Antepartum hemorrhage refers to vaginal bleeding occurring after the 20th week of gestation. It is most commonly seen during the third trimester and is associated with significant fetal as well as maternal morbidity and mortality. Common causes of antepartum hemorrhage are bloody show associated with labor, placental previa, and placental abruption. Rare causes include vasa previa and uterine rupture. Symptoms of placental abruption typically include lower abdominal pain, vaginal bleeding, and rigid uterus. Placenta previa and vasa previa on the other hand typically manifest prior to rupture of membranes or after rupture of membranes respectively, with painless vaginal bleeding and fetal distress. Uterine rupture, which occurs during labor, is discussed in a separate article. In cases of severe hemorrhage, patients may present with signs of hypovolemic shock. Fetal symptoms include signs of fetal stress, such as decelerations on heart monitoring and decreased fetal movements. The diagnosis is primarily clinical and is confirmed via transabdominal or transvaginal ultrasound. The treatment approach depends on maternal symptoms and fetal vitality. A conservative approach with continuous monitoring is advised for asymptomatic patients carrying a healthy fetus, while an emergency cesarean delivery is indicated in patients with acute symptoms and a live, distressed fetus.
|Differential diagnosis of antepartum bleeding|
|Condition||Onset||Pain||Additional symptoms||Risk factors|
|Placental abruption|| || |
|Placenta previa|| || || |
|Vasa previa|| || |
|Uterine rupture|| || |
| || |
|Bloody show|| || || |
|Cervical trauma|| || || || |
- The partial or complete separation of the placenta from the uterus prior to delivery; subsequent hemorrhage occurs from both maternal and fetal vessels.
- Incidence: ∼ 0.2–1% of pregnancies 
- Occurs most often in the third trimester
- The recurrence rate in subsequent pregnancies is 3–15%.
- Predisposing factors
- Vascular changes
- (Abdominal) trauma; (up to 10% of cases): car accidents, falls, iatrogenic (e.g., postamniocentesis)
- Sudden decrease in intrauterine pressure
- Previous abruption, chorioamnionitis, prolonged rupture of membranes, short umbilical cord
- Maternal age: < 20 years and > 35 years
- Alcohol and cigarette consumption, cocaine use
Following placental separation of more than 30%, there is a sudden onset of the following symptoms:
- Continuous vaginal bleeding (revealed abruptio placentae)
- In ∼ 20% of cases, the hemorrhage is mainly retroplacental; vaginal bleeding does not occur (concealed abruptio placentae)
- Sudden-onset abdominal pain or back pain , uterine tenderness
- Hypertonic contractions (rigid uterus), premature labor
- Fetal distress (60% of cases)
- Vaginal exam contraindicated: may worsen bleeding
- Ultrasound (transabdominal): only 25% sensitivity
- Fetal heart rate monitoring (see “Clinical features” above)
- Laboratory tests: CBC, coagulation factors
Rapid diagnosis and immediate treatment are vital for the survival of both mother and child.
- Hemodynamic control: monitor vital signs, maintain airways, volume resuscitation, type and crossmatch blood
- Correct coagulopathy if necessary
- RhD prophylaxis in RhD negative mothers
- See also .
Specific approach according to severity
Normal fetal findings and a hemodynamically stable mother
- Observation, bed rest, regular control
- Up to the 34th week of pregnancy
- 34th to 36th week
- All pregnancies are delivered if acute abruption occurs after 36th weeks.
- In acute symptoms and a live fetus
In acute symptoms and intrauterine fetal death
- Induction of vaginal delivery through pharmacologic uterine contraction inducers and opening of the amniotic sac
- An emergency cesarean delivery must be performed if there is a maternal risk; due to severe bleeding or slow progression of the birthing process, even in cases of intrauterine fetal death.
- Intrauterine fetal death
- Maternal DIC and hypovolemic shock: occurs as a result of blood loss and massive coagulation; the placenta is rich in tissue thromboplastin, which is released as a result of the placental abruption.
- Couvelaire uterus
Abruptio placentae is characterized by the “abrupt” onset of painful bleeding.
- Presence of the placenta in the lower uterine segment; ; can lead to partial or full obstruction of the neck of the uterus with high risk of hemorrhage (rupture of placental vessels) and birth complications
- ∼ 0.5% of all pregnancies 
Risk factors 
- Maternal age > 35 years, multiparity, short intervals between pregnancies
- Previous curettage or cesarean delivery
- Previous placenta previa, previous/recurrent abortion
- Placenta previa: placenta that covers the internal os either partially or completely
- Low-lying placenta: : lower edge of the placenta lies less than 2 cm from the internal cervical os
- Sudden, painless, bright red vaginal bleeding
- Usually occurs during the 3rd trimester (before rupture of the membranes), stops spontaneously after 1–2 hours, and recurs during birth
- Often causes preterm delivery (∼ 45% of cases)
- Soft, nontender uterus
- Usually no fetal distress
- Transvaginal ultrasound to assess the position of the placenta
- Digital vaginal examinations are contraindicated in cases of hemorrhage of unknown cause
Asymptomatic patients (with early detection of placenta previa on transvaginal ultrasound (gestational age ∼18–20 weeks'): Monitor placental placement.
- Follow up transvaginal ultrasound at 32 weeks: Determine if the placental edge is < 2 cm from or covers the internal os.
- In most patients diagnosed with placenta previa on early transvaginal ultrasound, the placenta returns to a normal position with progressive lengthening of the lower uterine segment.
- Gestational age < 37 weeks
- Gestational age > 37 weeks: immediate delivery
- Hospitalization and observation for 48 hours
- If gestational age is < 34 weeks: with corticosteroids (e.g., betamethasone)
- If gestational age is between 34 and 37 weeks and delivery is likely within 7 days: with corticosteroids
- If mild uterine contractions are present: tocolysis with magnesium sulfate may be performed (especially if the fetus is extremely premature)
Management of hemorrhage
- Prepare blood transfusion for possible massive hemorrhage.
- Bilateral uterine artery ligation, internal iliac artery ligation; packing with gauze or tamponade
- If severe, perform emergency cesarean hysterectomy.
Route of delivery
- Lower segment cesarean delivery; is almost always preferred; ideally scheduled at 36–37 weeks gestation
- Induction of labor and/or vaginal delivery may be performed in the operating room if the mother is hemodynamically stable, fetal cardiac status is reassuring, and the placenta lies > 2 cm away from the internal os on ultrasonography
Vaginal delivery should never be attempted outside the operating room in a patient with placenta previa.
- 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
- 1/2500 births
In most cases, at least one of the following risk factors is present.
Placental anomalies, such as:
Bilobate or succenturiate placenta
- Variation of the placental morphology with one or more accessory lobes developing separately from the main placental body
- Fetal vessels connecting the lobes are only supported by the chorioamniotic membranes.
- Risk factors: advanced maternal age, in vitro fertilization
- Can lead to vasa previa, placenta previa, and retained placental tissue
- Placenta previa
- Low-lying placenta
- In vitro fertilization
- Painless vaginal bleeding (fetal blood) that occurs suddenly after rupture of membranes
- Fetal distress (e.g., fetal bradycardia; decelerations or sinusoidal pattern on fetal heart tracings)
- Fetal death can occur quickly through exsanguination or asphyxiation if fetal vessels are compressed during labor.
- Transabdominal or transvaginal ultrasound with color Doppler shows fetal vessels overlying the internal os and decreased blood flow within fetal vessels.