A 36-year-old female eight months pregnant has painless vaginal bleeding. Which condition should you suspect?

• A. Progesterone imbalance
• B. Bloody show
• C. Endometrial sloughing
• D. Placenta previa

Answer: (D)

Painless vaginal bleeding in the late second to third trimester points to placenta previa. When the placenta implants low in the uterus, near or over the cervical opening, bleeding can occur with little or no pain because there’s no strong uterine contraction or stretching causing discomfort. The bleeding is often bright red and may come and go as the cervix dilates.

In contrast, placental abruption presents with sudden, painful vaginal bleeding and a tender, rigid uterus, often with fetal distress. The other options don’t fit this presentation: a progesterone imbalance isn’t diagnosed from acute bleeding in pregnancy, endometrial sloughing is menstruation, and a bloody show is mucus mixed with blood from cervical changes that isn’t typically heavy or the same clinical picture as placenta previa.

In the field, manage with this approach: place the patient on her left side to improve placental perfusion, monitor vitals and fetal status if possible, establish IV access, and transport promptly. Avoid vaginal exams if placenta previa is suspected to prevent provoking more bleeding.