Antepartum hemorrhage

Last updated: December 24, 2022

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Antepartum hemorrhage refers to vaginal bleeding occurring after 20 weeks of gestation. It most commonly occurs during the third trimester and is associated with significant fetal and maternal morbidity and mortality. Common causes of antepartum hemorrhage are bloody show associated with labor, placenta previa, and placental abruption. Rare causes include vasa previa and uterine rupture. Symptoms of placental abruption typically include lower abdominal pain, vaginal bleeding, and uterine rigidity. Placenta previa and vasa previa both manifest with painless vaginal bleeding, but bleeding from vasa previa typically occurs after rupture of membranes and more commonly causes fetal distress. In cases of severe hemorrhage, patients may present with signs of shock; fetal symptoms include signs of fetal distress such as decelerations on cardiotocography and decreased fetal movement. The diagnosis of antepartum hemorrhage is primarily clinical, but transabdominal or transvaginal ultrasound can help determine the etiology. The treatment approach depends on the results of the maternal and fetal status assessment. A conservative approach with continuous monitoring is advised for asymptomatic patients with reassuring fetal status, while emergency cesarean delivery is indicated for patients with significant active bleeding, hemodynamic instability, or fetal distress.

Uterine rupture, pregnancy loss, and postpartum hemorrhage are discussed in separate articles.

Differential diagnosis of antepartum bleeding
Condition Onset Pain Additional symptoms Risk factors
Placental abruption
  • Usually mild to moderate abdominal pain
Placenta previa
  • Painless
Vasa previa
  • Painless
Uterine rupture
  • Severe abdominal pain

Stillbirth

  • Cramping abdominal pain
Bloody show
  • Associated regular uterine contractions and cervical changes
  • A small amount of blood or blood-tinged mucus that is usually passed prior to labor or in early labor.
  • N/A
Cervical trauma
  • Sudden, typically caused by sexual intercourse
  • Mild to moderate pelvic pain depending on the extent of damage
  • Bruised and tender cervix without evidence of active bleeding
  • N/A

Initial management of antepartum hemorrhage [1][2][3]

Estimated blood loss is often inaccurate; assess for clinical signs of shock instead. [2]

Do not perform a digital cervical examination until placenta previa has been excluded on ultrasound. [1][2]

Definitive management of antepartum hemorrhage

Definitive management depends on the cause of bleeding, gestational age, fetal status, and maternal stability.

Placenta previa is an absolute contraindication to vaginal delivery. [3]

In patients with hemodynamic instability or nonreassuring fetal status, do not delay delivery to administer corticosteroids. [1]

When planning for delivery, ensure transfusion products and equipment to surgically control severe postpartum hemorrhage are readily available.

Definition [2]

  • The partial or complete separation of the placenta from the uterus prior to delivery; subsequent hemorrhage occurs from both maternal and fetal vessels.

Epidemiology

Etiology [2][11]

Predisposing factors include:

Clinical features [2]

Abruptio placentae is characterized by the “abrupt” onset of painful bleeding.

In cases of retroplacental hemorrhage, patients may present with signs of hypovolemic shock without evident vaginal bleeding!

Diagnostics [2][4]

For the initial management of patients with antepartum hemorrhage, see “Approach to antepartum hemorrhage.”

Placental abruption is a clinical diagnosis. Ultrasound is indicated in all patients to rule out placenta previa but is not diagnostic for abruption.

Digital vaginal examination is contraindicated unless placenta previa has been ruled out on ultrasound as it may worsen bleeding.

Management of placental abruption [1][2][3]

Placental abruption is an obstetric emergency. Delay in diagnosis and management is potentially life-threatening for the mother and fetus.

Complications [2][4]

Patients with placental abruption have a high risk of postpartum hemorrhage. [2]

Definition [2][4]

  • Presence of the placenta in the lower uterine segment; , which can lead to partial or full obstruction of the internal os; high risk of hemorrhage (rupture of placental vessels) and birth complications

Epidemiology

Risk factors [17]

Classification [18]

  • Placenta previa: placenta either partially or completely covers the internal os
    • Previously, this category included marginal previa (placenta reaching the internal os), partial previa (placenta partially covering the internal os), and complete previa (placenta completely covering the internal os); these terms have been excluded from the new classification.
  • Low-lying placenta: : lower edge of the placenta lies less than 2 cm from the internal cervical os

In placenta previa, we receive a “preview” of the placenta through the cervical os.

Clinical features [2][4]

Asymptomatic placenta previa is often diagnosed during a routine second trimester prenatal ultrasound. [4]

In contrast to placental abruption, bleeding in patients with placenta previa is painless.

Diagnostics [1][19][20]

In patients with antepartum hemorrhage, avoid digital vaginal examination unless placenta previa has been ruled out on transvaginal ultrasound. [1][19]

Transvaginal ultrasound can be performed in patients with antepartum hemorrhage and suspected placenta previa, as it has not been found to exacerbate bleeding. [1][19]

Management of placenta previa

Placenta previa detected on routine ultrasound during pregnancy [1][19][21]

In patients with placenta previa, delivery after 37 weeks' gestation is associated with bleeding complications and unscheduled emergency delivery. [22]

Placenta previa presenting as antepartum hemorrhage [1][2]

Route of delivery [6][24]

Vaginal delivery should never be attempted outside of the operating room in a patient with low-lying placenta.

Complications [2]

Definition

  • Condition in which the fetal vessels are located in the membranes near the internal os of the cervix, putting them at risk of injury if the membranes rupture

Epidemiology

  • 1/2500 births

Etiology

In most cases, at least one of the following risk factors is present.

