonographic assessment of lower uterine segment thickness at term in women with previous cesarean delivery. Arch Gynecol Obstet. 292(3):609-12, 2015 Sep.
30.	Ramaeker DM, Simhan HN. Sonographic cervical length, vaginal bleeding, and the risk of preterm birth. Am J Obstet Gynecol. 2012; 206(3):224 e221-224.
31.	Hasegawa J, Kawabata I, Takeda Y, et al. Improving the Accuracy of Diagnosing Placenta Previa on Transvaginal Ultrasound by Distinguishing between the Uterine Isthmus and Cervix: A Prospective Multicenter Observational Study. Fetal Diagn Ther. 41(2):145-151, 2017.
32.	Goto M, Hasegawa J, Arakaki T, et al. Placenta previa with early opening of the uterine isthmus is associated with high risk of bleeding during pregnancy, and massive haemorrhage during caesarean delivery. Eur J Obstet Gynecol Reprod Biol. 201:7-11, 2016 Jun.
33.	Gouhar GK, Sadek SM, Siam S, Ahmad RA. Role of transperineal sonography in diagnosis of placenta previa/accreta: A prospective study. The Egyptian Journal of Radiology and Nuclear Medicine 2012;43:637-45.
34.	Ruiter L, Kok N, Limpens J, et al. Systematic review of accuracy of ultrasound in the diagnosis of vasa previa. [Review]. Ultrasound Obstet Gynecol. 45(5):516-22, 2015 May.
35.	Oppenheimer L. Diagnosis and management of placenta previa. J Obstet Gynaecol Can. 2007; 29(3):261-273.
36.	Kapoor S, Thomas JT, Petersen SG, Gardener GJ. Is the third trimester repeat ultrasound scan for placental localisation needed if the placenta is low lying but clear of the os at the mid-trimester morphology scan?. Aust N Z J Obstet Gynaecol. 54(5):428-32, 2014 Oct.
37.	Olive EC, Roberts CL, Nassar N, Algert CS. Test characteristics of placental location screening by transabdominal ultrasound at 18-20 weeks. Ultrasound Obstet Gynecol. 2006; 28(7):944-949.
38.	Dashe JS, McIntire DD, Ramus RM, Santos-Ramos R, Twickler DM. Persistence of placenta previa according to gestational age at ultrasound detection. Obstet Gynecol. 2002; 99(5 Pt 1):692-697.
39.	Ananth CV, Demissie K, Smulian JC, Vintzileos AM. Placenta previa in singleton and twin births in the United States, 1989 through 1998: a comparison of risk factor profiles and associated conditions. Am J Obstet Gynecol. 2003; 188(1):275-281.
40.	Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies. J Matern Fetal Neonatal Med. 2003; 13(3):175-190.
41.	Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. Obstet Gynecol. 2002; 99(6):976-980.
42.	Heller HT, Mullen KM, Gordon RW, Reiss RE, Benson CB. Outcomes of pregnancies with a low-lying placenta diagnosed on second-trimester sonography. J Ultrasound Med. 33(4):691-6, 2014 Apr.
43.	Shin JE, Shin JC, Lee Y, Kim SJ. Serial Change in Cervical Length for the Prediction of Emergency Cesarean Section in Placenta Previa. PLoS ONE. 11(2):e0149036, 2016.
44.	Sekiguchi A, Nakai A, Okuda N, Inde Y, Takeshita T. Consecutive cervical length measurements as a predictor of preterm cesarean section in complete placenta previa. J Clin Ultrasound. 43(1):17-22, 2015 Jan.
45.	Rebarber A, Dolin C, Fox NS, Klauser CK, Saltzman DH, Roman AS. Natural history of vasa previa across gestation using a screening protocol. J Ultrasound Med. 33(1):141-7, 2014 Jan.
46.	Swank ML, Garite TJ, Maurel K, et al. Vasa previa: diagnosis and management. Am J Obstet Gynecol. 215(2):223.e1-6, 2016 Aug.
47.	American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=89+&releaseId=2.
48.	American College of Radiology. ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=28+&releaseId=2.
49.	American College of Radiology. Manual on Contrast Media. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual.
50.	Expert Panel on MR Safety, Kanal E, Barkovich AJ, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 37(3):501-30, 2013 Mar.
51.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.