CASE-BASED LEARNING
Antepartum haemorrhage
Satya P Battula
Nihal HA Mohammed
Shreelata Datta
Abstract
Antepartum haemorrhage (APH) is defined as bleeding from, or into,
the genital tract, occurring from 24þ0 weeks of pregnancy and prior
to delivery. It complicates 3e5% of pregnancies but is seen in up to
20% of very preterm deliveries, and an association with cerebral
palsy. MBBRACE -UK 2019 reported that 8% of UK maternal deaths
occurred secondary to bleeding (APH&PPH) in pregnancy during the
triennium 2015e2017. The high prevalence and the associated peri-
natal and maternal mortality and morbidity, demands a thorough un-
derstanding of APH and this review considers the most common
causes of APH (placenta praevia, placental abruption and local
causes), together with their management, using a case-based
approach.
Keywords Antepartum haemorrhage; blood transfusion; Jehovah’s
witness; MBBRACE; post-partum haemorrhage
Introduction
Obstetric haemorrhage is a leading cause of maternal mortality
worldwide. The MBBRACE report published in December 2019
showed that 11 of the 209 maternal deaths in the UK occurred as
a result of antepartum and postpartum haemorrhage in the 2015
e2017 triennium, representing a significant decrease from 2014
to 2016 (18/225). Bleeding in pregnancy is a common presenting
complaint to early pregnancy units, maternity triage, general
practice and labour wards in the UK, so early recognition and
management is a key aspect of antenatal assessment.
There are no consistent definitions of APH severity. The
extent of blood loss is frequently underestimated and the amount
of revealed haemorrhage may not represent the total blood loss.
Thus, signs of clinical shock and the presence of fetal compro-
mise and fetal demise is an important indicator of significant
volume depletion.
The RCOG Greentop guideline uses the following definitions
to assess the severity of APH:
 Spotting e Staining, streaking or spots noted on the sani-
tary pad
 Minor haemorrhage e blood loss <50 ml that has settled
Satya P Battula MBBS Specialty Registrar in Obstetrics and
Gynaecology at The Hillingdon Hospital Trust, London, UK. Conflict
of interest: none declared.
Nihal HA Mohammed MBBS Specialty Registrar in Obstetrics and
Gynaecology at The Hillingdon Hospital Trust, London, UK. Conflicts
of interest: none declared.
Shreelata Datta MBBS LLM BSc (Hons) MRCOG Locum Consultant
Obstetrician and Gynaecologist at The Hillingdon Hospital Trust,
London, UK. Conflicts of interest: none declared.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 31:4
Common causes of APH
Causes
Placental Placenta praevia
Placenta abruption
Vasa praevia
Genital tract Cervicitis
Erosion
Trauma
Vulvovaginal varicosities
Genital infection
Genital tumor
Others
Unclassified Marginal
Unexplained
Table 1
 Major haemorrhage e blood loss 50e1000 ml, with no
sign of clinical shock
 Massive haemorrhage e blood loss >1000 ml and/or signs
of clinical shock
Table 1 summarizes the most common causes of APH. The
following cases illustrate the importance of history taking, ex-
amination and investigation for appropriate diagnosis and treat-
ment of commonly presenting patients with APH.
Case 1
A 30-year-old woman presents at 25 weeks’ gestation in her
second pregnancy, attending triage with bleeding after inter-
course with no affiliated abdominal pain, history of contractions
or leaking of fluid vaginally. Her pregnancy was otherwise un-
complicated with a normal anomaly scan. Smear history was
normal. Assessment confirmed normal observations and exami-
nation confirmed a soft non-tender abdomen with a normal fetal
heart rate. Speculum examination confirmed minimal dark
brown blood, with a small cervical polyp noted which bled on
contact. No active bleeding was seen from the cervix and no li-
quor was noted. After a period of observation, the patient was
reassured and discharged, with the advice to avoid intercourse.
She was planned for colposcopy for subsequent cervical polyp
removal.
Discussion: benign cervical polyps in pregnancy are a common
cause of APH. If the bleeding does not clinically compromise the
mother or fetus, and the polyp appears unsuspicious then these
can be removed after pregnancy. Local causes (cervical and
vaginal causes) are commonly seen in triage, the most frequent
being a cervical ectropion. This occurs when columnar epithe-
lium, that usually lines the cervical canal, protrudes further onto
the vaginal surface of the cervix. This is more common in
pregnancy, and is thought to be related to high oestrogen levels.
