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Key messages

  • Antepartum haemorrhage (APH) is bleeding from the genital tract after 20 weeks gestation and before labour.
  • APH occurs in 2-5 per cent of pregnancies and half are of unknown cause. 
  • Blood loss is often underestimated, so it is vital to observe for maternal shock and fetal compromise.
  • APH is associated with increased risks of fetal growth restriction (FGR) and preterm labour, and adverse perinatal outcomes.
  • Prevention and treatment of anaemia in all pregnant women helps minimise maternal morbidity associated with APH.

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Antepartum haemorrhage (APH)

Table 1. Causes of APH

Placental site

Genital tract

Cord insertion

Placenta praevia

Show

Vasa praevia

Placental abruption

Cervix – cervicitis, polyp, ectropion, carcinoma

 

Marginal – sinus rupture

Trauma

 

 

Vulvovaginal varicosities

 

 

Genital tract tumours

 

 

Genital infections

 

 

Haematuria

 

 

Table 2. Risks associated with APH

Fetal growth restriction

Preterm labour

Oligohydramnios

Preterm pre-labour rupture of membranes (PPROM)

Increased rates of caesarean section

Postpartum haemorrhage

 

Preparation

All clinicians should:

  • know where to find all equipment for APH management in their service
  • know their local escalation procedures
  • understand which blood products are available at their service and how to access them
  • know how to activate their local massive transfusion protocol (MTP)
  • attend multidisciplinary obstetric emergency training annually (for example, PROMPT, MSEP).

Management

APH with significant bleeding or haemodynamic instability is an obstetric emergency – SUMMON HELP IMMEDIATELY

Practice points

  • Stabilise the woman before assessing fetal condition
  • Understand your health service capability:
  • If required, aim for in-utero transfer if safe to do so:
    • within Victoria, seek assistance from PIPER: 1300 137 650.

Initial assessment

Assess blood loss

  • Weigh blood loss
  • Document ongoing blood loss
  • Document history of blood loss in this pregnancy
  • Consider possible causes of APH:
    • placenta praevia
    • placental abruption
    • show
    • post-coital bleed
    • trauma
    • cervical abnormalities
    • infection
    • vasa praevia.

Maternal examination

  • Vital signs - heart rate, blood pressure, respiratory rate, O2 saturation, temperature
  • Document a running total of blood loss
  • Gentle abdominal palpation
  • Assess pain, rigidity, fetal presentation, size and movement
  • Avoid vaginal examination until placenta praevia is excluded.

Fetal surveillance

  • Cardiotocograph (CTG) is indicated from 26 weeks
  • CTG should be continued if there is:
    • ongoing bleeding
    • abdominal pain
    • uterine activity.

History

  • Document obstetric, medical, surgical and social history.

Speculum

  • Observe and document:
    • blood loss
    • cervical dilatation and length
    • membranes
    • presenting part.

Ultrasound

  • Investigate for:
    • placental position and condition
    • fetal growth and wellbeing
    • cervical length.

Investigations

  • Request:
    • full blood count (FBC)
    • group and hold, for minor APH (<50 ml)
    • group and cross match, for APH >50 ml and/or clinical shock
  • Kleihauer, if:
    • Rhesus negative
    • abdominal trauma
    • abnormal CTG
  • For blood loss >50 ml:
    • liver function tests
    • renal function tests
    • coagulation studies, including fibrinogen.

Immediate management

Resuscitation

  • Summon help - consider MET Call, Code Blue or Code Pink
  • Resuscitate and assess simultaneously
  • IV access x 2 16 g
  • Fluid replacement
  • Oxygen 8 L/min
  • In-dwelling catheter (IDC).

If immediate delivery is indicated

  • Consult with obstetric and paediatric clinicians
  • Prepare resuscitation equipment appropriate for gestation:
    • consider a rapid infusion of 20 ml/kg of Rh O-negative uncross-matched blood, for infants symptomatic of hypovolaemia secondary to blood loss 
  • Notify SCN/NICU
  • Counsel the woman and family about what to expect in terms of baby's condition and care.

Indications for caesarean section

  • Previous CS
  • Placenta praevia
  • Vasa praevia.

Possible indications for caesarean section

  • Breech and <32 weeks
  • Multiple pregnancy and <26 weeks
  • Maternal condition necessitating caesarean section

Corticosteroids

  • Administration of corticosteroids should not delay delivery
  • If ≤ 34 weeks:
    • Betamethasone 11.4 mg IM
      then
    • Betamethasone 11.4 mg IM in 24 hours
    • Consider second dose at 12 hours if birth likely within 24 hours
    • If risk of preterm birth remains ongoing in seven days, repeat dose
  • Between 34+1 and 36+6 weeks, consider cortiscosteroids if the woman is having a pre-labour CS.