Clinical features

Diagnostics

  • Transabdominal or transvaginal ultrasound with color Doppler shows fetal vessels overlying the internal os and decreased blood flow within fetal vessels.

Treatment

References:[25]

  1. Guleria K, Priya B, Chaudhary A. Vaginal Bleeding in Late Trimester. Springer Singapore ; 2019 : p. 163-172
  2. Ananth CV, Keyes KM, Hamilton A, et al. An international contrast of rates of placental abruption: an age-period-cohort analysis. PLoS ONE. 2015; 10 (5): p.e0125246. doi: 10.1371/journal.pone.0125246 . | Open in Read by QxMD
  3. Furuhashi M, Kurauchi O, Suganuma N. Pregnancy following placental abruption. Arch Gynecol Obstet. 2002; 267 (1): p.11-13. doi: 10.1007/s004040100227 . | Open in Read by QxMD
  4. Oyelese Y, Ananth CV. Placental Abruption. Obstet Gynecol. 2006; 108 (4): p.1005-1016. doi: 10.1097/01.aog.0000239439.04364.9a . | Open in Read by QxMD
  5. Ananth CV. Placental Abruption among Singleton and Twin Births in the United States: Risk Factor Profiles. Am J Epidemiol. 2001; 153 (8): p.771-778. doi: 10.1093/aje/153.8.771 . | Open in Read by QxMD
  6. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  7. Steane SE, Young SL, Clifton VL, Gallo LA, Akison LK, Moritz KM. Prenatal alcohol consumption and placental outcomes: a systematic review and meta-analysis of clinical studies. Am J Obstet Gynecol. 2021; 225 (6): p.607.e1-607.e22. doi: 10.1016/j.ajog.2021.06.078 . | Open in Read by QxMD
  8. Dynin M, Lane DR. Bleeding in Late Pregnancy. Springer International Publishing ; 2017 : p. 53-62
  9. Kadasne AR, Mirghani HM. The role of ultrasound in life-threatening situations in pregnancy. J Emerg Trauma Shock. 2011; 4 (4): p.508-10. doi: 10.4103/0974-2700.86648 . | Open in Read by QxMD
  10. Lyons P. Late-Pregnancy Bleeding. Springer International Publishing ; 2015 : p. 81-89
  11. Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period. Am J Obstet Gynecol. 2018; 218 (1): p.B2-B8. doi: 10.1016/j.ajog.2017.10.019 . | Open in Read by QxMD
  12. Jauniaux E, Grønbeck L, Bunce C, Langhoff-Roos J, Collins SL. Epidemiology of placenta previa accreta: a systematic review and meta-analysis. BMJ Open. 2019; 9 (11): p.e031193. doi: 10.1136/bmjopen-2019-031193 . | Open in Read by QxMD
  13. Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies. J Matern Fetal Neonatal Med. 2003; 13 (3): p.175-190. doi: 10.1080/jmf.13.3.175.190 . | Open in Read by QxMD
  14. Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging. J Ultrasound Med. 2014; 33 (5): p.745-757. doi: 10.7863/ultra.33.5.745 . | Open in Read by QxMD
  15. Silver RM. Abnormal Placentation. Obstet Gynecol. 2015; 126 (3): p.654-668. doi: 10.1097/aog.0000000000001005 . | Open in Read by QxMD
  16. Shipp TD, Poder L, Feldstein VA, et al. ACR Appropriateness Criteria® Second and Third Trimester Vaginal Bleeding. J Am Coll Radiol.. 2020; 17 (11): p.S497-S504. doi: 10.1016/j.jacr.2020.09.004 . | Open in Read by QxMD
  17. ACOG Committee. ACOG Committee Opinion No. 764: Medically Indicated Late-Preterm and Early-Term Deliveries. Obstet Gynecol. 2019; 133 (2): p.e151-e155. doi: 10.1097/aog.0000000000003083 . | Open in Read by QxMD
  18. Spong CY, Mercer BM, D’Alton M, Kilpatrick S, Blackwell S, Saade G. Timing of Indicated Late-Preterm and Early-Term Birth. Obstet Gynecol. 2011; 118 (2): p.323-333. doi: 10.1097/aog.0b013e3182255999 . | Open in Read by QxMD
  19. RCOG - Antepartum Haemorrhage - Green–top Guideline No. 63. https://www.rcog.org.uk/media/pwdi1tef/gtg_63.pdf. Updated: November 1, 2011. Accessed: August 11, 2022.
  20. Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. Am Fam Physician. 2007; 75 (8): p.1199-206.
  21. Jansen C, de Mooij YM, Blomaard CM, et al. Vaginal delivery in women with a low‐lying placenta: a systematic review and meta‐analysis. BJOG. 2019; 126 (9): p.1118-1126. doi: 10.1111/1471-0528.15622 . | Open in Read by QxMD
  22. Lockwood CJ, Russo-Stieglitz K. Velamentous umbilical cord insertion and vasa previa. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/velamentous-umbilical-cord-insertion-and-vasa-previa.Last updated: November 22, 2016. Accessed: April 25, 2017.
  23. Committee on Practice Bulletins—Obstetrics. Practice Bulletin No. 181. Obstetrics & Gynecology. 2017; 130 (2): p.e57-e70. doi: 10.1097/aog.0000000000002232 . | Open in Read by QxMD
  24. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins. Practice Bulletin No. 171: Management of Preterm Labor. Obstetrics & Gynecology. 2016; 128 (4): p.e155-e164. doi: 10.1097/aog.0000000000001711 . | Open in Read by QxMD
  25. Magnesium Sulfate Use in Obstetrics. https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Magnesium-Sulfate-Use-in-Obstetrics. Updated: January 1, 2016. Accessed: July 22, 2017.

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