The tissue of the ectropion is very friable and contact bleeding
can occur, usually during sexual intercourse or even on passing
hard stools. Ectropion can be easily diagnosed on speculum ex-
amination of the cervix.
117 Ó 2021 Published by Elsevier Ltd.
 CASE-BASED LEARNING

Cervicitis (inflammation or infection of the cervix) is an
underdiagnosed cause of bleeding in pregnancy and may be
caused by sexually transmitted infections (STIs) such as chla-
mydia and gonorrhoea, which can present with abnormal vaginal
bleeding. Treatment of STIs presenting in pregnancy is impor-
tant, as they can be associated with preterm labour and neonatal
morbidity. Bleeding or spotting can also occur from the vagina
and vulva secondary to non-sexually transmitted infections such
as thrush, folliculitis, and from trauma.
Finally, an uncommon cervical cause for APH is cervical
carcinoma. A detailed history at the booking appointment should
assess a woman’s smear history and history of previous cervical
treatments. If a cervical carcinoma is suspected on assessment of
the cervix then urgent referral to colposcopy is indicated. The
presentation of cervical cancer in pregnancy depends on the
stage at diagnosis and lesion size; most women with Interna-
tional Federation of Gynecology and Obstetrics (FIGO) stage I
cancer are asymptomatic; symptomatic pregnant women usually
present with APH (mostly postcoital) or vaginal discharge. In a
Swedish population study, the incidence of cervical cancer was
7.5 cases per 100, 000 deliveries; in over half of these cases, the
women had an abnormal cervical smear history.
key risk factors for placenta praevia. Diagnosis primarily in-
volves transvaginal ultrasound usually prompted by the finding
of a low lying placenta at the routine anomaly ultrasound scan.
The 2018 RCOG guideline defines placenta praevia as the
placenta covering the cervical internal os at any gestation beyond
16 weeks, and a low-lying placenta when the edge of placenta is
less than 20 mm from the internal os. 90% of low lying placentae
resolve by the third trimester due to placental ‘migration’
brought about by the expansion in size of the of the lower uterine
segment. Follow up sonogram, ideally transvaginally, is recom-
mended at 32 weeks’ gestation to look for persistent low-lying or
placenta praevia. According to the RCOG guideline, in cases of
persistent low lying placenta, follow up scan at 36 weeks with an
appointment to discuss the mode of delivery should follow.
Cervical length measurement may help facilitate management
decisions in asymptomatic women with placenta praevia. A short
cervical length on ultrasound before 34 weeks’ gestation in-
creases the risk of preterm emergency delivery and massive
haemorrhage at caesarean section, as does a history of multiple
APHs. The use of cervical cerclage to reduce bleeding and pro-
long pregnancy is not supported by sufficient evidence to
recommend its use outside of a clinical trial.

Case 2
A 36-year-old multiparous woman in her second pregnancy,
having had a previous caesarean section, presents at 36 weeks’ Risk factors for common causes of APH
gestation with her second episode of vaginal bleeding. There is
no history of abdominal pain, or loss of fluid per vaginum, and Conditions Risk Factors
fetal movements are normal. The anomaly scan showed a low-
Placenta praevia Large placenta area (multiple pregnancy)
lying anterior placenta, possibly covering the internal os
Advance maternal age
(placenta praevia). Repeat ultrasound scan at 30 weeks, by a
High Parity
sonographer specialized in looking for signs of abnormal
Uterine scar (caesarean section, myomectomy)
placentation, confirmed these findings, but with no sign of in-
Previous placenta praevia (0.7%)
vasion into the myometrium. The couple was counselled about
Smoking, cocaine use
the placenta praevia, risk of hemorrhage and mode of delivery at
Placenta pathology
38 weeks by caesarean section. The risk of hysterectomy was
ART (new 2018 update RCOG) (2%)
also discussed. She had previously presented with an episode of
Placenta abruption Previous placental abruption
painless vaginal bleeding at 34 weeks’ gestation and discharged
Hypertension
after a period of observation in hospital. On this occasion, her
Preeclampsia
observations are normal and examination confirms a soft non-
Smoking, cocaine use
tender abdomen. Speculum examination finds that the cervical
Premature rupture of membranes
os is closed with minimal dark blood noted in the vagina and no
Multiple pregnancy
active bleeding. The CTG is normal. Given this is her second
Advance maternal age
admission with a significant bleed, she is admitted for observa-
Abdominal trauma
tion until a planned delivery at 37 wks by caesarean section, or
Vasa praevia Velamentous insertion of umbilical cord
earlier if any further bleeding occurs. She receives steroid pro-
insertion
phylaxis and later undergoes a planned caesarean section by the
Succenturiate/bilobe placenta
advanced trainee, supervised by an obstetric consultant, at 37
Multiple pregnancy
weeks’ gestation, with blood cross matched.
