• Thurmond A, Fleischer AC, Andreotti RF, Bohm-Velez M, Fishman EK, Horrow MM, Hricak H, Zelop C, Expert Panel on Women's Imaging. Second and third trimester bleeding. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 2 p. [8 references]

This is the current release of the guideline.

It updates a previously published version: Thurmond A, Mendelson E, Bohm-Velez M, Bree R, Finberg H, Fishman EK, Hricak H, Laing F, Sartoris D, Goldstein S. Role of imaging in second and third trimester bleeding. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215 Suppl:895-7.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Second and third trimester vaginal bleeding

Diagnosis
Evaluation

Obstetrics and Gynecology
Radiology

Health Plans
Hospitals
Managed Care Organizations
Physicians
Utilization Management

To evaluate the appropriateness of radiologic examinations for patients with second and third trimester vaginal bleeding

Women in the second and third trimester of pregnancy who are experiencing vaginal bleeding

1. Ultrasound (US), uterus
   • Transabdominal (TA) and repeat TA
   • Transperineal
   • Transvaginal
2. Magnetic resonance imaging (MRI), pelvis

Utility of radiologic examinations in differential diagnosis

Searches of Electronic Databases

The guideline developer performed literature searches of peer-reviewed medical journals, and the major applicable articles were identified and collected.

The total number of source documents identified as the result of the literature search is not known.

Weighting According to a Rating Scheme (Scheme Not Given)

Not stated

Systematic Review with Evidence Tables

One or two topic leaders within a panel assume the responsibility of developing an evidence table for each clinical condition, based on analysis of the current literature. These tables serve as a basis for developing a narrative specific to each clinical condition.

Expert Consensus (Delphi)

Since data available from existing scientific studies are usually insufficient for meta-analysis, broad-based consensus techniques are needed for reaching agreement in the formulation of the appropriateness criteria. The American College of Radiology (ACR) Appropriateness Criteria panels use a modified Delphi technique to arrive at consensus. Serial surveys are conducted by distributing questionnaires to consolidate expert opinions within each panel. These questionnaires are distributed to the participants along with the evidence table and narrative as developed by the topic leader(s). Questionnaires are completed by the participants in their own professional setting without influence of the other members. Voting is conducted using a scoring system from 1 to 9, indicating the least to the most appropriate imaging examination or therapeutic procedure. The survey results are collected, tabulated in anonymous fashion, and redistributed after each round. A maximum of three rounds is conducted and opinions are unified to the highest degree possible. Eighty percent agreement is considered a consensus. This modified Delphi technique enables individual, unbiased expression, is economical, easy to understand, and relatively simple to conduct.

If consensus cannot be reached by this Delphi technique, the panel is convened and group consensus techniques are utilized. The strengths and weaknesses of each test or procedure are discussed and consensus reached whenever possible. If "No consensus" appears in the rating column, reasons for this decision are added to the comment sections.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

ACR Appropriateness Criteria®

Clinical Condition: Second and Third Trimester Vaginal Bleeding

Variant 1: No other signs or symptoms.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 2: Internal cervical os not visible by transabdominal ultrasound.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 3: Placenta previa diagnosed before 32 weeks.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Vaginal bleeding after the first trimester of pregnancy and before term may be due to premature delivery, placenta previa, placental abruption, placenta accreta or its variants, or of unknown origin. Placenta previa can be excluded if the placenta is shown to lie away from the internal os of the cervix, which can almost always be accomplished by transabdominal ultrasound examination of the cervix and lower uterine segment with the bladder full. If the anatomy is obscured by the fetal head, by hematoma, by a suspected lower uterine segment contraction, or by an overly full bladder, transperineal scanning or more commonly transvaginal scanning with the bladder empty will almost always result in the correct diagnosis. MRI has been suggested as an alternative to transvaginal or transperineal scanning if ultrasound is inconclusive; however, MRI is rarely needed.

Placenta previa diagnosed in the second trimester may not persist until term because of growth of the lower uterine segment. One should avoid the use of terms such as "low-lying placenta," "marginal previa," "total previa," or "complete previa" since these terms are vague and difficult to quantify. It is better to describe the relationship of the inferior placenta to the internal cervical os in centimeters. If a placenta extends to, or partially covers, the internal os of the cervix before 28 weeks gestation, there is a 4% to 5% chance it will persist in this abnormal location until term, as compared to more than a 50% chance if it completely covers the os at 28 weeks. At any point in gestation if the placenta covers the cervix and is fully implanted on both the anterior and posterior walls of the lower uterine segment, placenta location is unlikely to change.

Placental abruption can be imaged by ultrasound. However, the echogenicity of clot and the echogenicity of placenta can be similar, and therefore a normal exam does not exclude abruption. In general, in a patient with second or third trimester bleeding, in the absence of diagnosis of placenta previa by ultrasound, the management of the pregnancy depends on the clinical circumstances. If clinical circumstances or ultrasound findings are confusing, MRI may help better define the location of the placenta and the presence of abruption

Abbreviations

• MRI, magnetic resonance imaging
• TA, transabdominal
• US, ultrasound

Algorithms were not developed from criteria guidelines.

The recommendations are based on analysis of the current literature and expert panel consensus.

Selection of appropriate radiologic imaging procedures for the evaluation of patients with second and third trimester vaginal bleeding

Not stated

An American College of Radiology (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 exams 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 U.S. Food and Drug Administration (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.

An implementation strategy was not provided.

Getting Better

Effectiveness

• Thurmond A, Fleischer AC, Andreotti RF, Bohm-Velez M, Fishman EK, Horrow MM, Hricak H, Zelop C, Expert Panel on Women's Imaging. Second and third trimester bleeding. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 2 p. [8 references]

Not applicable: The guideline was not adapted from another source.

1996 (revised 2005)

American College of Radiology - Medical Specialty Society

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Women's Imaging

Panel Members: Amy Thurmond, MD; Arthur C. Fleischer, MD; Rochelle F. Andreotti, MD; Marcela Böhm-Vélez, MD; Elliot K. Fishman, MD; Mindy M. Horrow, MD; Hedvig Hricak, MD, PhD; Carolyn Zelop, MD

Not stated

This is the current release of the guideline.

It updates a previously published version: Thurmond A, Mendelson E, Bohm-Velez M, Bree R, Finberg H, Fishman EK, Hricak H, Laing F, Sartoris D, Goldstein S. Role of imaging in second and third trimester bleeding. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215 Suppl:895-7.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

None available

This NGC summary was completed by ECRI February 13, 2006.