REVIEW
Antepartum haemorrhage
Nadia Amokrane
E R F Allen
Anna Waterfield
Shreelata Datta
Abstract
Antepartum haemorrhage (APH) is bleeding from or into the genital
tract occurring between 24 þ 0 weeks’ gestation until birth. It compli-
cates 3e5% of pregnancies. The 2006e2008 report of the Confidential
Enquiries into Maternal Deaths in the UK (CMACE) reported APH as
the cause of death in four women. The high prevalence of APH, and
its associated perinatal mortality and morbidity makes a thorough un-
derstanding of APH is essential for the practising obstetrician. The
objective of this review is to consider the most common causes of
APH (placenta praevia, placental abruption and local causes), together
with their management.
Keywords antepartum haemorrhage; obstetric haemorrhage;
placenta accreta; placenta praevia; placental abruption
Introduction
Bleeding in pregnancy is a common reason for presentation to
labour wards, maternity triage units, GP surgeries and early
pregnancy centres in the UK.
The management of bleeding in pregnancy varies according to
gestation. In this review we specifically address antepartum
haemorrhage (APH) which is defined as bleeding from the genital
tract that occurs from viability onwards, defined here as greater
than 24 weeks’ gestation. Obstetricians may see women with
genital tract bleeding from 16 to 23 weeks’ gestation however
management of this group of women may differ.
APH and post-partum haemorrhage (PPH) are the leading
causes of maternal death worldwide. In the UK, maternal deaths
have continued to decrease. The recent MBRRACE-UK report
published in December 2014 showed that maternal mortality in
the UK had decreased from 11:100, 000 women between 2006
and 2008 to 10:10,000 between 2009 and 2012. Between 2009
and 2012, 17 mothers in the UK and Ireland died due to
Nadia Amokrane MBChB is a Specialist Registrar in Obstetrics and
Gynaecology at King’s College Hospital, London, UK. Conflicts of
interest: none declared.
E R F Allen MBBS BSc MRCOG is a Locum Consultant Obstetrician and
Gynaecologist at King’s College London (PRUH), London, UK.
Conflicts of interest: none declared.
Anna Waterfield MRCOG is a Senior House Officer in Obstetrics and
Gynaecology at King’s College Hospital, UK. Conflicts of interest:
none declared.
Shreelata Datta MBBS LLM BSc (Hons) MRCOG is a Consultant
Obstetrician and Gynaecologist at King’s College Hospital, London,
UK. Conflicts of interest: none declared.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016),
http://dx.doi.org/10.1016/j.ogrm.2015.11.009
haemorrhage. The report does not distinguish the women who
presented with APH, but three women were diagnosed with
placental abruption and placenta praevia.
The aim of this review is to define causes of APH and discuss
management in accordance with recent guidelines and published
evidence. The MBRRACE-UK report reminds us that APH and
PPH are not only important causes of maternal mortality but also
of maternal and perinatal morbidity. Therefore the early recog-
nition and management of women presenting with genital tract
blood loss is an important aspect of antenatal assessment. It is
essential that the obstetrician be prepared for potential sequelae,
and thorough antenatal, intrapartum, and postpartum planning
is required.
Causes of APH
Cervical and vaginal causes
A common cause of APH is bleeding from the cervix. A cervical
ectropion or ‘erosion’ is where the columnar epithelium that
lines the cervical canal protrudes further onto vaginal surface of
the cervix. This is more common in pregnancy, and is thought to
be related to high oestrogen levels. The tissue of the ectropion is
very friable and contact bleeding can occur, usually at sexual
intercourse or even on passing hard stools. Ectropion can be
easily diagnosed on speculum examination of the cervix.
Cervicitis (inflammation or infection of the cervix) may be an
under-diagnosed cause of bleeding in pregnancy and may be
caused by sexually transmitted infections (STIs) such as chla-
mydia and gonorrhoea, which can present with abnormal vaginal
bleeding. A high vaginal swab and screening for STIs should be
