Antepartum haemorrhage (APH) is defined as bleeding from the birth canal after the 24th week (some authors define this as the 20th week, others up to the 28th week) of pregnancy.¹ It can occur at any time until the second stage of labour is complete.

Bleeding before 24 completed weeks of pregnancy is miscarriage which is discussed in a separate article Miscarriage (Spontaneous Abortion).

Epidemiology

In the 2003-2005 Confidential Enquiry into Maternal and Child Health (CEMACH) Report, the mortality rate due to obstetric haemorrhage was 0.66 per 100,000 maternities.²

• It affects 3-5% of all pregnancies.³
• It is 3 times more common in multiparous than primiparous women.

Aetiology^1,4

No definite cause is diagnosed in about 40% of all women who present with antepartum haemorrhage (APH):

• Placenta praevia: insertion of the placenta, partially or fully, in the lower segment of the uterus. See separate article Placenta Praevia record for further details.
• Placental abruption: see separate article Placenta and Placental Problems for further details.
• Local causes, e.g. vulval or cervical infection, trauma or tumours.
• Vasa praevia (bleeding from fetal vessels in the fetal membranes):⁵
  • This occurs in about 1 of every 1,000 pregnancies.
  • The baby's blood vessels from the umbilical cord may attach to the membranes instead of the placenta.
• Uterine rupture:^6,7,8
  • This is rare but very dangerous for both mother and baby.
  • About 40% of women who have uterine rupture had prior surgery of their uterus, including Caesarean section.
  • Other risk factors for uterine rupture are these conditions:
    • More than 4 pregnancies
    • Trauma
    • Excessive use of oxytocin
    • Shoulder dystocia
    • Some forceps deliveries
  • The rupture may occur before or during labour or at the time of delivery.
• Inherited bleeding problems are very rare, occurring in 1 in 10,000 women.⁹

Presentation

• Bleeding, which may be accompanied by pain (suggestive of abruption) or be painless (suggesting praevia).
• Uterine contractions may be provoked.
• There may be malpresentation or failure of the fetal head to engage, with placenta praevia.
• There may be associated signs of fetal distress.
• If the bleeding is severe, the mother may show signs of hypovolaemic shock.

Management

Always admit to hospital for assessment and management. Phone 999 if there are any major concerns regarding maternal or fetal wellbeing.

• The mainstays of management are resuscitation and accurate diagnosis of the underlying cause.^10,11
• Severe bleeding or fetal distress: urgent delivery of the baby, irrespective of gestational age.
• Admit to hospital, even if bleeding is only a very small amount. There may be a large amount of concealed bleeding with only a small amount of revealed vaginal bleeding.
• No vaginal examination should be attempted at least until a placenta praevia is excluded by ultrasound. It may initiate torrential bleeding from a placenta praevia.¹
• Resuscitation can be inadequate because of underestimation of blood loss and misleading maternal response. A young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs.¹²
• Take blood for FBC and clotting studies. Crossmatch, as heavy loss may require transfusion.
• Gentle palpation of the abdomen to determine the gestational age of the fetus, presentation and position.
• Fetal monitoring.
• Arrange urgent ultrasound.
• With every episode of bleeding, a rhesus negative woman should have a Kleihauer test and be given prophylactic anti-D immunoglobulin.¹³

Further management

• Further management will depend on fetal distress, the cause of the antepartum haemorrhage (APH), the extent of bleeding and gestation.
• In slight haemorrhage with blood loss less than 500 ml and no disturbance of maternal or fetal condition, ultrasound shows the placenta not lying in the lower uterine segment, no retroplacental clots, the patient may be discharged or have the baby induced, if it is after 37 weeks and other conditions are suitable.
• Placenta praevia: see separate Placenta Praevia article for for details.
• Moderate or severe placental abruption: see separate Placenta and Placental Problems article for details.

Complications¹

• Premature labour.
• Disseminated intravascular coagulopathy.
• Renal tubular necrosis.
• Postpartum haemorrhage.
• Placenta accreta: this complicates approximately 10% of all cases of placenta praevia but is rare in the absence of placenta praevia.¹¹

Prognosis

• One study found that bleeding in the second half of pregnancy is an independent risk factor for perinatal mortality.¹⁴
• The fetus may die from hypoxia during heavy bleeding.
• Perinatal mortality less than 50 per 1,000 maternal mortality is low if managed by an experienced obstetrician and if no vaginal examination is performed before admission to hospital.

Document references

1. El-Mowafi D; Bleeding in Late Pregnancy (Antepartum Haemorrhage), Geneva Foundation for Medical Education and Research, 2008
2. Saving Mothers’ Lives:Reviewing maternal deaths to make motherhood safer 2003-2005, Executive Summary and Key Recommendations, Confidential Enquiry into Maternal and Child Health, December 2007
3. Mehboob, R, Ahmad N; Fetal outcome in major degree placenta praevia Pakistan J. Med. Res. Vol. 42 No.1, 2003.
4. Managing Complications in Pregnancy and Childbirth, Department of Reproductive Health and Research (RHR), World Health Organization, 2003
5. Lijoi AF, Brady J; Vasa previa diagnosis and management; J Am Board Fam Pract. 2003 Nov-Dec;16(6):543-8. [abstract]
6. Walsh CA, O'Sullivan RJ, Foley ME; Unexplained prelabor uterine rupture in a term primigravida. Obstet Gynecol. 2006 Sep;108(3 Pt 2):725-7. [abstract]
7. Walsh CA, Baxi LV; Rupture of the primigravid uterus: a review of the literature. Obstet Gynecol Surv. 2007 May;62(5):327-34; quiz 353-4. [abstract]
8. Leung AS, Farmer RM, Leung EK, et al; Risk factors associated with uterine rupture during trial of labor after cesarean delivery: a case-control study. Am J Obstet Gynecol. 1993 May;168(5):1358-63. [abstract]
9. Kadir RA, Aledort LM; Obstetrical and gynaecological bleeding: a common presenting symptom. Clin Lab Haematol. 2000 Oct;22 Suppl 1:12-6; discussion 30-2. [abstract]
10. Sinha P, Kuruba N; Ante-partum haemorrhage: an update. J Obstet Gynaecol. 2008 May;28(4):377-81. [abstract]
11. Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and Management, Royal College of Obstetricians and Gynaecologists (January 2011)
12. Crochetiere C; Obstetric emergencies; Anesthesiol Clin North America. 2003 Mar;21(1):111-25. [abstract]
13. The Use of Anti-D Immunoglobulin for Rhesus D Prophylaxis, Royal College of Obstetricians and Gynaecologists (April 2011)
14. Koifman A, Levy A, Zaulan Y, et al; The clinical significance of bleeding during the second trimester of pregnancy. Arch Gynecol Obstet. 2008 Jul;278(1):47-51. Epub 2007 Dec 8. [abstract]