Antepartum Haemorrhage

The most predictive risk factor is abruption in a previous pregnancy (recurrence rate 4.4% after one, 19–25% after two).

Other risk factors include: pre-eclampsia, fetal growth restriction, non-vertex presentation, polyhydramnios, advanced maternal age, multiparity, low BMI, assisted reproductive techniques, intrauterine infection, PPROM, abdominal trauma, and first-trimester bleeding (especially with an intrauterine haematoma).

Maternal thrombophilias (e.g., Factor V Leiden, Prothrombin 20210A) are associated with an increased risk, though the association may be weak.

Evidence for folic acid supplementation is conflicting.

There are no good data to support antithrombotic therapy (aspirin +/- LMWH) to prevent abruption, even in women with thrombophilia.

It is good practice to avoid vaginal and rectal examinations and advise women to avoid penetrative sexual intercourse.

Cervical cerclage is not recommended to prevent bleeding or prolong pregnancy outside of a clinical trial.

There is no role for prophylactic tocolytics to prevent bleeding.

Increased frequency of preterm delivery (OR 3.17), stillbirth (OR 2.09), and fetal anomalies (OR 1.42).

Babies are more likely to be small for gestational age, admitted to NICU, and develop hyperbilirubinaemia.

Abdominal palpation: A tense or 'woody' uterus suggests significant abruption. A soft, non-tender uterus may suggest placenta praevia or a lower genital tract cause.

Speculum examination: Can identify cervical dilatation or a local cause. Refer for colposcopy if the cervix appears suspicious.

A digital vaginal examination should NOT be performed if placenta praevia is a possible diagnosis until it has been excluded by ultrasound.

Women with spotting that has resolved, where placenta praevia is excluded, can go home after a reassuring assessment.

Women with APH heavier than spotting or with ongoing bleeding should remain in hospital at least until the bleeding has stopped.

Offer a single course of antenatal corticosteroids to women between 24+0 and 34+6 weeks of gestation at risk of preterm birth due to APH.

In women with minor, resolved spotting from a likely non-placental cause, corticosteroids are unlikely to be of benefit but can be considered.

Tocolysis should NOT be used in a woman with a major APH, who is haemodynamically unstable, or if there is fetal compromise. It is contraindicated in placental abruption.

A senior obstetrician should make any decision to initiate tocolysis. It may be considered for very preterm women needing transfer or to complete a course of corticosteroids, provided they are stable.

Following APH from a cervical ectropion, subsequent care need not be altered.

Following APH from placental abruption or unexplained APH, reclassify the pregnancy as ‘high risk’. Care should be consultant-led with serial ultrasound scans for fetal growth.

Women with APH and associated maternal and/or fetal compromise require immediate delivery.

If the fetus is compromised, caesarean section is the appropriate method, with concurrent maternal resuscitation.

If fetal death is diagnosed, vaginal birth is recommended for most women, provided the mother is stable.

For APH after 37+0 weeks that has settled, consider induction of labour to avoid risks of abruption.

For APH before 37+0 weeks with no compromise and settled bleeding, there is no evidence to support elective premature delivery.

Women in labour with active vaginal bleeding require continuous electronic fetal monitoring (EFM).

Recommend continuous EFM for women in preterm labour whose pregnancy was complicated by major APH, recurrent minor APH, or suspected abruption.

Intermittent auscultation is appropriate for women who have had one episode of minor APH with no subsequent concerns.

Regional anaesthesia is recommended for operative delivery unless contraindicated (e.g., maternal cardiovascular instability, coagulopathy).

Consider a general anaesthetic for caesarean section in cases of maternal or fetal compromise to facilitate resuscitation and expedite delivery.

Postpartum haemorrhage (PPH) should be anticipated in women who have experienced APH.

Women with APH from placental abruption or placenta praevia should be strongly recommended to receive active management of the third stage of labour.

Consider using ergometrine-oxytocin (Syntometrine®) for the third stage in these women, in the absence of hypertension.

Anti-D Ig should be given to all non-sensitised RhD-negative women after any presentation with APH, regardless of whether routine prophylaxis has been given.

For bleeding after 20+0 weeks, give at least 500 iu of anti-D Ig and perform a test to quantify FMH, giving more anti-D if required.

In recurrent bleeding, anti-D Ig should be given at a minimum of 6-weekly intervals.

Management should follow locally devised multidisciplinary protocols for massive obstetric haemorrhage.

The core team should include a consultant obstetrician, anaesthetist, haematologist, and the midwifery labour ward coordinator.

The four pillars of management are: Communication, Resuscitation, Monitoring/Investigation, and Arresting the bleeding (definitive treatment is delivery of fetus and placenta).

Consider Disseminated Intravascular Coagulation (DIC) in women with massive blood loss or a major placental abruption.

If DIC is suspected, urgently request clotting studies, platelet count, and seek advice from a haematologist.

Empirically give up to 4 units of FFP and 10 units of cryoprecipitate (two packs) while awaiting results in cases of relentless bleeding.

Advise women on anticoagulants to stop their medication and attend hospital urgently if any vaginal bleeding occurs.

For women at high risk of haemorrhage where continued heparin is essential, manage with intravenous unfractionated heparin until risk factors resolve.

In major or massive APH, the neonate should be assessed by a senior paediatrician/neonatologist due to the risk of fetal anaemia and compromise.

In abruption and vasa praevia, an experienced paediatrician/neonatologist should be present at delivery to manage potential neonatal anaemia.

An experienced paediatrician/neonatologist should attend delivery if an anterior placenta praevia is incised during caesarean section.

The mother’s life always takes priority; she must be resuscitated and stabilised before any decision regarding delivery.

A senior paediatrician/neonatologist should be involved in counselling women when extreme preterm birth is likely.

Conservative management is usually appropriate if the mother's condition is stable.

Postnatal management after major or massive APH should include thromboprophylaxis, debriefing, and clinical incident reporting.

An experienced obstetrician should debrief the woman and her partner, offering a follow-up appointment and support contacts.

Commence or reinstitute thromboprophylaxis as soon as the immediate risk of haemorrhage is reduced, as haemorrhage and transfusion are VTE risk factors.

Management of a major APH should be included in obstetric skill drills.

Practical, multi-professional training in obstetric emergencies increases knowledge and promotes effective teamworking.