by Sarah Craus
APH complicates 3–5% of pregnancies. It is bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the delivery of the baby. APH can lead to both fetal and maternal morbidity and mortality1 such as hypoxia, intrauterine growth retardation, infection, anaemia and post-partum haemorrhage1.
Causes of APH include placenta praevia and placental abruption (Figure 1a and b respectively2).
Risk factors include a previous pregnancy complicated by abruption or placenta praevia, multiparity, low BMI, advanced maternal age, pre-eclampsia, fetal malpresentation and smoking.
History and examination are vital when a woman presents with APH3. If there is a suspicion of placenta praevia, a vaginal examination should not be carried out as this leads to catastrophic bleeding. Ultrasound can be used to confirm the presence of a placenta praevia and then the mother should be kept in hospital until delivery, which is normally via caesarean section at 37 weeks.
If the mother is between 24+0 and 34 +6 weeks of gestation, dexamethasone should be given as the fetus’s lungs are not yet well developed. Tocolysis should not be used if the mother is hemodynamically unstable, has suffered major APH or there is evidence of fetal compromise4. The fetus should be monitored using a CTG to detect any signs of fetal distress.
In the acute setting, maternal blood should be taken for a complete blood count and coagulation screen, as well as to obtain a cross match. Oxygen should be given at 15L/minute via a mask with reservoir. Mother can be transfused with O negative blood if blood loss was significant (Figure 2).
Figure 2: Management of APH5
1. Calleja-Agius J, Custo R, Brincat MP, Calleja N. Placental abruption and placenta praevia. Eur Clin Obstet Gynaecol 2006; 2:121–7
2. Bleeding in Pregnancy/Placenta Previa/ Placental Abruption [http://www.stanfordchildrens.org/]
3. Royal College of Obstetricians and Gynaecologists. Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and Management. Green-top Guideline No. 27. London: RCOG; 2011
4. Royal College of Obstetricians and Gynaecologists. Tocolytic Drugs for Women in Preterm Labour. Green-top Guideline No. 1b. London: RCOG; 2011
5. Late Pregnancy Bleeding ELLEN SAKORNBUT, M.D., Family Health Center of Waterloo, Waterloo, Iowa, LAWRENCE LEEMAN, M.D., M.P.H., University of New Mexico, Albuquerque, New Mexico PATRICIA FONTAINE, M.D., M.S., University of Minnesota, Minneapolis, Minnesota. Am Fam Physician. 2007 Apr 15;75 (8):1199-1206.