undertaken. Treatment of STIs presenting in pregnancy is
important, as they can be associated with preterm labour and
neonatal morbidity. Bleeding or spotting can also occur from the
vagina and vulva secondary to non-sexually transmitted in-
fections such as thrush, folliculitis, and from trauma.
Benign cervical polyps are a further cause of APH. If the
bleeding does not clinically compromise the mother or fetus, and
the polyp appears non-suspicious then these should not usually
be removed in pregnancy.
Cervical carcinoma presenting in pregnancy is uncommon
and a detailed history at booking appointment should assess a
woman’s smear history and history of previous cervical treat-
ments. If a cervical carcinoma is suspected on assessment of the
cervix then urgent referral to colposcopy is indicated.
Placental causes
Placental abruption: abruptio placenta is the premature sepa-
ration of a normally sited placenta from the uterus. Placental
abruption can lead to maternal and fetal complications, and ul-
timately mortality. Bleeding occurs when the placenta starts to
separate from the decidua basalis. The presentation of placental
abruption usually includes pain (50%) and bleeding (70e80%)
however, a concealed abruption (20% of cases) can present with
no pain or bleeding. Premature labour is seen in nearly a third of
cases of abruption, however, the contraction pains may be
atypical in nature, with the patient describing severe unremitting
pain.
The incidence of placental abruption is reported between
0.26% and 0.80% in literature depending on the type of study
1 Ó 2016 Published by Elsevier Ltd.
 REVIEW
and population. The biggest risk factor for abruption is a previ-
ous abruption with a 10-fold increased risk of abruption if there
has been an abruption in the previous pregnancy. The risk in-
creases to nearly 25% if a woman has had two previous
abruptions.
Although there is no single aetiology for placental abruption, a
number of risk factors have been identified. These include hy-
pertension and pre-eclampsia. Notably, when examining risk
factors in a control population, chronic hypertension has a
stronger association with abruption (OR 3.13) than pre-
eclampsia (OR 1.73). Smoking is associated with a 90% in-
crease in the risk of abruption. There is a three-fold increased
risk in pregnancies complicated by prolonged rupture of mem-
branes (PROM). Cocaine use has also been linked to a higher rate
of placental abruption. However, despite numerous risk factors
and associations, abruption is usually an unexpected event and
the vast majority will occur in low risk pregnancies.
Placenta praevia, placenta accreta, increta and placenta per-
creta: placenta praevia is the insertion of the placenta partially or
entirely within the lower segment of the uterus after 32 weeks. If
the placenta does not cover the internal os then it is described as
a minor praevia and if it partially or fully covers the os then it is
classified as a major praevia. A morbidly adherent placenta such
as a placenta accreta, increta or percreta invades through the
decidua basalis. In placenta accreta the chorionic villi attach to
the myometrium. In placenta increta the placenta has invaded
into the myometrium; in placenta percreta the placenta invades
through the myometrium and breaches the uterine serosa.
Placenta percreta may then invade other organs such as the
bladder.
The incidence of low-lying placenta can be up to 28% at the
routine 20 week anomaly ultrasound scan, but the majority of
these will have migrated higher by the following scan, usually at
32 weeks or later. The incidence of true placenta praevia at term
is approximately 3%.
There are several hypotheses about the aetiology of placenta
praevia. One theory is that the position of the placenta depends
on the site of implantation of the discoid trophoblast when the
pregnancy is developing and from where the placenta will arise.
A further theory postulates that areas of deficient endometrium
from procedures such as caesarean sections, surgical manage-
ment of miscarriage and myomectomies may affect how the
placenta attaches in these cases.
The risk factors for placenta praevia include multiparity,