Tocolysis

  • Contraindicated if woman is actively bleeding.

Magnesium sulfate (MgSO4)

  • Contraindicated if woman is actively bleeding
  • Indicated at <30 weeks for neuroprotection, if delivery is imminent
  • Regimen:
    • loading dose MgSO4 4 g IV bolus over 20 minutes
    • maintenance dose MgSO4 1 g/hr IV for 24 hours or until birth - whichever is first.

Blood products

  • Be familiar with blood products available at your service (Appendix 1)
  • Consider cell salvage
  • If a woman does not consent to blood transfusion, transfer her to a service with cell salvage
  • Indications for blood transfusion* (from the National Blood Authority Guidelines - Obstetrics and Maternity module):
    • Hb concentration >90 g/L, Red blood cell (RBC) transfusion is usually inappropriate.
    • Hb concentration of 70-90 g/L, RBC transfusion not associated with reduced mortality. Decision to transfuse (with a single unit followed by reassessment) should be based on the need to relieve clinical signs and symptoms of anaemia, availability of other therapies for the treatment of anaemia, expected timeframe to giving birth, and individual risk factors for haemorrhage.
    • Hb concentration <70 g/L, RBC transfusion may be associated with reduced mortality and may be appropriate. However, transfusion may not be required in well-compensated patients or where other specific therapy is available.

*Direct evidence of the efficacy of RBC transfusion for treatment of anaemia is not available in maternity patients. This advice draws on evidence from other patient groups and CRG consensus.

Inpatient management

  • Prolonged inpatient care can be associated with an increased risk of venous thromboembolism (VTE):
    • encourage mobility
    • use TED stockings
    • ensure adequate hydration.
  • Prophylactic anticoagulation in women at high risk of bleeding can be hazardous and the decision to use it should be taken on an individual basis.
  • Weekly FBE
  • Treat anaemia:
  • Administer Anti-D if indicated
  • Plan for timing of birth.

Observation

  • Frequency of observation depends on:
    • maternal condition
    • ongoing bleeding
    • other clinical findings
  • Fetal monitoring daily and as clinically indicated
  • Review by the paediatric/neonatal and anaesthetic teams
  • Ultrasound (US) as clinically indicated.

Discharge

  • Women with an APH have an increased risk of adverse perinatal outcomes: (Table 2)
    • Counsel the woman about the risk of adverse outcomes.
    • Refer the woman for serial US for growth (timing will depend on gestation).
    • Plan for active management of third stage
  • Discharge criteria:
    • Spotting = if placenta clear of os and no further bleeding
    • Minor APH = 24 hours after last observation of fresh blood loss
    • Major or massive APH = as per obstetric team.

Outpatient management

  • Home-based care requires:
    • the woman’s consent
    • the woman to be aware of signs and symptoms which mean she should attend hospital
    • a plan and method to attend hospital if needed.

Timing of birth

  • Planning for birth should be tailored to the individual patient, based on:
    • gestation
    • ultrasound findings
    • history of bleeding
    • medical comorbidities
    • surgeon availability
    • patient preferences
  • Patient counselling and consent form should include:
    • increased risk of post-partum haemorrhage (PPH)
    • risks associated with caesarean section
    • specific risks of placenta praevia in terms of massive obstetric haemorrhage
    • potential need for blood transfusion
    • risk of hysterectomy.
  • A woman with a placental edge less than 2 cm from the internal os in the third trimester is likely to need delivery by caesarean section (after 34 weeks).
  • Elective delivery by caesarean section in asymptomatic women is not recommended before 38 weeks of gestation.
  • Placenta praevia without previous caesarean section carries a risk of massive obstetric haemorrhage and hysterectomy and should be carried out in a unit with a blood bank and facilities for high dependency care.
  • Placenta accreta - maternal and neonatal outcome is optimised in stable patients with a planned delivery at 34–36 weeks gestation. The gestation for elective delivery should balance the neonatal risks of prematurity against the maternal risks of emergent delivery.
  • At <30 weeks gestation, consider magnesium sulphate for neuroprotection (see - Preterm birth).
  • Significant APH is an obstetric emergency:
    • Any woman going to theatre with suspected placenta praevia/accreta should be attended by a consultant obstetrician and anaesthetist.
    • If delivery is unexpected, alert out-of-hours consultant staff to attend as soon as possible.

