ARTICLE IN PRESS

Current Obstetrics & Gynaecology (2006) 16, 79–83

Available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/curobgyn

Antepartum haemorrhage
Nicholas Ngeh, Amarnath Bhide

Fetal Medicine Unit, Department of Obstetrics and Gynaecology, 4th floor, Lanesborough Wing, St George’s Hospital,
Blackshaw Road, SW17 0QT, London, UK

KEYWORDS Summary
Pregnancy complica- Antepartum haemorrhage is bleeding from the genital tract in the second half of
tions; pregnancy. It continues to be an important cause of maternal and fetal mortality and
Placenta previa; morbidity. In those cases where a cause is identified, placental abruption and placenta
Abruptio placentae; praevia are two common responsible conditions. In the remaining half, the cause remains
Placenta diseases unidentified even after investigations. Placental abruption is diagnosed clinically, and is
unpredictable. The management has changed little over the recent past. Availability of
ultrasound has radically changed screening, diagnosis and management of women with
placenta praevia. The frequency of placenta accreta appears to be increasing, and
ultrasound can be useful for antenatal identification. Prenatal diagnosis dramatically
improves the perinatal mortality associated with vasa praevia. Massive haemorrhage is still
responsible for maternal deaths. A clear protocol for massive haemorrhage should be
available in all units, be regularly updated and rehearsed.
& 2006 Published by Elsevier Ltd.

Antepartum haemorrhage (APH) defined as bleeding from  Vasa praevia

the genital tract in the second half of pregnancy, remains a  Bleeding from the lower genital tract
major cause of perinatal mortality and maternal morbidity
in the developed world. In approximately half of all women
presenting with APH, a diagnosis of placental abruption or
placenta praevia will be made; no firm diagnosis will be Placental abruption
made in the other half even after investigations. In cases
presenting with APH, the evaluation consists of history, Usually the placenta is situated in the upper uterine
clinical signs and symptoms and once the mother is segment. Placental abruption is the premature separation
stabilized, a speculum examination and an ultrasound scan. of a normally situated placenta from the uterine wall,
Causes include: resulting in haemorrhage before the delivery of the fetus. It
occurs in around one in 80 deliveries and remains a
significant source of perinatal mortality and morbidity.
 Abruptio placentae
 Placenta praevia
 APH of indeterminate origin Incidence

Corresponding author. Tel.: +44 20 87250080; Recent large epidemiological studies report an incidence
fax: +44 20 87250079. ranging from 5.9 to 6.5 per 1000 singleton births and
E-mail address: [email protected] (A. Bhide). 12.2 per 1000 twin births. Perinatal mortality is reported

0957-5847/$ - see front matter & 2006 Published by Elsevier Ltd.

doi:10.1016/j.curobgyn.2006.01.003
 ARTICLE IN PRESS
80 N. Ngeh, A. Bhide

to be 119 per 1000 births complicated by abruption. The risk In less severe cases, the diagnosis of placental abruption
of abruption recurring in a subsequent pregnancy is may not be obvious, particularly if the haemorrhage is
increased as much as 10-fold. largely concealed and it may be misdiagnosed as idiopathic
preterm labour. The majority of fetal morbidity is thought to
be due to prematurity, with low birth weight, fetal growth
Pathology and aetiology
restriction, anaemia, and hyperbilirubinaemia significantly
more common. Placental abruption cannot be eliminated as
The precise cause of abruption is unknown. Abruption arises
a potential diagnosis in the absence of vaginal bleeding, as
from haemorrhage into the deciduas basalis of the placenta,
haemorrhage may be retroplacental and concealed. Placen-
which results in the formation of haematoma and an
tal abruption is concealed in 20–35% and revealed in 65–80%
increase in hydrostatic pressure leading to separation of
of cases.
the adjacent placenta. The resultant haematoma may be
In severe abruption, complications include haemorrhage
small and self-limited or may continue to dissect through
requiring transfusion, disseminated intravascular coagulo-
the decidual layers. However, the bleeding may be in whole
pathy (DIC), infection and rarely, maternal death. Couve-
or in part concealed, if the haematoma does not reach the
laire uterus may occur and occasionally may require
margin of the placenta and cervix for the blood loss to be
hysterectomy. The incidence of stillbirth is related to the
revealed. Therefore the amount of revealed haemorrhage
size of the abruption. Separation exceeding 50% of the
poorly reflects the degree of blood loss. The bleeding may
placenta causes a marked elevation in stillbirth rate.
infiltrate the myometrium resulting in so-called Couvelaire
uterus.
A causal relationship between hypertension and abruption Management
is controversial. Most explanations implicate vascular or
placental abnormalities, including increased fragility of Once placental abruption has been suspected, action should
vessels, vascular malformations, or abnormalities in placen- be swift and decisive because the prognosis for mother and
tation. The absence of transformation from muscular fetus is worsened by delay. Treatment consists of initial
arterioles to low-resistance, dilated vessels as in normal resuscitation and stabilization of the mother, treatment of
pregnancy and the lack of trophoblastic invasion of uterine the abruption, and recognition and management of compli-
vessels is thought to result in decreased placental blood flow cations. It is individualized based on the extent of the
and dysfunctional endothelial responses to vasoactive abruption, maternal and fetal reaction to this insult, and
substances. These abnormal placental vessels may predis- gestational age of the fetus. Maternal resuscitation and
pose to ischaemia and rupture of involved vessels, thus treatment of hypovolaemic shock are a subject of a review
causing placental abruption. in its own right, and will not be discussed further. For the
Placental abruption is seen more often in gestational purpose of management or abruption, Sher and Statland
hypertensive disease, advanced maternal age, increasing divided placental abruption into three degrees of severity.
parity, the presence of multiple gestations, polyhydramnios, These are mild (grade 1): not recognized clinically before
chorioamnionitis, prolonged rupture of membranes, trauma, delivery and usually diagnosed by the presence of a
and possibly thrombophilias. Potential preventable risk retroplacental clot; moderate (grade 2): intermediate, the
factors include maternal cocaine and tobacco use. Unex- classical signs of abruption are present but the fetus is
plained elevated maternal serum alpha-fetoprotein (MSAFP) still alive; and severe (grade 3): the fetus is dead and
levels in the second trimester is associated with pregnancy coagulopathy may be present.
complications such as placental abruption. There are three practical options for management:

