FFinalistSouthampton · 2027
Obstetrics & gynaecology
AKT · Obstetrics & gynaecology/Late pregnancy & labour

Antepartum haemorrhage (approach)

Bleeding from 24 weeks until birth

Overview

Bleeding from the genital tract from 24 weeks’ gestation until birth. The three discriminators to separate are placenta praevia (painless), placental abruption (painful) and vasa praevia (painless bleeding + fetal distress after membrane rupture). NEVER do a digital vaginal exam until praevia is excluded.

Recognise

  • Placenta praevia: PAINLESS bright-red bleeding, soft non-tender uterus, often malpresentation
  • Placental abruption: PAINFUL bleeding, tense/"woody" tender uterus, fetal distress; bleed may be concealed
  • Vasa praevia: painless bleeding at ROM with acute FETAL distress (fetal blood loss)

Red flags

  • Maternal shock, fetal distress, concealed abruption (shock out of proportion to visible blood)

Differentials & how to tell them apart

Placenta praeviaPAINLESS bleed, non-tender uterus
Placental abruptionPAINFUL, tense tender "woody" uterus, fetal distress
Vasa praeviapainless bleed AT rupture of membranes with sudden fetal compromise
Local causes (show, cervical lesion)minor, after praevia excluded

Investigations

Assess maternal and fetal status (CTG) first. USS to locate the placenta. DO NOT perform a digital vaginal examination until placenta praevia is excluded. Kleihauer if rhesus-negative.

Management

Resuscitate mother + assess fetus + locate placenta (no digital VE until praevia excluded)

  1. 1ABC resuscitation, large-bore IV access, bloods/crossmatch, continuous CTG, locate placenta on USS.Gate: NEVER perform a digital vaginal examination in APH until placenta praevia is excluded — it can provoke catastrophic haemorrhage
  2. 2Anti-D for rhesus-negative women; corticosteroids if preterm delivery likely; deliver by urgency (emergency caesarean for major abruption/praevia with compromise).
Resuscitate (ABC, IV access, fluids/blood) — maternal priority
Anti-D if rhesus-negative — sensitising event
Corticosteroids — fetal lung maturation if preterm delivery likely

Key points

The pain status is the master discriminator: praevia painless, abruption painful. Concealed abruption can cause shock with little visible blood. Vasa praevia bleeding is FETAL blood — rapid fetal exsanguination.

Monitor & prognosis

Maternal haemodynamics, fetal CTG, ongoing blood loss.

Depends on cause and speed of response.

Source: RCOG Green-top 63