Antepartum hemorrhage

Last updated: April 5, 2022

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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
  • Usually mild to moderate abdominal pain
Placenta previa
  • Painless
Vasa previa
  • Painless
Uterine rupture
  • Severe abdominal pain


  • 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


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



Clinical features

Following placental separation of more than 30%, there is a sudden onset of the following symptoms:

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


Placental abruption is a clinical diagnosis.

Rapid diagnosis and immediate treatment are vital for the survival of both mother and child.


General approach

Specific approach according to severity


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


Risk factors [6]

Classification [7]

  • Placenta previa: placenta that covers the internal os either partially or completely
    • 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

Clinical features

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


Treatment [8]


Expectant management

Management of hemorrhage

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.

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



  • 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.

Clinical features


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



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