Antepartum Haemorrhage (APH)

Key Points ⚡

APH: genital tract bleeding from 24+0 weeks gestation onwards.
Major causes: placenta praevia, placental abruption, vasa praevia. All cause high morbidity and mortality.

Placenta located in lower uterine segment; can partially or completely cover cervical os.
Risk factors: previous C-section, previous termination of pregnancy, multiparity, advanced maternal age (>40), multiple pregnancy, smoking, assisted conception.
Clinical features: painless vaginal bleeding, non-tender uterus, abnormal fetal lie, low-lying placenta on 20-week anomaly scan.
Investigations: vital signs, FBC, U&Es, LFTs (to exclude HELLP/pre-eclampsia), coagulation profile, Kleihauer test, blood group and crossmatch, ultrasound, cardiotocography (CTG).
Management: rescan at 32 and 36 weeks; elective C-section if placenta remains low or covers os at 36 weeks.
Complications: major haemorrhage requiring emergency interventions including C-section, uterine artery ligation, embolisation, balloon tamponade, or hysterectomy.

Partial or complete premature separation of placenta before delivery.
Accounts for ~25% of APH cases; significant cause of perinatal mortality (10-20%).
Risk factors: maternal age >35, multiparity, hypertension, pre-eclampsia, previous abruptions, antiphospholipid syndrome, thrombophilia, smoking, cocaine use, trauma.
Clinical features: painful vaginal bleeding, abdominal pain, woody/tender uterus, fetal distress or absence of fetal heart sounds.
Types: revealed (external bleeding), concealed (internal bleeding).
Investigations: same as placenta praevia plus ultrasound to identify bleeding, CTG to monitor fetus.
Management:
Fetus <36 weeks, no distress: observe closely.
Fetus ≥36 weeks, no distress: induce labor vaginally.
Signs of distress: immediate C-section.
Fetus dead: induce vaginal delivery unless maternal instability requires C-section.
Complications: maternal hemorrhage, shock (risk of Sheehan syndrome), DIC, postpartum hemorrhage; fetal hypoxia, prematurity, stillbirth.

Fetal vessels run unprotected across the internal cervical os within fetal membranes.
Risk factors: IVF, multiple pregnancy, low-lying placenta.
Clinical features: painless vaginal bleeding often after rupture of membranes, fetal bradycardia, soft non-tender uterus.
Investigations: vital signs, blood tests as above, ultrasound, CTG.
Management: elective C-section at 34-36 weeks, corticosteroids from 32 weeks for fetal lung maturity. Emergency C-section if bleeding occurs.
Complications: major hemorrhage, fetal hypoxia, IUGR, stillbirth.

Lower genital tract: cervical polyps, carcinoma, cervicitis, vaginitis, vulval varicosities.
Uterine: circumvallate placenta, placental sinuses, uterine rupture.

Feature	Placenta Praevia	Placental Abruption	Vasa Praevia
Pain	No	Yes	No
Uterus	Non-tender	Tender, woody	Soft, non-tender
Vaginal bleeding	Yes (painless)	Yes (painful)	Yes (painless)
Fetal heart	Normal	Distressed/absent	Bradycardia
Haemodynamic shock	Consistent with blood loss	Often more than visible loss	Consistent with blood loss
Coagulation abnormalities	Rare	Common (DIC)	Rare

Royal College of Obstetricians and Gynaecologists. Antepartum Haemorrhage. Green-top Guideline No. 63, 2011.
Royal College of Obstetricians and Gynaecologists. Placenta Praevia and Management. Green-top Guideline No. 27, 2011.
Sigrid de Rooij. Vasa Praevia. [CC BY-SA]
Additional clinical guidelines and expert reviews.