Obstetrics

Antepartum Haemorrhage

Bleeding from or into the genital tract from 24+0 weeks until birth, where the visible loss understates the true loss and two patients are bleeding at once.

In a nutshell

Antepartum haemorrhage (APH) is bleeding from or into the genital tract from 24+0 weeks until birth. Resuscitate the mother first, grade the loss by the RCOG categories, and give anti-D 500 units intramuscularly within 72 hours if she is rhesus D (RhD) negative.

Classic presentation

A woman at 32 weeks with continuous abdominal pain, a woody tender uterus, a small amount of dark vaginal blood, a pulse of 120 and a pathological CTG (cardiotocograph).

Key points

RCOG Green-top Guideline No. 63 (GTG 63) was reviewed on 5 December 2011 and is still the current UK guideline. A second edition is in development.
Recurrent APH means more than one episode. It makes the pregnancy high risk, with consultant-led care and serial growth scans.
APH complicates 3% to 5% of pregnancies, and up to a fifth of very preterm babies are born in association with one.
About 70% of abruptions occur in low-risk pregnancies, which is why APH cannot usefully be predicted or screened for.
Vasa praevia affects 1 in 1200 to 1 in 5000 pregnancies. Fetal mortality is at least 60% undiagnosed and survival is over 95% when planned antenatally.
For recurrent vaginal bleeding after 20+0 weeks, repeat anti-D at a minimum of 6-weekly intervals.
Below 20+0 weeks the anti-D dose is 250 units, and GTG 63 attaches fetomaternal haemorrhage testing only to events after 20+0 weeks.
Below 26+0 weeks, where active intervention in the fetal interest is not planned, continuous fetal heart rate monitoring is not advised.

First-line investigation

Pulse and blood pressure with a primary survey, FBC, coagulation screen, group and cross-match 4 units, ultrasound for placental site, and a CTG once the mother is stable.

Management

Resuscitate the mother

ABCDE (airway, breathing, circulation, disability, exposure), oxygen 10 to 15 litres/minute by facemask, two 14-gauge cannulae, left lateral tilt, keep her warm. Stabilise the mother first.^1,2
Take 20 mL of blood: FBC, coagulation screen, U&E, LFT, cross-match 4 units, and a Kleihauer if she is RhD-negative.¹
Until blood arrives, up to 3.5 litres of warmed fluid: Hartmann's up to 2 litres and colloid 1 to 2 litres. Group O RhD-negative red cells if urgent.^1,3

Grade it, then find the cause

Spotting; minor under 50 mL settled; major 50 to 1000 mL without shock; massive over 1000 mL and/or clinical shock. Massive activates the major obstetric haemorrhage protocol.¹
No digital vaginal examination until ultrasound has excluded praevia. Abdominal palpation always; speculum once praevia is excluded; ultrasound for placental site.^1,2
Continuous CTG in labour with active bleeding, in preterm labour after major or recurrent minor APH, or when abruption is suspected. Otherwise intermittent auscultation.^1,2

Blood products, anti-D and steroids

Red cells almost always below haemoglobin 60 g/L and rarely above 100 g/L. Fresh frozen plasma (FFP) 12 to 15 mL/kg for every 6 units of red cells.³
Cryoprecipitate two 5-unit pools early, keeping fibrinogen above 1.5 g/L. Platelets above 50 × 10⁹/L while bleeding, with a transfusion trigger of 75 × 10⁹/L.³
Anti-D at least 500 units deep intramuscularly within 72 hours; a further 100 to 125 units per mL if fetomaternal haemorrhage exceeds 4 mL of fetal red cells.^6,1,7
Corticosteroids: offer at 24+0 to 33+6 weeks, consider at 34+0 to 35+6 weeks, maximum two courses. Never delay a life-saving birth for a steroid course.^8,1

Birth, and what not to do

Maternal or fetal compromise means immediate birth, usually caesarean, with maternal resuscitation running concurrently. After fetal death, vaginal birth is recommended for most women.¹
Do not use tocolysis in major APH, haemodynamic instability or fetal compromise. It is contraindicated in abruption, and a senior obstetrician makes the decision.¹
Regional anaesthesia unless contraindicated. Cardiovascular instability and coagulopathy are the contraindications that matter here; general anaesthesia expedites birth when either applies.¹

After the bleed

Spotting that has settled with praevia excluded: home after reassuring assessment. Anything heavier, or still bleeding: admit at least until the bleeding stops.¹
Anticipate postpartum haemorrhage: active management of the third stage, and consider ergometrine with oxytocin unless she is hypertensive.¹
Abruption or unexplained APH: reclassify as high risk, consultant-led, with serial growth scans. Thromboprophylaxis, debriefing and incident reporting after major APH.¹

Exam traps

'Major haemorrhage' antepartum is 50 to 1000 mL. Postpartum it is over 1000 mL. Same phrase, two different numbers, and exams test the difference.
The Kleihauer sizes the anti-D dose by quantifying fetomaternal haemorrhage. It is not a test for abruption, and a normal result excludes nothing.
Anti-D is given after every APH even if routine antenatal prophylaxis at 28 and 34 weeks has already been given.
A normal ultrasound does not exclude abruption: sensitivity for retroplacental clot is 24%, so it misses about three-quarters of cases.
Do not use tocolysis to buy time in major APH, haemodynamic instability or fetal compromise. It is contraindicated in abruption.
Fetal compromise or fetal death is a sign of maternal volume depletion. Treat the mother's circulation, not just the trace.
One episode of minor APH with no further concern needs only intermittent auscultation in labour, not continuous monitoring.
There is no antepartum tranexamic acid dose to learn. RCOG Green-top Guideline No. 47 says consider it in major obstetric haemorrhage and gives no figure.

Illustrations

Placental abruption: retroplacental clot on the maternal surface, the finding ultrasound misses in about three-quarters of casesGross pathology specimen of a delivered placenta with an adherent retroplacental haematoma indenting and separating the maternal surface.Mikael Häggström, Wikimedia Commons · CC0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.