IVF pregnancy
Uterine rupture Multiparity
Discussion: placenta praevia is defined as a placenta which
Congenital uterine anomalies
covers the internal os, either partially or completely. It compli-
Uterine scar (caesarean section, myomectomy,
cates 0.3e2% of pregnancies, although the prevalence is
uterine distension (secondary to
increasing as the rate of caesarean section rises. A history of one
polyhydramnios, multiple pregnancy,
prior caesarean section increases the risk 4e5 fold, two sections
macrosomia)
by 7e8 fold, and by four or more sections almost half of all
Gestation >40 weeks
women will have a subsequent placenta praevia. The exact cause
Obstructed labour
of placenta praevia remains unknown, but there is an association
with endometrial damage and uterine scarring. Table 2 outlines Table 2

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 CASE-BASED LEARNING
The presence of placenta praevia can also increase a woman’s
risk for placenta accrete spectrum (PAS). An alternative term is
‘Abnormally Invasive Placentation’ (AIP) This spectrum of con-
ditions includes placenta accreta, increta, and percreta. Placenta
accreta is the attachment of the placenta beyond the normal
boundary of the myometrium that is established by the Nitabuch
fibrinoid layer. Placenta increta is the invasion of the placenta
into the myometrium, and placenta percreta is the invasion into
the uterine serosa and or surrounding organs. The incidence of
abnormal placentation in the presence of placenta praevia in-
creases with the prior number of caesarean sections, being 3%,
11%, 40%, 61% and 67% after 1, 2, 3, 4 or 5 previous sections,
respectively. Ultrasound is the preferred modality to diagnose
PAS with high sensitivity and specificity but MRI is useful for
cases of posterior placenta praevia or to assess potential invasion
into the bladder. However, MRI is not cost effective and there is
no evidence that it improves outcome or diagnosis. If PAS is
suspected, the possibility of cesarean hysterectomy should be
discussed with the patient and an alternative plan to leave the
placenta in situ to avoid massive haemorrhage considered, if
fertility preservation is desired.
The timing of delivery is tailored to the gestational age,
amount of bleeding, and maternal and fetal well-being.
Caesarean section is the preferred mode of delivery. The 2018
Green Top RCOG guideline recommends delivery between 36
and 27 weeks’ gestation for asymptomatic women with a low
lying placenta or placenta praevia. Repeated episodes of bleeding
should encourage earlier birth. However, women with placenta
praevia/low lying placenta who experience episodes of bleeding
should be delivered between 34 and 37 weeks’ gestation. Women
presenting with severe bleeding or fetal distress may require
immediate delivery by emergency caesarean section at earlier
gestations, or the timing of an elective procedure might be
brought forward if there are repeated episodes of mild to mod-
erate bleeding during the third trimester. A senior obstetrician,
anaesthetic team, neonatologists, and blood bank should be
informed when admitting a patient with placenta praevia. If PAS
is suspected, or has been diagnosed, then a multi-disciplinary
plan should be made for caesarean delivery at 35e37 weeks,
involving gynaecology, interventional radiology, blood bank and
possibly urology and general surgery.
