Introduction
Antepartum haemorrhage is bleeding from the genital tract after 20–24 weeks and before birth. It affects 3–5% of pregnancies. The two main causes are placenta praevia and placental abruption; vasa praevia and uterine rupture are rare but dangerous.
Placenta praevia
- Diagnosis by ultrasound (transvaginal is safe); a low placenta at 20 weeks is rescanned at 32 weeks, since most move up.
- Never do a digital vaginal examination until praevia is excluded: it can provoke massive bleeding.
- Classification: placenta praevia (covers the os) or low-lying (edge within 20 mm of the os).
- Management: admit if bleeding, resuscitate, steroids if < 34 weeks, anti-D if RhD-negative, blood ready.
- Delivery by caesarean section if the placenta covers or is within 2 cm of the os, planned at about 36–37 weeks; earlier if bleeding is heavy. Plan for accreta if the placenta lies over a previous scar.
Placental abruption
- A clinical diagnosis; ultrasound often misses it.
- Resuscitate: two large IV lines, crossmatch, full blood count, coagulation and fibrinogen, catheter for urine output.
- Live fetus with distress → urgent caesarean section; dead fetus → vaginal delivery is usually preferred once the mother is stabilised and coagulopathy corrected; small abruption, preterm, mother and fetus stable → close monitoring and steroids.
- Expect postpartum haemorrhage.