increasing maternal age, smoking, previous praevia and surgical
procedures that may result in deficient endometrium (Table 1).
The number of previous Caesarean sections also increases the
risk of placenta praevia.
In well-resourced settings such as in the UK, the majority of
placenta praevia cases may be picked up on ultrasound scan at
20 weeks. Currently the UK National Screening Committee does
not recommend screening for placenta praevia however, along-
side the RCOG, they support most local practice of identifying
women by ultrasound whose placenta lies near the internal os at
the routine 20 week scan. Evidence shows that at the second
trimester scan about 26e60% of women with a low lying
placenta on abdominal ultrasound would be reclassified with a
more accurate transvaginal scan. There have been no reports to
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016),
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suggest that transvaginal scanning in suspected placenta praevia
cases is unsafe.
Women with a low-lying placenta at 20 weeks should be
followed up in the third trimester, usually at 32e36 weeks.
However, if women have had a previous Caesarean section and
have a low-lying placenta, then a placenta accreta should be
suspected. If major placenta praevia is suspected in the third
trimester, then this significantly raises the risk of morbidity and
preterm delivery. However the diagnosis of placenta praevia
should be considered in any patient who presents with painless,
fresh vaginal bleeding or bleeding after intercourse.
The most likely symptom from a placenta praevia is painless
bleeding in contrast to abruption where pain is likely to co-
present. The bleeding is usually fresh, red and the amount of
APH can vary. The patient may also present with fresh bleeding
in early labour, with the onset of labour and cervical dilatation
triggering the bleed or vice versa.
Other causes
Uterine rupture: uterine rupture is a rare event that is defined as
loss of the full thickness of the uterine wall integrity. It usually
occurs during labour in a woman with a previous Caesarean
section or myomectomy. Within this group the risk is still small;
the incidence of uterine rupture has been estimated at 7 per
10,000 planned vaginal births after Caesarean section. Uterine
rupture may present with CTG abnormalities, pain or APH. Early
recognition and quick stabilisation of the mother and baby is
required as mortality and morbidity is high.
Vasa praevia: vasa praevia is a rare obstetric complication where
fetal blood vessels cross the internal cervical os. As the incidence
is rare (between 1 in 2000 and 1 in 6000 pregnancies) it is not
currently screened for during routine ultrasound. The risk of APH
mainly comes with rupture of the membranes or labour, as a
direct consequence of tearing of the blood vessels. The fetus can
be comprised quickly and management if diagnosed or suspected
is usually by immediate category 1 Caesarean section.
Unexplained APH
Some women will present with bleeding that cannot be attributed
to any of the above causes. The RCOG Greentop Guideline ref-
erences a number of studies over the last four decades that
demonstrate that pregnancies with unexplained APH are at
higher risk of preterm birth and stillbirth. A recent retrospective,
observational study noted that pregnancies complicated by APH
of unknown aetiology are at a higher risk of preterm birth, lower
birthweight, induction of labour, and neonatal unit admissions.
Repeated presentations with unexplained APH in pregnancy
should raise suspicion and the pregnancy should be monitored as
high risk, with the need for additional ultrasound scans for fetal
growth.
Healthcare providers should be aware that maternal trauma,
including domestic violence, can result in APH, possibly from
placental abruption. A third of domestic violence is known to
start or escalate in pregnancy. A retrospective study of 2070
women subjected to physical violence in pregnancy found an
increased odds ratio of APH in this cohort, compared with con-
trols, of 3.79 (95% CI 1.38e10.40). Women who present with
2 Ó 2016 Published by Elsevier Ltd.
 REVIEW

