Disclaimer:
This article provides an overview of antepartum haemorrhage and covers the shared clinical principles, high-yield comparisons, and distinguishing features of its main causes.
The key causes have a dedicated article (linked below) where full diagnostic and management details can be found.
| Cause of antepartum haemorrhage | Article link |
|---|---|
| Placental abruption | Placental Abruption |
| Placenta praevia | Placenta Praevia |
| Vasa praevia | Vasa Praevia |
Definition
Antepartum haemorrhage is defined as bleeding from or into the genital tract that occurs from 24 weeks of pregnancy onwards, and prior to the birth of the baby.
Antepartum haemorrhage complicates 3-5% of pregnancies and is a leading cause of maternal and perinatal mortality worldwide.
Aetiology and Overview Table
| Cause of antepartum haemorrhage | Key clinical features |
|---|---|
| Placental abruption | Painful vaginal bleeding:
Little or no bleeding is possible in concealed cases; do NOT exclude abruption due to the absence of bleeding |
| Placenta praevia | Painless vaginal bleeding:
|
| Vasa praevia | Onset is shortly after rupture of fetal membranes:
|
| Cervical ectropion | NO abdominal pain / uterine tenderness + soft non-tender uterus
Often presents as:
Identifiable via speculum examination |
| Cervical cancer | |
| Cervical dilatation |
Where no identifiable cause is found, the bleeding is classified as unexplained antepartum haemorrhage.
Work-Up and Diagnosis
The following investigations reflect the general workup applicable to all presentations of antepartum haemorrhage.
| Assessment / investigation | Description / notes |
|---|---|
| Clinical assessment | The first step is to establish if urgent intervention is required to manage maternal compromise
If urgent resuscitation is NOT necessary:
IMPORTANT: digital vaginal examination should NOT be performed until an ultrasound has definitively excluded placenta praevia, as it could provoke catastrophic bleeding. |
| Maternal blood test | The specific blood tests depend on the volume of bleeding:
Kleihauer Test must be performed in all RhD-negative women to quantify fetomaternal haemorrhage and calculate the appropriate dose of anti-D immunoglobulin |
| Ultrasound | ALL patients presenting with antepartum haemorrhage should undergo an ultrasound (no specific recommendation on trans-abdominal or trans-vaginal ultrasound)
The primary goal is to confirm or exclude placenta praevia |
| Fetal monitoring | Perform CTGCardiotocography to assess for fetal distress
If a fetal heartbeat cannot be heard via external auscultation, an immediate ultrasound is required to check for fetal viability |
Management
Key principles:
- Mother’s life is the priority
- Regardless of the gestation, if a woman presents with major or massive haemorrhage, or clinical shock, the mother must be resuscitated and stabilised first, before any decisions are made regarding the delivery or assessment of the fetus
- Patients should be transferred to a hospital maternity unit with immediate access to a multidisciplinary team and facilities for rapid blood transfusion and emergency operative delivery
- Women presenting with any bleeding heavier than spotting, or those with ongoing bleeding, must remain in the hospital at least until the bleeding has stopped
- Medical interventions
- Antenatal corticosteroids: A single course of antenatal corticosteroids should be offered to women presenting between 24+0 and 34+6 weeks of gestation to prepare the fetal lungs, as antepartum haemorrhage carries a high risk of preterm birth
- Tocolysis is contraindicated in emergencies (e.g. major bleeding, haemodynamic instability, any evidence of fetal compromise)
- All non-sensitised RhD-negative women must be given Anti-D following any presentation of antepartum haemorrhage, regardless of whether they have already received routine antenatal prophylaxis
- Delivery decisions
- Any maternal and/or fetal compromise mandates immediate delivery (usually by caesarean section) concurrently with maternal resuscitation
See the corresponding articles on cause-specific management.
| Cause of antepartum haemorrhage | Article link |
|---|---|
| Placental abruption | Placental Abruption |
| Placenta praevia | Placenta Praevia |
| Vasa praevia | Vasa Praevia |