Case 3
A 25-year-old primiparous woman presents at 36 weeks’ gestation
to the maternity triage with a 4-hour history of significant vaginal
bleeding and contractions. Her pregnancy had been assessed as
low risk up until this point, with an anomaly scan showing an
anterior high placenta. She is immediately admitted to labour ward
in view of her history of active bleeding with clots. Observations
are normal, and intravenous access is obtained with blood taken
for investigation. Abdominal examination confirms uterine con-
tractions, a longitudinal lie and cephalic presentation. Her uterus is
tender to palpation between the contractions and she has persis-
tent pain. On speculum, a large blood clot is noted and active
bleeding from the os seen, with an approximate blood loss of 200
ml. On commencement of the cardiotocograph a prolonged
deceleration for 4 minutes is noted, and she is moved immediately
to theatre for a grade 1 emergency caesarean section. At the time of
delivery, a large retroplacental clot is noted.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 31:4
Discussion: placental abruption is defined as the partial or
complete separation of the placenta from the uterus prior to de-
livery. It complicates 0.2e1% of pregnancies, and has a recur-
rence rate of 3e15%. It commonly presents with a sudden onset
of continuous vaginal bleeding following placental separation,
however in a fifth of cases bleeding is retroplacental, and the
bleeding is ‘concealed’. The bleeding may be associated with
sudden onset of abdominal or back pain and uterine tenderness.
Sixty per cent of placental abruptions present with fetal distress
which can manifest as reduced fetal movements or a pathological
CTG. The risk factors associated with placental abruption are
listed in Table 2. Placental abruption is a clinical diagnosis; the
sensitivity of ultrasound is only 25%. Initial management in-
cludes rapid stabilization of maternal cardiopulmonary status
and assessment of fetal well-being. This includes serial evalua-
tion of the haematocrit and coagulation studies to determine
whether disseminated intravascular coagulation is present.
Tocolysis is generally contraindicated, except perhaps in mild
abruption before 34 weeks’ gestation when it may be considered
to facilitate the effective administration of corticosteroids. De-
livery should be considered if acute abruption occurs after 36
weeks’ gestation. Emergency caesarean delivery, independent of
gestational age, should be considered if the fetus is viable and the
presumed abruption is causing ongoing moderate to heavy
bleeding and/or there are signs of fetal compromise. A vaginal
birth may still be possible if the CTG is normal, labour is pro-
gressing, or the cervix is very favourable for induction by artifi-
cial rupture of membranes, and the maternal condition is stable.
Vaginal birth is usually considered the optimal mode of birth if
there has been an associated intrauterine fetal death, but only
whilst the maternal condition remains stable.
Other causes of APH
Vasa praevia: vasa praevia is the term used to described the
situation when fetal vessels run through the placental mem-
branes, unprotected by the umbilical cord. The prevalence is
between 1 in 1200 and 1 in 5000. It can be subclassified as:
 Type I when the vessels connect to a velamentous umbil-
ical cord
 Type II when the vessels connect the placenta with a
succenturiate or accessory lobe
Vasa praevia may be diagnosed during early labour by vaginal
examination, detecting the pulsating fetal vessels inside the in-
ternal os, or by acute fetal compromise with dark -red vaginal
bleeding after rupture of membranes. The fetal mortality rate is
60% despite urgent caesarean section due to the speed at which
fetal exsanguination occurs. The risk factors are listed in Table 2.
Increasingly, the diagnosis is being made during the antenatal
period by targeted ultrasound prompted by the discovery of
succenturiate lobes and velamentous cord insertions of low lying
placentae on routine scans. The combination of both trans-
abdominal and transvaginal colour doppler imaging provides the
best diagnostic accuracy. Where vasa praevia is confirmed
antenatally, delivery should be considered electively before
membranes rupture by caesarean section at 34e36 weeks’
gestation.