multidisciplinary team including a senior obstetrician, anaes-

Risk factors for placenta praevia thetist, and senior midwife. Input is also frequently required
Risk factors from blood transfusion technicians, haematologists, neo-
natologists, and porters. Obstetric units will usually have fixed
Placenta praevia Large placental area protocols for the management of massive obstetric haemorrhage
(multiple pregnancy) that should be activated if a woman presents with or develops
Advanced maternal age massive haemorrhage. These protocols should be actively
High parity rehearsed in annual skills training in order to prepare for such
Uterine scar (caesarean section, cases.
myomectomy) The RCOG Greentop Guideline defines the severity of APH, as
Previous placenta praevia outlined in Table 2. However, it should be remembered that the
Smoking, cocaine use amount of blood lost can be underestimated, particularly as the
Placental pathology amount of blood seen on vaginal examination may not be an
Placental abruption Previous placental abruption accurate representation of the total blood lost.
Hypertension The initial assessment of a woman with APH should include
Pre-eclampsia the ABC approach to stabilise the patient (Table 3) and assess the
Smoking, cocaine use total estimated blood loss. However, it is important to remember
Premature rupture of membranes that not all blood loss is revealed, so the clinical features of blood
Coagulopathies loss are extremely important (e.g. grade of shock) to formulating
Multiple gestation appropriate management plans.
Advanced maternal age Patients with major or massive obstetric haemorrhage should
Abdominal trauma be managed in left lateral tilt to reduce hypotension secondary to
Vasa praevia Velamentous insertion of umbilical cord uterine compression of the inferior vena cava. Resuscitation and
Succenturiate, bilobe placenta stabilization of the mother is the key priority. Following the
Multiple gestation initial survey and after commencing resuscitation, the cause and
IVF pregnancy extent of the APH should be assessed by history taking and
Uterine rupture Multiparity carrying out a full examination.
Congenital uterine anomalies Abdominal examination may illicit a ‘woody’ or tense uterus,
Uterine scar (secondary to caesarean which is characteristically seen in placental abruption or it may
section, myomectomy etc) show the patient is contracting and could be in labour. If a pa-
Maternal age tient with known placenta praevia presents with bleeding, then a
Abnormal placentation digital examination or speculum examination is not necessary. A
Uterine distension (multiple gestation, digital examination or speculum may be indicated where
polyhydramnious, macrosomia) placenta praevia has been excluded to check for a cause for the
Gestation >40 weeks APH and to assess cervical dilatation. The diagnosis of vasa
Uterine rupture Obstructed labour praevia should be considered when the APH has been associated
with rupture of membranes.
Table 1
Investigations
APH and other signs suggestive of domestic violence or, who The RCOG guideline recommends that all patients with APH
disclose violence, should be identified and managed appropri- should have a full blood count (FBC) and a group and save. A
ately by a multidisciplinary team who have been specially Kleihauer test is also necessary for all Rhesus negative women.
trained in domestic violence to safeguard pregnant women. Women who present with major or massive haemorrhage should
also have liver and renal function blood tests and a coagulation
Diagnosis and management of APH screen including fibrinogen. They also may benefit from a
bedside blood check such as a Hemacue since the FBC may not
Women who present with major haemorrhage and signs of give an accurate immediate estimate of blood loss.
shock should be seen in a maternity unit with involvement of a

RCOG definition of APH severity

Description Blood volume

Spotting Staining, streaking or blood spotting noted on underwear or sanitary protection

Minor haemorrhage Blood loss less than 50 ml that has settled
Major haemorrhage Blood loss of 50e1000 ml, with no signs of clinical shock
Massive haemorrhage Blood loss greater than 1000 ml and/or signs of clinical shock

Table 2

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Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016),
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 REVIEW

Resuscitation pathway for major APH

Assessment Management

A(irway) Check patency

B(reathing) Respiratory rate
Oxygen saturations
10e15L via non rebreathing mask
C(irculation) Heart rate
Capillary refill time
Blood pressure
IV access (consider x 2 16 gauge cannulas)
IV fluid resuscitation crystalloid/colloid/blood
Assess blood loss
Consider catheterisation (input/output monitoring)
D(isabilty) Glasgow coma score
E(xposure) Abdominal examination
Speculum
Vaginal examination
F(etus) CTG Method used gestation dependent
Auscultation FHR
Ultrasound

