Makindo Medical Notes

⚠️ Antepartum haemorrhage (APH) = vaginal bleeding after 24 weeks until delivery. Occurs in ~3–5% of pregnancies and is a major cause of maternal & perinatal morbidity/mortality. 💡 Uterine blood flow at term is 600–800 mL/min → even short delays can be catastrophic.

📊 Incidence

• 3–5% of pregnancies.
• Still one of the leading causes of maternal and fetal death worldwide.

🔎 Causes of APH

• 🌸 Placenta praevia (~1:200 pregnancies) – Painless bright red bleeding. – Placenta partially/completely covers os. – Diagnosed by TVS (transvaginal safest). – ⚠️ Never do PV exam before praevia excluded.
• 💥 Placental abruption – Premature detachment of placenta. – Painful, tense (“woody”) uterus, bleeding (revealed or concealed). – RFs: pre-eclampsia, smoking, cocaine, trauma. – Complications: DIC, fetal compromise, renal failure.
• 🚨 Vasa praevia (~1:2500) – Fetal vessels cross near os → rupture after ROM. – Presents with PV bleed + fetal HR decelerations. – Dx: USS with Doppler. – ⚡ Emergency C-section needed.
• 🧩 Other: circumvallate placenta, cervicitis, cervical polyps, malignancy.
• ❓ Unexplained: ~50% have no identifiable cause but still ↑ perinatal risk.

🩺 Clinical Features

• Praevia: painless, soft uterus, normal FHR.
• Abruption: painful, tense uterus, abnormal FHR.
• Vasa praevia: bleeding + fetal HR changes after ROM.
• Maternal obs, fetal movements, CTG essential.
• ⚠️ Avoid PV exam until praevia excluded on scan.

📏 Severity of Bleed

• Spotting → minor (<50 mL, settled).
• Major → 500–1000 mL, stable.
• Massive → >1000 mL ± maternal shock.

🧪 Investigations

• 🩸 Bloods: FBC, group & save / X-match ≥4 units, clotting, U&E, LFTs.
• 💉 Kleihauer test if Rh− → guides anti-D.
• 🧪 Urinalysis: check proteinuria (pre-eclampsia).
• 📊 CTG: assess fetal wellbeing.
• 🧲 USS: TVS for placental localisation, Doppler for vasa praevia.

🏥 Management

• 🚑 Resuscitation (ABC): O₂, 2x wide-bore IVs, fluids, blood products (O-neg if urgent).
• 📞 Call senior help: obstetrician, anaesthetist, neonatology team.
• 💊 Steroids: 24–34+6 wks if preterm delivery likely.
• 🚺 Placenta praevia: elective C-section if placenta <2 cm from os.
• 💥 Abruption: manage shock (concealed bleed often > visible loss), correct DIC, expedite delivery if unstable.
• ⚡ Massive haemorrhage: Activate major obstetric haemorrhage protocol → immediate delivery (often C-section).
• ➕ Don’t forget: anti-D for Rh−, catheter for fluid balance, monitor urine output.

⚠️ Maternal Complications

• Anaemia, hypovolaemic shock.
• DIC, renal failure (ATN).
• PPH (~25% after abruption).
• Infection, Sheehan’s syndrome, transfusion risks.

⚠️ Fetal Complications

• Hypoxia, IUFD.
• Prematurity, growth restriction.

📌 Exam Pearls

• Praevia = painless + normal FHR.
• Abruption = painful + abnormal FHR.
• Vasa praevia = bleed + FHR drop post-ROM.
• Shock may be concealed → treat aggressively.
• Always ask: maternal stability? fetal compromise? → delivery timing depends on both.

📖 References

• RCOG Green-top Guideline 63: Antepartum Haemorrhage