Uterine rupture: Uterine rupture is defined as full thickness loss
of integrity of the uterine wall. It usually occurs during labour in
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 CASE-BASED LEARNING

women who have had a previous Caesarean section or trans-

myometrial surgery. It is characterized by sudden onset severe Assessment of woman with APH
abdominal pain and can be associated with sudden pause in Assessment Management
contractions, fetal distress, vaginal bleeding, or hemodynamic
instability. A (Airway) Check the patency
B (Breathing) Respiration rate
Unexplained APH: some women will present with bleeding that Oxygen saturation
cannot be attributed to any of the above causes. The RCOG 10e15 L via non-rebreathing mask
Greentop Guideline references a number of studies over the last C (circulation) Heart rate
four decades which demonstrate that pregnancies with unex- Capillary refill time
plained APH are at higher risk of preterm birth and stillbirth. A IV access (wide bore cannula) þ IV fluid
recent retrospective, observational study noted that pregnancies resuscitation
complicated by APH of unknown aetiology are at a higher risk of Assess blood loss
preterm birth, lower birthweight, induction of labour, and D (Disability) Glasgow score
neonatal unit admissions. Repeated presentations with unex- E (Exposure) Abdominal examination
plained APH in pregnancy should raise suspicion and the preg- Speculum examination
nancy should be monitored as high risk, with the need for Vaginal examination
additional ultrasound scans for fetal growth. Healthcare pro- F (Fetus) Auscultation FHR
viders should be aware that maternal trauma, including domestic CTG
violence, can result in APH, possibly from placental abruption. A Ultrasound
third of domestic violence is known to start or escalate in preg-
nancy. Women who present with APH and other signs suggestive Table 3
of domestic violence or, who disclose violence, should be iden-
tified early and managed appropriately by a multidisciplinary
immediately. The mother is the priority in these situations and
team who have been specially trained in domestic violence to
should be stabilized prior to establishing the fetal condition.
safeguard pregnant women.
If there is no maternal compromise a full history should be
taken. Table 4 provides an overview of the symptoms of the
Assessment
differential diagnosis of APH.
Women who present with major haemorrhage and signs of shock The risk factors for the most common causes of APH should
should be seen in a maternity unit which can provide a multi- be considered when taking a history, along with direct ques-
disciplinary team including a senior obstetrician, senior midwife, tioning regarding fetal movements and rupture of membranes.
anaesthetist, neonatologist, haematologist and blood transfusion Previous cervical smear history may be useful in order to the
technician. Every maternity unit should have fixed protocols for assess the possibility of cervical cancer.
the management of massive obstetric haemorrhage and this
should be activated if a woman presents with, or develops, Examination
ongoing haemorrhage. Simulation skills drills should be con- The main objective of examination is to make an early diagnosis
ducted at regular intervals to ensure staff are appropriately of APH for immediate resuscitation and management:
trained in order to prepare for such cases. The assessment of
woman with APH begins with the ABC resuscitation approach Abdominal palpation: the women should be assessed for the
(as outlined in Table 3) to stabilize the patient and assess the tenderness or sign of acute abdomen. The tense or woody
total estimated blood loss. However, where blood loss is con- abdominal palpitation is highly suggestive of abruption. A soft
cealed, clinical features of blood loss and signs of shock may and non-tender abdomen may be more consistent with placenta
direct appropriate management. Following the initial survey, and praevia, vasa praevia or bleeding from the lower genitial tract.
after commencing resuscitation, the cause and extent of the APH Uterine contractions will also be detected by abdominal
should be assessed by history taking and carrying out a full examination.
examination.
Speculum examination: a speculum examination can be useful
Clinical history to identify cervical dilatation or visualize a lower genital tract
The role of clinical assessment in women presenting with APH is cause for the APH. If a woman presents with a clinically suspi-
first to establish whether urgent intervention is necessary to cious cervix she should be referred for colposcopic evaluation in
manage any maternal or fetal compromise. The first step of triage line with guidelines from the British Society for Colposcopy and
includes history taking to assess coexisting symptoms of pain, Cervical Pathology.
the extent of vaginal bleeding, cardiovascular condition of the
mother, and an assessment of fetal well-being. Digital vaginal examination: digital vaginal examination can
In women presenting with active major or massive haemor- provide information on cervical dilatation if APH is associated
rhage, or if the woman is unable to provide a history due to a with pain or uterine activity. Where placenta praevia is a possible
compromised clinical state, an acute appraisal of maternal diagnosis, digital vaginal examination should not be performed
wellbeing should be performed and resuscitation started until an ultrasound has excluded it.