Management of specific conditions

Placenta praevia

  • Refer the woman for follow-up imaging if a low-lying placenta is identified at the 20/40 US.
  • Have a high index of suspicion for placenta accreta if placenta praevia is diagnosed in a woman with a history of caesarean section.
  • Counsel the woman about the risks of preterm birth and obstetric haemorrhage.
  • The woman with placenta praevia who is admitted with an APH not requiring immediate delivery should remain in hospital until 24 hours after bleeding has ceased.
  • Recurrent APH in the third trimester may be an indicator for inpatient management.

Placenta accreta

  • All diagnoses of placenta accreta should be flagged with the appropriate Level 6 service, as future potential transfers.
  • Morbidly adherent placentation may be suspected when placenta praevia is diagnosed in a woman with a history of caesarean section or other uterine surgery.
  • Diagnosis is by COGU US and occasionally confirmed by MRI.
  • Ideally, placenta accreta will be diagnosed before 20–24 weeks gestation.
  • Care planning and management must be undertaken by a multidisciplinary team, led by a senior registrar or consultant obstetrician.
  • The woman with diagnosed placenta accreta must have a plan and method to attend hospital in the event of PV bleeding.
  • If a woman presents with bleeding and a diagnosis of placenta accreta, organise transfer to a Level 6 service for ongoing care, if/when her condition is stable.

Vasa praevia

  • Vasa praevia can be accurately diagnosed with colour Doppler US.
  • See RANZCOG’s statement on Vasa praevia for more information.
  • Bleeding in the context of known vasa praevia is an indication for a RANZCOG Category 1 caesarean section.
  • A diagnosis of vasa praevia at term is an indication for caesarean birth:
    • RANZCOG recommends considering delivery by 35 weeks.
  • If vasa praevia is diagnosed in the third trimester, antenatal admission to a unit with appropriate neonatal facilities is recommended.
  • If vasa praevia is diagnosed in the second trimester, repeat imaging in the third trimester.

More information

Audit and performance improvement

All maternity services should have processes in place for:

  • auditing clinical practice and outcomes
  • providing feedback to clinicians on audit results
  • addressing risks, if identified
  • implementing change, if indicated.

Auditable standards:

  • adherence to standard of care for assessment and management.

For further information or assistance with auditing, please contact us on maternityehandbook@safercare.vic.gov.au.

References

Appendix

1. Blood product availability

Service Level

Blood product availability

1

No onsite or on-call blood or transfusion service

2

Ability to administer blood within 1 hour

3

Blood and volume expanders on site

Established pathways to obtain complex blood products

4

Blood and volume expanders on site

Established pathways to obtain complex blood products

5

Full range of blood and blood products available 24 hours a day

6

Full range of blood and blood products available 24 hours a day

2. Definitions

Spotting

Staining, streaking or blood spotting noted on underwear or sanitary protection

Minor haemorrhage

Blood loss <50 ml

Major haemorrhage

Blood loss 50–1000 ml with no signs of clinical shock

Massive haemorrhage

Blood loss >1000 ml and/or clinical shock

Placenta praevia

Placenta is inserted wholly or partially in the lower uterine segment

Grade 1: (minor) the placenta is mainly in the upper part of the uterus, but some extends to the lower part

Grade 2: (marginal) the placenta reaches the cervix, but doesn't cover it

Grade 3: (major) the placenta partially covers the cervix

Grade 4: (major) the placenta completely covers the cervix

Placental abruption

Separation of the placenta from the uterine wall

Abnormal placentation

Placenta accreta – abnormal adherence of the placental chorion to the myometrium

Placenta increta – chorionic invasion of the myometrium

Placenta percreta – chorionic invasion of the myometrium and serosa

Abnormal placental shape

Bilobed/bipartite – the placenta is separated into two lobes of similar size

Succenturiate lobe/s – one or more accessory lobes, separate from the main placental disc, connected by vessels running through the membranes

Vasa praevia

Fetal vessels coursing through the membranes over the internal cervical os and below the fetal presenting part, unprotected by placental tissue or the umbilical cord.

  • Type 1: Secondary to a velamentous cord insertion in a single or bilobed placenta 

  • Type 2: Arises from fetal vessels running between lobes of a placenta with one or more accessory lobes 


Unclassified, painless bleeding

Thought to be due to marginal haemorrhage or circumvallate placenta.

Can be associated with perinatal morbidity and mortality in the context of preterm birth.

Get in touch

Centre of Clinical Excellence - Women and Children
Safer Care Victoria

Version history

First published: December 2018

Last web update: December 2018

Review by: December 2020

Uncontrolled when downloaded

Page last updated: 12 Nov 2020

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