Antepartum haemorrhage (APH) is bleeding from or into the genital tract occurring between 24 weeks of pregnancy until birth. The most common causes are placenta praevia and placental abruption. APH complicates 3-5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide. Management of APH involves assessing the severity of bleeding and signs of shock, investigating the cause, monitoring the fetus, and considering conservative management or delivery depending on gestational age and stability of the mother and fetus. Definitive treatment depends on the specific cause and can involve induction, vaginal delivery, or caesarean section.

1. D R . T H E I N T W A I P H Y O
P G 3 , E M
Antepartum Haemorrhage

2.  Antepartum haemorrhage (APH) is defined as
bleeding from or in to the genital tract, occurring
from 24+0 weeks of pregnancy and prior to the birth
of the baby.
 The most important causes of APH are placenta
praevia and placental abruption.
 APH complicates 3–5% of pregnancies
 leading cause of perinatal and maternal mortality
worldwide
 Up to one-fifth of very preterm babies are born in
association with APH

3. Severity
 NO consistent definitions of the severity of APH. It is
recognised that the amount of blood lost is often
underestimated
 The amount of blood coming from the introitus may
not represent the total blood lost (for example in a
concealed placental abruption).
 It is important to assess for signs of clinical shock
 The presence of fetal compromise or fetal demise is
an important indicator of volume depletion

4. Different terminology used
 Spotting – staining, streaking or blood spotting
noted on underwear or sanitary protection
 Minor haemorrhage – blood loss less than 50 ml
that has settled
 Major haemorrhage – blood loss of 50–1000 ml,
with no signs of clinical shock
 Massive haemorrhage – blood loss greater than
1000 ml and/or signs of clinical shock.
 Recurrent APH - > one occasion.

5. Placenta praevia
 Placenta praevia exists when the placenta is inserted
wholly or in part into the lower segment of the
uterus.
 classified by ultrasound imaging according to what
is relevant clinically:
 if the placenta lies over the internal cervical os -
major praevia;
 if the leading edge of the placenta is in the lower
uterine segment but not covering the cervical os,
minor or partial praevia exists

8. Risk factors for placenta praevia
 Previous placenta praevia (4-8%)
 Previous caesarean sections (risk increased with no. of CS)
 Previous termination of pregnancy
 Multiparity
 Advanced maternal age (>40 years)
 Multiple pregnancy
 Smoking
 Deficient endometrium due to presence or history of:
• uterine scar
• endometritis
• manual removal of placenta
• curettage
• submucous fibroid
 Assisted conception

9. Clinical assessment in women presenting with
APH
 First and foremost  Mother and fetal well being
 establish whether urgent intervention is required to
manage maternal or fetal compromise.
 The process of triage includes
 history taking to assess coexisting symptoms such as
pain,
 an assessment of the extent of vaginal bleeding,
 the cardiovascular condition of the mother, and an
assessment of fetal wellbeing

10. history should be taken.
 pain associated with the haemorrhage.
 Placental abruption - continuous.
 Labour pain- intermittent.
 Risk factors for abruption and placenta praevia should be
identified.
 Reduced fetal movements?
 If the APH is associated with spontaneous or iatrogenic
rupture of the fetal membranes, bleeding from a ruptured
vasa praevia
 Previous cervical smear history -to assess the possibility of
a neoplastic lesion of the cervix

11. Examination of the woman should be performed
to assess the amount and cause of APH
 General examination- pulse and blood pressure recorded.
 Abdominal palpation
 tenderness or signs of an acute abdomen. The tense or
‘woody’ feel to the uterus on abdominal palpation
indicates a significant abruption.
 Painless bleeding,high presenting part – placenta praevia
 A soft, non-tender uterus may suggest a lower genital
tract cause or bleeding from placenta or vasa praevia.

12. Speculum examination
 to identify cervical dilatation or visualise a lower
genital tract cause for the APH.
Digital vaginal examination
 If placenta praevia is a possible diagnosis, digital
vaginal examination should not be performed until
an ultrasound has excluded placenta praevia.

13. Investigation
 FBC
 Coagulation profile
 Bd Gp & Rh and cross match
 USS –location of placenta
 D-dimer
 Colour doppler- TVS –VP
 In all women who are RhD-negative, a Kleihauer test
should be performed to quantify FMH to gauge the dose
of anti-D Ig required
 Fetal monitoring- CTG monitoring

14. Management
 If preterm delivery is anticipated, a single course of
antenatal corticosteroid (Dexa 12 mg 12hrly 2 doses)
to women between 24 and 34 wk of gestation
 Tocolytics should not be given unless for very
preterm women who need time to transfer to
hospital with NICU

15.  For very preterm (24 – 26 wk)
 Conservative management – if mother stable
 Delivery of fetus – life threatening
 At these gestations, experienced neonatologists
should be involved

16. For placenta praevia
 Conservative –MacCafee ‘s regime
 (Premature < 37 wk ,mother haemodynamically
stable , no active bleeding,fetus stable)
 Advise bed rest ,keep pad chart,vital signs
monitoring,USG, Steroids,GSH,daily CTG, and
biophysical profile,Fetal movement count.
 Plan for delivery (>37 wk)
 Crossmatch 4 U of blood

17. Definitive treatment
 Type I, II (ant)  ARM +/- oxytocin
 If satifactory progress without bleeding  VD
 If bleeding continue  CS
 Type II (post ),III, IV  CS

18. For Rh negative mother
 Anti-D Ig should be given to all non-sensitised RhD-
negative women after any presentation with APH,
independent of whether routine antenatal prophylactic
anti-D has been administered.
 In the non-sensitised RhD-negative woman in the
event of recurrent vaginal bleeding after 20+0 weeks
of gestation, anti-D Ig should be given at a minimum
of 6-weekly intervals.
 In the non-sensitised RhD-negative woman for all
events after 20+0 weeks of gestation, at least 500 iu
anti-D Ig should be given followed by a test to identify
FMH greater than 4 ml red blood cells; additional anti-
D Ig should be given as required.

19. Complications of APH
Maternal complications
 Anaemia
 Infection
 Maternal shock
 Renal tubular necrosis
 Consumptive
coagulopathy
 Postpartumhaemorrhage
 Prolonged hospital stay
 Complication of blood
transfusion
Fetal complications
 Fetal hypoxia
 Small for gestational age
and fetal growth
restriction
 Prematurity (iatrogenic
and spontaneous)
 Fetal death

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