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 CASE-BASED LEARNING

Summary of clinical presentation of different causes of APH

Condition Onset Pain Additional symptoms/sign

Placental abruption C Sudden C Usually mild to C Continuous, dark vaginal bleeding

C Occurs most moderate C Hypertonic contraction
often in 3rd abdominal pain C Fetal distress
trimester C Uterine C Premature labor
tenderness
Placental praevia Sudden Painless Bright red vaginal bleeding
Vasa praevia C Sudden Painless C Vaginal bleeding (fetal blood)
C After rupture of C Fetal distress
membranes
Cervical cause Sudden typically C Mild C Vaginal discharge (Thrush)
caused by sexual C moderate pain C Ectropion on speculum
intercourse mainly seen in C Minimal bleeding
cervical trauma C Bruises and tender cervix
Uterine rupture C Sudden Severe abdominal C Sudden pause in contraction
C During labor pain C Fetal distress
C Hemodynamic instability
Bloody show Associated regular Intermittent A small amount of blood or blood tinged
uterine contraction associated with mucus that is usually in early labour
and cervical changes contraction

Table 4

Management of APH
Investigations
Blood tests: the RCOG guideline states that in cases of major
haemorrhage, blood should be analysed for full blood count,
urea and electrolyte, liver function and coagulation, with 4 units
of blood cross-matched. In case of minor haemorrhage a full
blood count, and group and save should be performed. The
initial haemoglobin may not reflect a true estimate of blood loss,
hence clinical judgement should be used to initiate the massive
haemorrhage protocol, as per the local obstetric unit guideline,
and also to help judge whether a blood transfusion is required. In
such cases, a bedside blood test (Haemacue) may be very useful.
A coagulation screen should be considered if there is thrombo-
cytopenia, which may indicate a consumptive process secondary
to abruption or severe ongoing bleeding.
The rhesus D status of the women should be confirmed; if
Rhesus D negative, a Kleihauer test should be performed to
quantify the level of fetomaternal haemorrhage to calculate the
appropriate anti D dose. Women who have had non-invasive
fetal Rhesus D status testing earlier in the pregnancy and found
to be carrying a RhD negative fetus will not need Anti-D. A
Kleihauer may still be requested for diagnostic purposes however
it is important to note that a Kleihauer test is not a sensitive
diagnostic test for placental abruption.
Ultrasound: ultrasound plays a vital role in diagnosing or
excluding placenta praevia if the placental site is not known
already. However, the sensitivity of ultrasound for detecting
retroplacental clots is poor. A study done by Glantz and col-
leagues reported the sensitivity, specificity and positive and
negative predictive value of ultrasound for abruption is 24%,
96%, 88% and 53% respectively. Hence, when ultrasound does
suggest an abruption then the likelihood that there is an abrup-
tion is high.
Fetal Investigation: an assessment of the fetal heart rate should
be performed, usually with a cardiotocograph (CTG) in women
presenting with APH once the mother is stable or resuscitation
has commenced, to aid decision making on the mode of delivery.
Continuous or frequent cardiotocography should be considered;
however, in line with the British Association of Perinatal Medi-
cine guidance in cases of extreme preterm, if active obstetric
intervention is not planned continuous fetal monitoring is not
advised. Ultrasound should be carried out to establish fetal heart
pulsation if fetal viability cannot be detected using external
auscultation.
There is a lack of published evidence regarding the role and
usefulness of fetal heart-rate monitoring in women presenting
with APH. However, conservative (expectant) management ap-
pears to be safe in preterm pregnancies with placental abruption
and a normal CTG.
Hospital Admission: currently, there is no prescriptive guidance
regarding the duration of inpatient management following APH.
Women presenting with spotting who are no longer bleeding,
where placenta praevia has been excluded, can go home after
clinical assessment and a period of observation, but if the APH is
heavier than spotting and in women with ongoing bleeding,
observation in hospital is warranted at least until the bleeding
has stopped and fetal and maternal well-being is ensured.
Women should be encouraged to contact the maternity unit if
any further bleeding, abdominal pain or reduction of fetal
movements is experienced. However, where recurrent APH oc-
curs in the third trimester for any pathology, patients may be

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 CASE-BASED LEARNING
hospitalized until delivery. Women with placenta praevia in the
third trimester should be counselled about the risk of preterm
delivery and obstetric haemorrhage The risk of emergency pre-
term caesarean birth due to ongoing heavy bleeding from a
placenta praevia increases with a history of previous caesarean
section and with the number of previous APHs. A short cervix is
also associated with an increased risk of preterm emergency
birth.
