Antepartum haemorrhage (APH) is defined as bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby. The most important causes of APH are placenta praeviaand placental abruption, although these are not the most common. APH complicates 3–5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide.
The total amount of blood loss and signs of circulatory shock due to blood determine the severity of the antepartum haemorrhage.
There are 4 degrees of antepartum haemorrhage –
Stages & Amount of Blood Loss
• Spotting – Stains, streaking, or spotting of blood
• Minor Haemorrhage – Less than 50mL
• Major Haemorrhage – 50-1000mL without signs of circulatory shock
• Massive Haemorrhage – Greater than 1000mL with or without signs of circulatory shock
• Bleeding, which may be accompanied by pain (suggestive of abruption) or be painless (suggesting praevia).
• Uterine contractions may be provoked.
• There may be malpresentation or failure of the fetal head to engage, with placenta praevia.
• There may be associated signs of fetal distress.
• If the bleeding is severe, the mother may show signs of hypovolaemic shock; however, young, fit, pregnant women can compensate very well until sudden and catastrophic decompensation occurs
No definite cause is diagnosed in about 50% of all women who present with antepartum haemorrhage; however, placenta praevia and placental abruption are the major identifiable causes:
• Placenta praevia: insertion of the placenta, partially or fully, in the lower segment of the uterus.
• Placental abruption: premature separation of a normally placed placenta.
• Local causes – eg, vulval or cervical infection, trauma or tumours.
• Partner violence in pregnancy, may result in APH. Women should be asked about this, particularly if there are repeated episodes.
• Vasa praevia: bleeding from fetal vessels in the fetal membranes, leading to high risk of fetal haemorrhage and death at rupture of the membranes.
• Uterine rupture: rare but very dangerous for both mother and baby.
• Inherited bleeding problems are very rare, occurring in 1 in 10,000 women.
Other causes of APH –
Other uterine sources of APH include:
• Circumvallate placenta
• Placental sinuses
Other lower genital tract sources of APH include:
• Cervical polyps
• Cervical erosions and carcinoma
• Vulval varicosities
▪︎ Primary Care
• Primary Survey
• Offer continuous support and reassurance
• Position patient appropriately (being mindful to avoid aortocaval compression)
• Vital Sign Survey
• Consider Oxygen if indicated as per CPG
• Secondary / CNS Survey (as required)
▪︎ Advanced Care (AP)
• Apply cardiac monitor
• Establish vascular access
• Fluid therapy as per CPG
• Consider pain relief
• Consider anti-emetic
• Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
• Transport- Priority 1 to nearest obstetric unit if patient time critical
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