Antepartum hemorrhage (APH) is vaginal bleeding occurring between 24 weeks of pregnancy and birth. It affects 3-5% of pregnancies and can range from light spotting to heavy bleeding with signs of shock. The main causes are placenta previa, placental abruption, and unknown origins. APH poses risks to both mother and fetus, including anemia, infection, shock, and fetal hypoxia. Diagnosis involves examination, ultrasound, and tests. Management depends on gestational age and severity of bleeding, and may involve admission, monitoring, resuscitation, corticosteroids, tocolysis, and delivery.

1. By:
Dr. Sana Lodhi

2.  Definition:
Bleeding from or into the genital
tract, occuring from 24th week of pregnancy
& prior to the birth of baby.
Incidence: 3-5% of pregnancies

3.  * Spotting – staining, streaking or blood
spotting noted.
 * Minor haemorrhage – blood loss < 50 ml that
has settled.
 * Major haemorrhage – blood loss of 50–1000
ml, with no signs of clinical shock.
 * Massive haemorrhage – blood loss > 1000 ml
and/or signs of clinical shock.
 • Recurrent APH – episodes of APH on more
than one occasion.

4.  Placenta praevia.
 Placental abruption.
Vasa Previa
 Uncertain origin causes:
 * Cervical lesions – polyp, ectropion.
* Vaginal lesions.
* Varicosities
* Excessive show.

5.  MATERNAL
Anemia
Infection
Maternal shock
RTN
Consumptive coagulopathy
PPH
Prolonged hospital stay
Psychological sequelae
Complications of blood
transfusion
 FETAL
Fetal hypoxia
SGA/IUGR
Prematurity
Fetal death

6.  placenta that lies wholly or partly within the lower uterine segment –
 leading to haemorrhage as the lower segment forms or the cervix
dilates.
Incidence – 1:200.
RISK FACTORS:
Previous placenta previa
Previous caesarean section
Multiparity
Advanced maternal age >40yrs
Multiple pregnancy
Smoking
Deficient endometrium d/t presence or h/o:
Uterine Scar
Endometritis
Manual removal of placenta
Currettage
Submucous fibroid
Assisted conception

8.  Painless, bright red vaginal bleeding
 Examination:
 Pallor, if present, will be proportionate to the amount of bleeding.
 Size of the uterus corresponds to the period of amenorrhoea.
 Uterus is soft and non tender.
 Malpresentations is common
 Usually no sign of fetal distress until severe maternal compromise
P/V not done
Diagnosis:
TVS – improves the accuracy of placental localization and is safe

9.  bleeding following premature separation of a normally sited placenta.
 RISK FACTORS:
 previous abruption;
 ●family history of abruption;
 ●fetal abnormality;
 ●rapid uterine decompression (rupture of membranes with
polyhydramnios);
 ●trauma;
 ●chorioamnionitis/premature rupture of membranes;
 ●smoking/illicit drug use (cocaine and amphetamines especially);
 ●abnormal placentation (circumvallate placenta etc.);
 ●pre-eclampsia;
 ●underlying thrombophilia;
 ●Trauma

10. Types of abruption. A. Revealed abruption. Blood tracks between
the membranes, and escapes through the vagina and cervix. B.
Concealed abruption. Blood collects behind the placenta, with no
evidence of vaginal bleeding

11.  Severe and constant abdominal pain
 Signs
 • Pallor, which is usually out of proportion to the extent of bleeding
 • Hypertension
 • The uterus will be larger than expected for the period of amenorrhoea
 • Uterus may be tense and tender and even rigid (woody hard)
 • Difficulty in palpating the underlying fetal parts easily
 • Fetal distress or absent fetal heart sounds
Features of hypovolemic shock may be present

12.  Major haemorrhage – FBC, U&Es, LFTs, coagulation screen, and
4 units of blood crossmatched.
 The initial haemoglobin may not reflect the amount of blood lost.
The platelet count, if low, may indicate a consumptive process
seen in relation to significant abruption;
 this may be associated with a coagulopathy.
 Minor haemorrhage – FBC and ‘Group & Save (G&S)’.
 The Kleihauer test in rhesus D (RhD)-negative women to quantify
FMH. It is not a sensitive test for diagnosing abruption.
 USS
CTG

13.  Advised to report all vaginal bleeding to antenatal care
provider
Admit to hospital for clinical assessment & management
Senior staff must be involved – Senior obstetrician, anesthetist,
neonatologist
May need resuscitation measures if in shock or severe bleeding
Airway(A), breathing(B) & circulation(C)
Two wide bore cannula
Take blood for Grouping, CBC, coagulation profile, Liver & renal
function
Volume should be replaced by Crystalloid /colloid until blood is
available
Severe bleeding or fetal distress: Urgent delivery of baby
irrespective of gestational age
MOTHER IS THE PRIORITY IN ABOVE MENTIONED CONDITION

14. History:
Obtain history if no maternal compromise –
Colour and consistency of bleeding
Quantity & rate of blood loss
Precipitating factors i.e. Sexual intercourse, Vaginal
examination
Degree of pain, site and type
Placental location-review ultrasound report if
available
Ascertain fetal movements
Ascertain blood group
Previous cervical smear history if available
Examination
To assess amount & cause of APH
Assess maternal & fetal well-being
Pallor, record temperature, pulse & BP
Perform abdominal examination
• Note areas of tenderness & hypertonicity
•Determine gestational age of fetus, presentation &
position, auscultate fetal heart
No vaginal examination should be attempted at least
until placenta previa is excluded
Do speculum examination to assess cervix / bleeding
& exclude local lesions

15. Corticosteroids:
For preterm delivery between 24+0 & 34+6 weeks POG, antenatal
corticosteroids - to promote fetal lung maturity
Tocolytic:
Do not use tocolysis to delay delivery in a woman presenting
with a major APH who is haemodynamically unstable, or if
there is fetal compromise.
• Tocolysis is contraindicated in placental abruption and is
‘relatively contraindicated’ in ‘mild haemorrhage’ due to
placenta praevia.
• Women most likely to benefit from use of a tocolytic drug are
those who are very preterm, those needing in utero transfer, and
those who have not yet completed a full course of corticosteroids.
• If tocolysis is used, choose a drug which has minimal maternal
cardiovascular side effects. Avoid calcium antagonist (nifedipine) as
it has risk of maternal hypotension.

16.  Fetal death • Vaginal birth for most women (provided the
maternal condition is satisfactory), but CS may be necessary in
some.
Maternal or fetal compromise Obstetric emergency –
resuscitate mother and deliver to control the bleeding. Delivery
will usually be by CS, unless the woman is in established labour.
Extremely preterm pregnancy (24 to 26 weeks)
 A senior paediatrician/neonatologist for counseling of
 women.
 • Conservative management is usually appropriate when
 the mother’s condition is stable.
 • When the bleeding is considered life-threatening for
 the woman or there is evidence of cardiovascular
 compromise that fails to respond to resuscitation –
 consider delivery.

17.  Before 37 weeks
 • Where there is no maternal or fetal compromise and bleeding
has settled, there is no evidence to support elective premature
delivery of the fetus; therefore can delay delivery.
After 37 weeks
 • Differentiate between APH and blood-stained ‘show’.
 If the APH is spotting or the blood is streaked through mucus it is
unlikely to require active intervention.
 However, in the event of a minor or major APH, consider IOL for
vaginal delivery.

18.  Fetus may die from hypoxia during heavy
bleeding
Perinatal mortality more than 50 per 1000
even with tertiary care facilities
High rates of maternal mortality