Antepartum Haemorrhage
Definition and Classification
Antepartum haemorrhage (APH) is bleeding from or into the genital tract from 24+0 weeks of gestation until birth. It complicates 3–5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide; up to one-fifth of very preterm births are associated with APH.
Severity (visible loss often underestimates true loss, e.g. concealed abruption — assess for clinical shock):
- Spotting: staining/streaking on underwear or pad
- Minor: <50ml, settled
- Major: 50–1000ml, no clinical shock
- Massive: >1000ml and/or signs of clinical shock
- Recurrent APH: episodes on more than one occasion
Causes
The most important causes are placenta praevia and placental abruption, though neither is the most common presentation. Other causes include vasa praevia and local lower genital tract causes (cervical, vaginal, vulval — including ectropion, infection, and, rarely, cervical malignancy). A cause is often not identified, termed unexplained APH, which itself carries increased risk of preterm delivery, stillbirth, fetal anomaly, and smaller-for-gestational-age babies.
Diagnosis, prediction, and detailed management of placenta praevia, placenta accreta, and vasa praevia are covered in the dedicated guidelines Green-top 27/27a (placenta praevia and accreta) and 27b (vasa praevia), and are not duplicated here.
APH has a heterogeneous pathophysiology and cannot reliably be predicted (Grade C) — around 70% of abruptions occur in low-risk pregnancies. Modifiable risk factors (smoking, cocaine/amphetamine misuse) should be addressed. Vaginal/rectal examination and penetrative intercourse should be avoided in women with known placenta praevia.
Assessment
Triage first establishes whether urgent intervention is needed for maternal or fetal compromise; the mother is stabilised before the fetal condition is established. History should assess pain (continuous pain suggests abruption; intermittent pain suggests labour), risk factors for abruption/praevia, fetal movements, and rupture of membranes (raising suspicion of vasa praevia). A tense, "woody" uterus on palpation suggests significant abruption. Digital vaginal examination should not be performed until placenta praevia has been excluded by ultrasound.
Investigations
- FBC and group and save in minor haemorrhage; coagulation screen only if platelets abnormal
- In major/massive haemorrhage: FBC, coagulation screen, U&E, LFTs, and 4 units cross-matched
- Kleihauer test in all RhD-negative women to quantify fetomaternal haemorrhage and guide anti-D dosing (Grade D) — it is not a sensitive test for diagnosing abruption (Grade C)
- Ultrasound can diagnose placenta praevia but does not exclude abruption (Grade C); placental abruption remains a clinical diagnosis — no sensitive or reliable diagnostic test exists (Grade D)
- CTG once the mother is stable, to guide timing/mode of delivery
Management
- Corticosteroids: offer a single course between 24+0 and 34+6 weeks where preterm birth is at risk (Grade A)
- Tocolysis: should not be used to delay delivery with major APH, haemodynamic instability, or fetal compromise; a senior obstetrician should decide on its use; nifedipine is probably best avoided due to hypotension risk
- Delivery: immediate delivery for maternal or fetal compromise (caesarean if the fetus is compromised); vaginal birth is usually appropriate if fetal death has occurred, provided the maternal condition allows
- Third stage: active management is strongly recommended after APH from abruption or praevia (Grade A); consider ergometrine–oxytocin in the absence of hypertension (Grade B), given the elevated PPH risk
- Anti-D: give to all non-sensitised RhD-negative women after any APH presentation, regardless of routine antenatal prophylaxis (Grade B); at least 500 IU with a Kleihauer to detect FMH >4ml (Grade D); for recurrent bleeding after 20+0 weeks, re-dose at minimum 6-weekly intervals (Grade D)
- Massive APH: managed via a multidisciplinary massive obstetric haemorrhage protocol (obstetrician, anaesthetist, haematologist, midwifery coordinator) following an ABCD approach, with delivery of the fetus/placenta as the definitive way to arrest bleeding
High-Yield Exam Points
- APH = bleeding from 24+0 weeks; unexplained APH is a recognised entity, not just "no cause found and move on" — it independently raises preterm birth, stillbirth, and FGR risk
- Ultrasound rules IN placenta praevia but never rules OUT abruption — abruption is a clinical diagnosis
- Kleihauer test guides anti-D dosing, not abruption diagnosis
- Corticosteroids 24+0–34+6 weeks = Grade A; tocolysis contraindicated in major APH/instability/fetal compromise
- Anti-D after APH is required even if routine prophylactic anti-D was already given
- For full detail on placenta praevia, accreta, and vasa praevia, see Green-top Guidelines 27, 27a, and 27b
Source: RCOG Green-top Guideline No. 63 (November 2011 (first edition; a second edition was in development as of the last confirmed review — no updated edition has been published, so this remains the current guidance))
Read the original on rcog.org.uk
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