 The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: publications@acr.org Second and Third Trimester Vaginal Bleeding In the setting of premature rupture of membranes, there is a paucity of evidence on whether the introduction of the transvaginal probe may be associated with an increased risk of chorioamnionitis. Carlan et al [19] in a randomized trial of 92 patients did not find any associated increased risk. Nonetheless, caution should be applied in this setting. Special Imaging Considerations Transrectal US is a useful technique and is generally well tolerated when transvaginal and transperineal US are either unsuccessful or declined [20,21]. OR Discussion of Procedures by Variant Variant 1: Second and third trimester vaginal bleeding. Painless bleeding. Initial imaging. US Cervix Transperineal The literature is sparse with regard to defined indications for the use of transperineal US or translabial US among those with painless vaginal bleeding. In current US use, if transabdominal US demonstrates an open cervix with bulging membranes or if the history and physical examination suggests ruptured membranes, then transperineal US might be considered. If transabdominal US is inconclusive and transvaginal US is declined by the patient, transperineal US or transrectal US may be useful for making an accurate diagnosis. US Duplex Doppler Pelvis Although Doppler velocimetry US is an adjunct to any of the other procedures for evaluation of painless vaginal bleeding, it can be invaluable for identification of pathologic entities such as vasa previa [22].
Second and Third Trimester Vaginal Bleeding.  The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: publications@acr.org Second and Third Trimester Vaginal Bleeding In the setting of premature rupture of membranes, there is a paucity of evidence on whether the introduction of the transvaginal probe may be associated with an increased risk of chorioamnionitis. Carlan et al [19] in a randomized trial of 92 patients did not find any associated increased risk. Nonetheless, caution should be applied in this setting. Special Imaging Considerations Transrectal US is a useful technique and is generally well tolerated when transvaginal and transperineal US are either unsuccessful or declined [20,21]. OR Discussion of Procedures by Variant Variant 1: Second and third trimester vaginal bleeding. Painless bleeding. Initial imaging. US Cervix Transperineal The literature is sparse with regard to defined indications for the use of transperineal US or translabial US among those with painless vaginal bleeding. In current US use, if transabdominal US demonstrates an open cervix with bulging membranes or if the history and physical examination suggests ruptured membranes, then transperineal US might be considered. If transabdominal US is inconclusive and transvaginal US is declined by the patient, transperineal US or transrectal US may be useful for making an accurate diagnosis. US Duplex Doppler Pelvis Although Doppler velocimetry US is an adjunct to any of the other procedures for evaluation of painless vaginal bleeding, it can be invaluable for identification of pathologic entities such as vasa previa [22].