Antepartum haemorrhage: Causes, Management & Prevention

What is Antepartum haemorrhage?

Antepartum refers to existing or occurring before birth. Hence, antepartum haemorrhage (APH) is defined as vaginal or genital  bleeding during pregnancy after the 28th week’s gestation. Another name  for antepartum haemorrhage (APH)  is called pre-partum haemorrhage. 

How common is antepartum haemorrhage?

APH as one of obstetric haemorrhages affects 3-5% of all pregnancies and accounts for 27% of all maternal deaths. 

Antepartum bleeding is associated with increased perinatal morbidity and mortality and can occur at any time until completion of the second stage of labour .

Antepartum haemorrhage causes

The aetiology of APH are multifaceted and may include:

  • Incidental factors: cervical erosion, cancer of cervix, cervical polyps, cervical ectropion,vulvovaginal varicosities,genital tract tumours, cervicitis
  • Accidental factors: placenta praevia, Vasa praevia, abruptio placenta 

Risk factors of antepartum haemorrhage

The predisposing factors for APH are:

  • Previous history of  APH
  • Multiple pregnancy
  • Previous cesarean section,
  •  Advanced maternal age (< 35)
  • Previous termination of pregnancy (curettage)
  • Gestational hypertension/ pregnancy-induced hypertension (PIH)
  • Multiparity(High parity)

Types of Antepartum haemorrhage

APH can be divided into two based on duration or period of its occurrences. These are:

  • Bleeding in early pregnancy 
  • Bleeding in late pregnancy 

Bleeding in early pregnancy

This occurs when a pregnant woman experiences vaginal bleeding or bleeding from genital tract before the 20th week of gestation. Its causes are cervical erosion, cancer of cervix, abortion/miscarriage and ectopic pregnancy.

 However, major causes of bleeding in early pregnancy are ectopic pregnancy and abortion —whether spontaneous or induced.  Bleeding before 24 weeks of pregnancy denotes miscarriage.

Bleeding in late pregnancy

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This is the vaginal blood loss  that occurs during 24th or 28th weeks of pregnancy. This type of antepartum haemorrhage  is associated with increased maternal and perinatal morbidity and mortality.

Placenta praevia and placental abruption are major causes of vaginal bleeding in late pregnancy.  

Vaginal bleeding often dark in colour and accompanied by pain during pregnancy indicates  abruptio placenta. While bright vaginal bleeding during  pregnancy which is painless denotes placenta praevia.

What are the signs and symptoms of antepartum haemorrhage?

Antepartum haemorrhage symptoms are:

  • Bleeding that may be accompanied by pain denotes placental abruption) but  painless  vaginal bleeding suggests placenta praevia. 
  • Uterine contractions and tenderness may be present;
  • Abdominal pain;
  • Back ache
  • Malpresentation or failure of the fetal head to engage especially in   placenta praevia
  • Signs of fetal distress depending on level of blood loss;
  • In severe bleeding, the patient may show signs of cardiovascular decompensation or hypovolaemic shock;
  • Fear and restlessness;

Diagnosis of antepartum haemorrhage

Apart from detailed history from the woman and examining her vaginally with aid of speculum, antepartum ultrasound helps to diagnose and confirm the actual cause of bleeding in pregnancy.

Prenatal ultrasound is a safe and painless test which can be performed during the first, second, or third trimester based on what the health care provider is looking for.

Note: Experienced midwife knows that bright vaginal blood loss which is painless is associated with placenta praevia while that which is dark in colour and accompanied with pain suggests placental abruption.

Complications of antepartum haemorrhage

These complications can be grouped into:

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Maternal complications

  • Anaemia
  • Oligohydramnios
  • Premature labour
  • Preterm pre-labour rupture of membranes (PPROM)
  • puerperal infections (Infection/sepsis related to procedures in arresting the bleeding or caesarean section)
  • Retained placenta. 
  • Acute kidney failure
  • Cardiac failure
  • Obstetric shock
  • Coagulation failure/Disseminated intravascular coagulopathy(DIC)
  • Postpartum haemorrhage
  • Psychological sequelae
  • Increased rates of caesarean section
  • peripartum hysterectomy
  • Prolonged hospitalization
  • Maternal death 

Fetal complications

  • Fetal hypoxia or fetal distress
  • Fetal anaemia 
  • Intrauterine growth retardation(fetal growth restriction)
  • Prematurity (About 20% of very preterm babies are born in association with APH)
  • Cerebral palsy
  • Fetal demise related to asphyxiation and poor placental perfusion

Antepartum haemorrhage management

Management for bleeding in pregnancy depends on the causative factor (s), stage of pregnancy, degree of haemorrhage and maternal and fetal conditions.

  • Read:
  • a. Treatment bleeding in pregnancy related to placenta praevia
  • b. Teatment bleeding in pregnancy related to placental abruption
  • c. Teatment bleeding in pregnancy related to vasa praevia
  • d. Antepartum haemorrhage related to abortion and/or miscarriage

What is the prevention of antepartum haemorrhage?

No specific ways you prevent antepartum haemorrhage. However, encouraging early booking, regular antenatal care, early detection of high risk cases and early referral to a higher center help in preventing bleeding in pregnancy. The patient is encouraged to get adequate bed rest, avoid intercourse and limit physical activity.

Those at higher risk of APH are advised on the use of contraceptives in order to prevent subsequent pregnancy.

Aspirin  at doses of 75-100mg can be used before 16 weeks of pregnancy to prevent pre-eclampsia which is also effective at preventing antepartum bleeding.

While pregnant women who have suffered bleeding during should be referred to higher facilities where there are good facilities for cesarean section and availability of blood banks so as to improve maternal and perinatal outcomes.