Makindo Medical Notes

Related Subjects: |Antepartum haemorrhage |Postpartum haemorrhage |Acute Haemorrhage |Placenta praevia |Placenta abruption |Anti-D immunoglobulin

The most important causes of antepartum hemorrhage (APH) are placenta praevia and placental abruption, although these are not the most common. See the link to RCOG guidance below.

About

• APH is defined as any vaginal bleeding after 24 weeks of gestation up until the birth of the infant.
• It is an important cause of maternal and perinatal morbidity and mortality.
• There can be severe and rapid blood loss as uterine blood flow is very high (600-800 mL/min) at term.

Incidence

• APH complicates 3-5% of pregnancies.
• It is a leading cause of perinatal and maternal mortality worldwide.

Causes of Uterine Bleeding in Pregnancy

Causes of Uterine Bleeding in Pregnancy

Clinical Features

• Placental abruption should be considered when the pain is continuous.
• Labor should be considered if the pain is intermittent.
• Ask about awareness of fetal movements.
• Attempt to auscultate the fetal heart rate.
• If APH is associated with spontaneous or iatrogenic rupture of the membranes, consider vasa praevia.
• Avoid pelvic examination initially as it may exacerbate bleeding in cases of placenta praevia. Perform an ultrasound to rule it out first.
• Abdominal exam: assess for tenderness or signs of an acute abdomen.
• A tense or woody-feeling uterus suggests significant abruption.
• If the uterus is soft and non-tender, consider lower genital tract bleeding or bleeding from a placenta or vasa praevia.
• If no obvious cause is identified, perform a speculum exam to exclude lower genital tract causes (e.g., cervical polyp, trauma).

Assessing Severity

• Spotting: Small amounts of blood noted on underwear or sanitary protection.
• Minor hemorrhage: Blood loss less than 50 mL that has settled.
• Major hemorrhage: Blood loss between 500-1000 mL, without clinical signs of shock.
• Massive hemorrhage: Blood loss over 1000 mL and/or signs of clinical shock.

Investigations

• Full blood count, coagulation screen, and cross-match for 4 units of blood.
• Urea, electrolytes, and liver function tests.
• Check blood pressure and perform urinalysis for proteinuria.
• Cardiotocography to assess fetal wellbeing.
• For RhD-negative women, perform a Kleihauer test to quantify fetomaternal hemorrhage (FMH) and determine the dose of anti-D immunoglobulin.

Management

• Resuscitation (ABC): Ensure oxygen (15 L/min via mask), establish IV access, and start crystalloids.
• Call for help and prepare for possible massive transfusion.
• If available, administer ABO rhesus-matched blood; if not, give O-negative blood.
• For placenta praevia lying within 2 cm of the internal os, cesarean section is advised.
• With abruption, the patient may appear severely shocked despite minimal visible blood loss (concealed hemorrhage).
• Administer antenatal corticosteroids for women between 24+0 and 34+6 weeks of gestation who are at risk of preterm birth.
• If coagulopathy is suspected, consult a haematologist and consider giving fresh frozen plasma (FFP) and cryoprecipitate while awaiting results of coagulation studies.

Delivery

• If the fetus is compromised, immediate cesarean section is indicated along with maternal resuscitation.
• For women with APH and associated maternal and/or fetal compromise, immediate delivery is necessary.
• Ensure involvement of a senior obstetrician and paediatrician/neonatologist.

Complications for the Mother

• Anaemia, infection, maternal shock, and renal tubular necrosis.
• Postpartum hemorrhage occurs in 25% of cases following abruption.
• Sheehan’s syndrome, consumptive coagulopathy, disseminated intravascular coagulation (DIC).
• Acute kidney injury (AKI), postpartum hemorrhage, and transfusion-related complications.

Complications for the Fetus

• Fetal hypoxia, fetal death, and prematurity.
• Small for gestational age (SGA) and intrauterine growth restriction (IUGR).

References

• Antepartum Haemorrhage - RCOG Guidance