[CG] Antepartum haemorrhage (APH)

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Definition: bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to birth of the baby.

APH complicated 3-5% of pregnancies – leading cause of perinatal and maternal mortality worldwide.

Risk Factors for APH include:

APH and placental abruption in a previous pregnancy

Threatened miscarriage earlier in their pregnancy

Placenta praevia

Pre-eclampsia

FGR

Polyhydramnios

PPROM

Smoking

Multiple pregnancy

Drug misuse

Advanced maternal age

ART

Causes for APH include:

Unexplained

Placenta praevia

Placental abruption

Uterine rupture

Vasa praevia

Trauma

Cervical lesions

Infection

Malignancy

It is recognised that the volume of blood lost is often underestimated as blood loss may be concealed. It is important to assess for signs of clinical shock as well as fetal compromise or fetal demise as important indicators of volume depletion.

Prompt assessment of maternal and/or fetal compromise is key to establishing if urgent intervention is necessary and will guide your management.

APH Definitions:

Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection.

Minor Haemorrhage – blood loss <50ml that has settled

Major Haemorrhage – blood loss of 50-1000ml, with no signs of clinical shock

Massive Haemorrhage – blood loss >1000ml and/or signs of clinical shock

Recurrent APH – episodes of APH on more than one occasion

Spotting/Minor APH

  • record an accurate, detailed history
    • include onset, amount of bleeding, associated pain, recent intercourse, smear history, associated shortness of breath or dizziness, presence of fetal movements
    • risk factors for placental abruption/praevia should also be sought
  • Record MEOWS – blood pressure, heart rate, respiratory rate, temperature
  • Record urinalysis
  • Gentle abdominal palpation and assessment of fundal height as well as uterine activity
  • Auscultate fetal heart and commence CTG (if over 26 weeks) – if unable to locate FHR with Doppler then USS should be utilised
  • Maternal Rhesus status should be noted
  • Review previous USS reports for documentation of placental site

Speculum Examination/Digital Vaginal Examination

  • Vaginal examination should not be performed until placental site is established
  • In cases of placenta praevia digital vaginal examination should be avoided Placenta Praevia guideline
  • Can be useful to identify cervical dilatation or cause for APH in lower genital tract
  • If clinically suspicious cervix refer to management of cervical abnormalities in pregnancy guideline
  • HVS should be performed if appropriate

Maternal Investigations

  • Should be performed to assess the extent and physiological consequences of APH and will depend on amount of bleeding
  • In minor APH a FBC and G&S should be performed. A coagulation screen is not indicated unless platelet count is abnormal.  BOS Guideline
  • Kleihauer test should be performed in Rhesus D – negative mothers to quantify fetomaternal haemorrhage in order to gauge the dose of anti-D immunoglobulin required. Anti-d

Management

  • Management will depend on severity of bleeding/cause/maternal and fetal compromise
  • Involve senior obstetric consultant/clinician early if concerns
  • Consider IV access (16G) if clinically appropriate
  • Consider antenatal corticosteroid therapy for fetal lung maturation – refer to relevant guidelines
  • All women with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until bleeding has settled
  • Women presenting with spotting who are no longer bleeding and where placenta praevia has been excluded can go home if initial clinical assessment is reassuring with appropriate consideration to patient’s geographically location.
  • In women with APH >37 weeks gestation consider expediting delivery
  • Following a single episode of APH or recurrent episodes thought to be from a cervical ectropion, subsequent antenatal care need not be altered.
  • Following APH from placental abruption or unexplained causes, the pregnancy should be reclassified in Badgernet as High Risk and antenatal care should be consultant-led with serial growth scans, at least until subsequent growth scans demonstrate normal fetal growth and there is no further risk of APH.

Recurrent APH (more than 1 episode)

  • If recurrent APH, including from unexplained causes, then the pregnancy should be classified in Badgernet as High Risk and antenatal care should be consultant-led with serial growth scans.

Major/Massive Antepartum Haemorrhage

Aims of management:

  • RESUSCITATION
  • DELIVERY and management of Third Stage
  • CORRECT COAGULOPATHY

 

Resuscitation:

  • Resuscitation of the mother is paramount and should be prioritised prior to establishing fetal condition
  • GET HELP – obstetric/anaesthetic/neonatal/haematology
  • Major Obstetric Haemorrhage #2222
  • ABC approach
    • Left lateral tilt
    • Airway = secure airway
    • Breathing
      • apply oxygen - non-rebreathing mask, 15L/min
      • commence pulse oximetry
    • Circulation
      • gain IV access x 2 (16G);
      • Obtain bloods including FBC/Coagulation Screen (including fibrinogen)/Kliehauer/Urea & Electrolytes – send as URGENT and alert laboratory. Consider venous blood gas.
      • Crossmatch as per blood ordering schedule – consider group specific or O negative blood if unable to wait for fully crossmatched blood
      • Commence IV fluids – crystalloid up to 2L; colloid up to 1.5L
      • Continuous pulse and blood pressure recording
      • Consider catheter insertion and monitor urine output hourly
      • Record observations on MOEWS chart
      • Keep the patient warm
    • Assess fetus – CTG/USS

Decide on Delivery

  • Delivery may be needed to control haemorrhage
  • Women with APH and associated maternal and/or fetal compromise are required to be delivered immediately
  • In the presence of maternal and/or fetal compromise delivery should be by Caesarean section with obstetric consultant present (consideration of anaesthetic consultant presence if maternal compromise)
  • Anticipate postpartum haemorrhage – pph link
  • Administer Magnesium Sulphate if gestation <30+0 for fetal neuroprotection. This should not delay delivery if there is evidence of maternal compromise.

Correct Coagulopathy:

  • Disseminated intravascular coagulation (DIC) should be considered
  • Coagulation screen and fibrinogen should be assessed – use near patient testing if available and send samples as URGENT or– alert laboratory.
  • Early liaison with Haematology is paramount
  • Consideration of Fresh Frozen Plasma/Cryoprecipitate
References

Antepartum Haemorrhage Green Top Guideline No. 63 RCOG 2011

Practical Obstetric Multi-Professional Training (PROMPT)

Last reviewed: 31 December 2021

Next review: 31 July 2025

Author(s): Julie Murphy, Donald Wilson

Version: 1

Approved By: Obstetric Guideline Group

Document Id: 1036