Role of steroid prophylaxis: APH is associated with up to 20%
of preterm deliveries, causing significant neonatal morbidity and
mortality. Steroid prophylaxis is known to reduce the risk of
neonatal death, respiratory distress syndrome, and intraventric-
ular haemorrhage. Therefore in women with APH and no im-
mediate indication to deliver the baby, an assessment should be
made in each individual case as to the value of steroid use. If
bleeding is associated with pain suggestive of uterine activity or
abruption, the risk of preterm birth is increased and therefore
steroids may be beneficial. Women presenting with vaginal
spotting which has stopped (particularly in cases with an iden-
tified lower genital tract cause such as postcoital from a cervical
ectropion), with no abdominal pain or tenderness may not
require steroids.
The NICE ‘Preterm Labour and Birth’ guideline of 2019 has
updated the guidance for the use of steroids for promoting lung
maturation. Firstly, consideration should be given to adminis-
tering steroids from 23þ0 weeks’ gestation if the risk of delivery
over the next seven days is high, and active intervention on
behalf of the fetus is being planned. Secondly, an ‘elective’ single
course of antenatal corticosteroid therapy is recommended be-
tween 34þ0 and 35þ6 weeks’ gestation for pregnant women with
a low-lying placenta or placenta praevia and is appropriate prior
to 34þ0 weeks’ gestation in women at higher risk of preterm
birth.
Role of tocolytic therapy: tocolysis is not recommended in a
women presenting with major APH, particularly in cases of
suspected placental abruption, placenta praevia or if there is a
fetal or maternal compromise. Tocolysis may be considered at
extremely premature gestations, particularly when transfer to
another hospital for neonatal care is deemed appropriate, and for
those who have not yet had a full course of steroids. Moreover
the decision of tocolysis should be made by senior obstetrician.
The tocolytic agent of choice should have fewest maternal car-
diovascular side effects; nifedipine should be avoided because it
may contribute to maternal hypotension.
Labour and delivery: there is a paucity of evidence regarding the
optimum timing of delivery of a women presenting with APH in
the absence of maternal and fetal compromise. However RCOG
guidance from 2018 suggests that women with ‘uncomplicated’
placenta praevia should plan for elective caesarean section be-
tween 36 and 37 weeks’ gestation. Women experiencing third
trimester bleeding not requiring emergency delivery should be
advised to plan caesarean birth at between 34þ0 and 36þ6
weeks. APH associated with maternal or fetal compromise is an
obstetric emergency, and therefore emergency caesarean section
should be expedited unless the woman is in established labour
and a vaginal birth is thought to be possible.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 31:4
In cases of unexplained APH, with no associated maternal or
fetal compromise, the optimum timing and mode of delivery
should be determined by the senior obstetrician. During intra-
partum care, continuous fetal monitoring is required in cases of
significant APH or minor APH where placental abruption is
suspected. However, induction of labour will often be offered to
women who have experienced unexplained APH in the third
trimester.
Following delivery, in the third stage of labour, PPH should be
anticipated in women who have experienced APH. Hence, in
APH from placental abruption or placenta praevia active third
stage is recommended. Bleeding should be managed according
the normal post-partum protocol with uterotonic agents and
surgical interventions such as intra intrauterine balloons, B-
Lynch suture, uterine artery embolization and hysterectomy as
required.
In cases of placenta accreta managed by caesarean section,
where the placenta fails to separate, management options include
leaving it in situ and proceeding to either elective hysterectomy
or conservative management. There are no randomized
controlled trials to compare approaches directly but case series
show successful outcomes with both approaches. If the placenta
is left in situ and the uterus is spared, conservative management
involves prophylactic antibiotics and lengthy follow-up with
beta-HCG measurement and imaging to ensure resolution (but
not treatment with methotrexate). In these cases, women should
be warned of the risk of persisting bleeding and infection.
