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Table of Contents
Antepartum haemorrhage (APH) is defined as genital tract bleeding from 24+0 weeks’ gestation and complicates 3-5% of pregnancies.1
The three most important causes of APH are placenta praevia, placental abruption and vasa praevia, these result in high morbidity and mortality for both mother and baby.
Other causes of APH include lower genital tract sources such as cervical polyps, vaginitis and cervicitis.
Placenta praevia occurs when the placenta lies in the lower uterine segment. It can lead to the complete or partial covering of the internal cervical os.
Placenta praevia increases the likelihood of APH due to poor attachment of the placenta to the uterine wall.
Figure 1 shows the classical grading of placenta praevia.
Placenta praevia can also be grouped into two subtypes:
Risk factors for placenta praevia include:2
Typical symptoms of placenta praevia include:1
Typical clinical findings in placenta praevia include:
Relevant bedside investigations include:
Relevant laboratory investigations include:
Relevant imaging investigations include:
Cardiotocography (CTG) is used to monitor the fetus.
Differential diagnoses to consider for placenta praevia include:
Placenta praevia is typically identified at the 16-20 week scan. If placenta praevia is identified the mother is rescanned at 32 weeks and if it is still present, again at 36 weeks.2
If placenta praevia is still present at 36 weeks gestation, delivery via caesarean section is recommended, due to the significant risk of spontaneous labour and associated haemorrhage.
The main complication of placenta praevia is major haemorrhage.
Methods that may be used to stop the bleeding include emergency caesarean section, uterine artery ligation or embolisation, intrauterine balloon tamponade or emergency hysterectomy.
Placental abruption is the complete or partial detachment of the placenta before delivery.
Complete abruption accounts for 7% of cases whilst partial abruption is more common, accounting for 93% of cases.
Overall placental abruption accounts for around a quarter of all cases of APH. It is a large cause of perinatal mortality accounting for 10-20% of all perinatal deaths.
The cause of placental abruption is often unknown. It may occur due to trauma or injury to the abdomen.
Risk factors for placental abruption include:2
Typical symptoms of placental abruption include:1
The amount of blood loss often correlates poorly with the degree of abruption.
Abruption may be ‘revealed’ where blood tracks between membranes and out of the vagina. It can however be ‘concealed’ where the blood accumulates with no obvious external bleeding.
Typical clinical findings in placental abruption include:
Differential diagnoses for placental abruption include:
Table 1. An overview of the management of placental abruption.
No signs of fetal distress
Induce and deliver vaginally
Signs of fetal distress
Immediate caesarean section
Induce vaginal delivery (unless mother haemodynamically compromised and/or ongoing massive haemorrhage, delivery then expedited by caesarean section to arrest bleeding)
Complications of placental abruption for the mother include:
Complications of placental abruption for the fetus include:
Vasa praevia occurs when fetal blood vessels (the two umbilical arteries and single umbilical vein) are within the fetal membranes and run across the internal cervical os.
Normally, the fetal vessels are protected within the umbilical cord or placenta.
In vasa praevia, the vessels are exposed which increases the risk of the vessels rupturing following rupture of the supporting membranes.2
Types of vasa praevia include:
Risk factors for vasa praevia include:2
Typical symptoms of vasa praevia include:1
Typical clinical findings in vasa praevia include:
Differential diagnoses for vasa praevia include:
If a woman is found to have vasa praevia on ultrasound, an elective caesarean section at 34-36 weeks is recommended.
In addition to this, corticosteroids are given from 32 weeks gestation to promote fetal lung maturity.2
In the event of APH, an emergency caesarean section is required to deliver the fetus.
The main complication for vasa praevia is major haemorrhage.
Other uterine sources of APH include:
Other lower genital tract sources of APH include:
Table 2. An overview of the clinical features of placenta praevia, placental abruption and vasa praevia.
Features of haemodynamic shock in keeping with visible blood loss
Features of haemodynamic shock not in keeping with visible blood loss
Abnormal lie and/or presentation
Normal lie and presentation
Fetal heart normal
Fetal heart absent/distressed
Coagulation problems rare
Coagulation problems present
ST7 Obstetrics & Gynaecology