Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby. APH complicates 3–5% of pregnancies; and is a leading cause of perinatal and maternal mortality worldwide.
The causes of APH include: placenta praevia, placental abruption and local causes (such as bleeding from the vulva, vagina or cervix). Placenta previa & placental abruption constitute 50% of APH.
Symptoms of antepartum haemorrhage (APH) consist of vaginal bleeding in late pregnancy and before delivery. Along with vaginal bleeding other symptoms may be-
(a) In APH due to placenta previa, vaginal bleeding is painless, or bleeding occurs after sexual intercourse. Initial episodes are usually mild and ceases spontaneously only to recur. Some types of placenta previa resolve on their own by 32–35 weeks of pregnancy as the lower part of the uterus stretches and thins out. Labor and delivery then can occur normally. If placenta previa does not resolve, cesarean delivery may be needed.
(b) In APH due to placental abruption symptoms include:
The causes of APH include: placenta praevia, placental abruption and local causes (such as bleeding from the vulva, vagina or cervix). Abruption is more likely to be related to conditions occurring during pregnancy and placenta praevia is more likely to be related to conditions existing prior to pregnancy.
Placenta praevia is defined as a placenta that lies wholly or partly within the lower uterine segment. It occurs in .4%-.8 % of pregnancies. The condition is mostly diagnosed on ultrasound examination.
Classification of placenta previa (Williams)
Factors associated with the development of placenta praevia include:
Placental abruption/ abruptio placentae –Placental abruption is the premature separation of a normally situated placenta from the uterine wall, resulting in haemorrhage before the delivery of the foetus. In placental abruption some of the bleeding escapes through the cervix causing external haemorrhage and sometimes bleeding is concealed when blood does not escape externally. Placental abruption can occur in up to 5% of pregnancies.
The precise cause of abruption is unknown, but risk factors for placental abruption include: pre-eclampsia, fetal growth restriction, non-vertex presentations, polyhydramnios, advanced maternal age, multiparty, low body mass index (BMI), pregnancy following assisted reproductive techniques, intrauterine infection, premature rupture of membranes, abdominal trauma (both accidental and resulting from domestic violence), smoking, drug misuse (cocaine and amphetamines) during pregnancy and maternal thrombophilia. Bleeding in first trimester also increases the risk of abruption later in the pregnancy.
Placental abruption is mostly diagnosed on ultrasound examination. Though Sonography is not sensitive for the detection of placental abruption but it is highly specific.
Placenta accrete- When the placenta (or part of the Placenta) invades and is inseparable from the uterine wall, it is called placenta accrete. It can cause bleeding during the third trimester and severe blood loss during delivery.
Other causes-In a small proportion of cases cervicitis, trauma, vulval varicosities (varicose veins at the outer surface of the female genitalia -vulva), genital tumours, genital infections and vasa previa may be the cause of APH. Many of these conditions are evident on the initial speculum examination.
Rosalba Giordano, Alessandra Cacciatore, Pietro Cignini, Roberto Vigna, Mattea Romano, Antepartum haemorrhage J Prenat Med. 2010 Jan-Mar; 4(1): 12–16. Accessed from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263934/
Diagnosis of antepartum hemorrhage is first based on clinical suspicion. Initially clinical assessment of women presenting with APH is done by medical person to establish urgency of intervention required to manage maternal or fetal compromise.
If there is no maternal compromise a full history should be taken. It includes history taking to assess coexisting symptoms such as pain, an assessment of the extent of vaginal bleeding, the cardiovascular condition of the mother, and an assessment of fetal wellbeing.
In placenta previa, uterus is felt to be relaxed on palpation and non-tender. Generally presenting part is high up and floating.
In placental abruption, the triad of sudden onset of abdominal pain, bleeding per vagina, tense and tender uterus constitutes the main diagnostic criteria.
Speculum examination- A speculum examination can be useful to identify cervical dilatation or can visualise a lower genital tract cause for the APH.
If placenta praevia is a possible diagnosis (for example, a previous scan shows a low placenta, or there is a high presenting part on abdominal examination, or the bleeding is painless), digital vaginal examination should not be performed until an ultrasound has excluded placenta praevia.
If APH is associated with pain or uterine activity digital vaginal examination can provide information on cervical dilatation.
·Full blood count with haemoglobin estimation
·Blood grouping with Rh factor
·Screening for coagulation factor
·Liver function tests
·Urea and electrolyte test
Ultrasound scan (USG)-
Women presenting with APH should have an ultrasound scan performed to confirm or exclude placenta praevia, if the placental site is not already known. Transvaginal ultrasound is more accurate than transabdominal in diagnosing placenta previa.
The sensitivity of ultrasound for the detection of retroplacental clot (abruption) is poor. However, when the ultrasound suggests an abruption, the likelihood that there is an abruption is high.
Transvaginal ultrasound (an ultrasound view of the cervix) in combination with color Doppler (which can show blood flowing through veins) is the most effective tool in the diagnosis of vasa previa during pregnancy and can be utilized in patients at risk.
MRI is used only to differentiate different degrees of myometrial invasion.
Management of APH depends on various factors. These are- amount and cause of APH, condition of mother and foetus, duration of pregnancy and presence of associated complication. Each pregnant woman with APH is assessed on an individual basis and according to that clinical judgment is applied.
It includes: a) General measures (common to all patients with bleeding)
b) Specific measures: Immediate delivery or expectant management and management of complications
APH associated with maternal or fetal compromise is an obstetric emergency. Management includes maternal resuscitation and delivery of the foetus. Delivery should be planned in an appropriate setting with adequate resources.
Expectant management may be considered when the mother is stable, foetus is immature (<37 weeks). The goal is to prolong pregnancy with the hope of improving foetal maturity and survival.
Anti – D Ig prophylaxis may be given to those women who are Rh negative.
APH is associated with complications for the mother and her foetus. Complications are more likely to occur:
For the mother, APH can lead to:
For the baby, APH can lead to:
Routine antenatal checkups for early detection of any complication during pregnancy with their proper management such as high blood pressure / pre-eclampsia can help in reducing maternal and foetal complications.
By preventing certain risk factors during pregnancy such as smoking, drug misuse the chances of APH can also be reduced.
Pregnant women should wear seatbelt when in a motor vehicle and seek medical help immediately in case of abdominal trauma from an auto accident, fall or other injury.