Table 3

Even with bedside haemoglobin checks and laboratory FBC, it
should be noted that after acute major blood loss these tests can
be misleading during or soon after the initial haemorrhage.
Therefore, initial diagnosis and management of APH should be
based on clinical criteria and observations.
After stabilizing the mother, the fetal heart rate should be
checked. There is no clear guidance or evidence to support
monitoring fetuses during APH as there may be transient ab-
normalities with the CTG. Clinical judgement is essential to make
a decision regarding mode and timing of delivery based on likely
diagnosis and the maternal and fetal status. For example, if an
abruption is suspected and there is an abnormal CTG then the
CTG findings are likely to be associated with fetal hypoxia and so
delivery would be indicated for fetal benefit.
Ultrasound can be used to determine placental site, or to
check fetal growth, liquor and Doppler studies once the bleeding
has settled. It is not recommended as a diagnostic tool to di-
agnose abruption as the reported sensitivity is only between 25
and 50%.
Generally most clinicians currently do not recommend tocol-
ysis if a patient is actively bleeding. The RCOG recommends a
single course of steroids between 24 and 34 weeks if delivery is
likely to be preterm.
Conservative management of placenta praevia
Women with placenta praevia were previously advised to remain
as inpatients from 34 weeks until elective delivery. Currently
there is limited evidence to support either hospital-based or
home-based care in the third trimester. Women with placenta
praevia who have APH that resolves spontaneously without
requiring immediate delivery are likely to remain in hospital until
bleeding has completely ceased. With recurrent APH in the third
trimester for any pathology, it is common practice for patients to
be hospitalised until elective delivery although there is no evi-
dence to support this. In accordance with the RCOG Green-top
guideline, women with placenta praevia in the third trimester
should be counselled about the risks of preterm delivery and
obstetric haemorrhage. The place and package of care should be
individualised to meet the needs of each patient. If care is at
home, the woman should be within close proximity to the hos-
pital, have a constant companion at home, and be aware of when
she should attend hospital immediately.
Blood products
Managing severe antepartum haemorrhage frequently requires
blood transfusion and considering delivery with surgical in-
terventions to arrest the bleeding. If women require blood
transfusion then individually cross-matched blood is ideal.
Rarely, if blood loss is so excessive that the processing time for
this would be clinically unacceptable then Group O Rhesus
negative red cells should be utilised. Commencing red cell
transfusion is based on clinical evaluation and haematological
investigations, if available. If a coagulopathy develops then fresh
frozen plasma (FFP) should be administered before one blood
volume is lost. Haematological investigation and specialist
advice should guide the further use of FFP, cryoprecipitate, and
platelets in massive obstetric haemorrhage. The RCOG Green-top
guideline on blood transfusion in obstetrics advises that cry-
oprecipitate may be indicated when there is bleeding with
fibrinogen concentration below 1 g/L. The platelet count should
be maintained at above 75  109/L.
It is important that women who will refuse blood products in
an emergency, including Jehovah’s witnesses, are identified in
the antenatal period and referred to consultant-led care. These
women are at higher risk of morbidity and mortality in the case
of APH. The healthcare provider and patient should discuss what

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Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016),
http://dx.doi.org/10.1016/j.ogrm.2015.11.009
 REVIEW
blood components and blood derivatives (for example clotting
factor concentrates) would be acceptable to the woman in the
event of serious blood loss, and also if autologous transfusion in
the form of cell salvage can be used. There should be a signed
advanced directive and all discussions clearly documented.
Antenatally, any woman who would refuse blood transfusion or
blood products should have their haemoglobin levels optimised.
In the event of major APH or indeed PPH, a consultant obste-
trician, anaesthetist and haematologist should be informed. If a
woman who would refuse donor blood is diagnosed antenatally
with placenta accreta or this is suspected, it is recommended that
delivery is planned in a facility with access to interventional
radiology. There is insufficient evidence on whether prophylactic
catheter placement for balloon occlusion or embolisation is
advantageous.
Delivery techniques and post-partum care
Placental abruption and placenta praevia can lead to ongoing
bleeding after delivery. Bleeding should be managed according to
normal post-partum haemorrhage protocols, with uterotonic
agents and surgical interventions such as intrauterine balloons,
B-Lynch suture, uterine artery embolization and hysterectomy as
required. In cases of placenta accreta managed by Caesarean
section, where the placenta fails to separate, managament op-
tions include leaving it in situ and proceeding to either elective
hysterectomy or conservative management. There are no rand-
omised control trials to compare approaches directly but case
series show successful outcomes with both approaches. If the
placenta is left in situ and the uterus is spared, conservative
management involves prophylactic antibiotics and lengthy
follow-up with beta-HCG measurement and imaging to ensure
resolution. Women should be warned of the risk of persisting
bleeding and infection.
Conclusion
APH can be a traumatic and concerning event for women in
pregnancy. Early recognition and management is therefore vital,
together with a relevant postnatal debrief. The MBRRACE-UK
report highlights that haemorrhage is still a significant contrib-
utor to UK maternal morbidity and mortality. Therefore, local
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Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016),
http://dx.doi.org/10.1016/j.ogrm.2015.11.009
audits and reviews are imperative for individual units to learn
through previous experiences and near-misses. All maternity
multidisciplinary team must be regularly updated in their ob-
stetric haemorrhage protocols e both antenatal and post-
partum. A
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