Blood transfusion: managing massive APH frequently requires
blood transfusion as well as delivery by surgical intervention. All
women presenting with APH should be cross matched. Where
blood loss is acute and excessive Group O Rhesus negative red
cells should be available and utilized. Commencing transfusion is
based on the clinical and haematological ground. The use of cell-
savage should be considered. Fresh frozen plasma (dose 12e15
ml/kg) should be administrated with every 6 units of red cell
during major obstetric haemorrhage, given the high risk of
developing coagulopathy. Subsequent FFP transfusion should be
guided by clotting factors. Similarly, cryoprecipitate at a standard
dose of two 5-unit pools should be administered early in major
obstetric haemorrhage and subsequent cryoprecipitate trans-
fusion should be guided by fibrinogen results, aiming to keep
levels above 1.5 g/l. Platelet transfusion may be required to
maintain the platelet count above 50 x109/l in the acute bleeding
phase.
It is important that women who decline blood products in
emergency, such as Jehovah’s witnesses, are identified in the
antenatal period and referred for consultant-led care as they are
at higher risk of morbidity and mortality in the case of APH. The
healthcare provider and patient should discuss what blood
components and blood derivatives (for example clotting factor
concentrates) are acceptable to the woman in the event of serious
blood loss, and also if autologous transfusion in the form of cell
salvage can be used. There should be a signed advanced directive
and all discussions clearly documented, with optimisation of
their antenatal haemoglobin levels. In the event of major APH or
indeed PPH, a consultant obstetrician, anaesthetist and haema-
tologist should be consulted early. If a woman refusing blood
transfusion is admitted antenatally with suspected or confirmed
122 Ó 2021 Published by Elsevier Ltd.
 CASE-BASED LEARNING
placenta accreta, it is recommended that delivery is planned in a
facility with access to interventional radiology. There is, how-
ever, insufficient evidence on whether prophylactic catheter
placement for balloon occlusion or embolisation is
advantageous.
Conclusion
Antepartum haemorrhage is a common and serious condition.
The most recent MBBRACE -UK report highlights that haemor-
rhage remains a significant contributor to maternal and fetal
mortality and morbidity. Local audits, investigations into near-
misses and maternal deaths, and regular simulation skill
training for health care professionals are vitally important. A
FURTHER READING
Anderson-Bagga FM, Sze A. Placenta Previa. (Updated 2020 Jun 27).
In: Star pearls treasure island (FL): StatPearls.
Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and
treatment of placental abruption. J Ultrasound Med, 2002.
MBRRACEUK. Saving lives, improving mothers’ care e lessons
learned to inform future maternity care from the UK and Ireland
confidential enquiries into maternal deaths and morbidity, 2015-
2017.
Royal College of Obstetrician and Gynaecologists. Antepartum hae-
morrhage green-top guideline No.63, November 2011.
Royal College of Obstetricians and Gynaecologists. Placenta praevia,
placenta praevia accreta diagnosis and management. Green-top
Guideline No., 2018; 27a.
Royal College of Obstetricians and Gynaecologists. Vasa praevia:
diagnosis and management green-top guideline No, 2018; 27b.
Royal College of Surgeons. Code of practice for management of Je-
hovah witnesses. London: IBSA Press, 2002.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 31:4
Schmidt P, Skelly CL, Raines DA. Placental abruption. (Updated 2020
Jul 5) in star pearls Treasure island.
Practice points
C Antepartum haemorrhage is a common condition in pregnancy
causing significant maternal and fetal mordidity and mortality.
C Identifying risk factors for the common causes for APH along with
early recognition and management play a pivotal role in reducing
adverse outcomes
C Women diagnosed with conditions such as placenta praevia and
vasa praevia, should have an appropriate plan for delivery in a
suitable unit with access to the wider multidisciplinary team.
C Counselling and consenting of the women with placenta praevia
regarding the risk of prematurity, massive haemorrhage, need for
blood transfusion and obstetric hysterectomy helps to prepare
women for the most serious complications.
C Identifying women who would decline blood transfusion and/or
blood products in the event of life-threatening haemorrhage is
vitally important so that their exact wishes can be determined and
documented before an emergency arises. This prevents them
receiving products they would not have consented to, gives time
to optimize the haemoglobin, and to seek out alternatives and
make an individualized plan of care.
C Management of APH requires a multidisciplinary approach
involving senior obstetrician, anaethesist, haematologist, trans-
fusion team and neonatologist
C Postpartum haemorrhage should be anticipated in all cases of the
APH. Strategies should be in place to manage this, medically and
surgically.
123 Ó 2021 Published by Elsevier Ltd.