Clinical presentation  Expectant: in the hope that the pregnancy will continue
 Immediate caesarean section
The diagnosis of placenta abruption is made clinically and  Rupture the membranes and aim at vaginal delivery
then confirmed by evaluation of the placenta after delivery.
It presents classically with vaginal bleeding, abdominal pain, In mild placental abruption, the bleeding may stop and
uterine contractions and tenderness. On clinical examina- the symptoms gradually resolve with satisfactory fetal
tion, the uterus is irritable, with increased baseline tone. monitoring and the patient can often be managed as an
There may be evidence of fetal distress. In severe cases, the outpatient. The management of moderate or severe
mother may show cardiovascular decompensation with placental abruption is resuscitation, delivery of the fetus
evidence of hypovolaemia. The fetal heart may be absent, and observation for and correction of any coagulation defect
and there is a serious risk of development of coagulopathy in that arises. This requires management in the labour ward
the mother due to consumption of clotting factors. The with intensive monitoring of both mother and fetus. A trial
clinical signs of blood loss are out of proportion to the of labour and vaginal delivery is recommended whenever
amount of vaginal bleeding. Ultrasound is an insensitive and tolerated by the maternal–fetal pair. Labour is usually rapid
unreliable tool for detecting or excluding placental abrup- and progress should be monitored with continuous fetal
tion, as negative sonographic findings are common with heart rate assessment. If fetal distress is present then
clinically significant abruptions. The diagnosis may be delivery should be expedited in the form of Caesarean
confirmed postpartum on gross examination of the placenta, section.
which reveals a clot and/or depression in the maternal Major abruption should be regarded as an emergency,
surface, known as a delle. requiring multidisciplinary input from the obstetrician,
 ARTICLE IN PRESS
Antepartum haemorrhage 81

anaesthetist and haematologist. A fulminant maternal DIC development of placenta praevia include increasing mater-
can ensue within hours of a complete abruption and delivery nal parity, advancing maternal age, increasing placental size
should be effected, as it is the only means with which to halt (multiple pregnancy), endometrial damage (previous dilata-
the DIC. Replacement of blood and its components should tion and curettage), previous Caesarean section, uterine
begin before surgery. Abruption also places the patient at scars and pathology (previous myomectomy or endometri-
risk of severe postpartum haemorrhage. This is as a result of tis), placental pathology (marginal cord insertions and
a combination of uterine atony and coagulation failure. succenturiate lobes), previous placental praevia, and
Invasive monitoring with arterial lines and central venous curiously, cigarette smoking.
access may be necessary, and patients are best treated in
the high-dependency unit. Urine output should be closely
monitored, as renal failure is a potential complication.
Clinical presentation and diagnosis
Multiple studies have shown expectant management with
or without tocolytics to be safe and effective in a select Most women in the UK will have a routine scan at 21–23
population of patients with preterm placental abruption. In weeks (anomaly scan). The placenta will be low-lying in
some observational studies, tocolysis allowed a median some, necessitating a repeat scan later in pregnancy,
delay of delivery of several days without increasing neonatal typically at 34–36 weeks.
or maternal morbidity, including the need for transfusion or Women classically present with minor degrees of painless
delivery by Caesarean section. However, in the absence of vaginal bleeding in the absence of labour pains. The bleeds
randomized controlled trials, the benefits of tocolysis tend to occur due to the formation of the lower uterine
remain uncertain. segment. Fetal malpresentation or unstable lie is found in
one-third of cases and many cases of placenta praevia do not
bleed until the onset of labour. The diagnosis of placental
Placenta praevia praevia is most commonly made on ultrasound examination.
Up to 26% of placentas are found to be low lying on
Placenta praevia is defined as a placenta that lies wholly or ultrasound examination in the early second trimester.
partly within the lower uterine segment. The prevalence of Several studies have demonstrated that unless the placental
clinically evident placenta praevia at term is estimated to edge is at least reaching the internal cervical os at mid-
be approximately 4 or 5 per 1000 pregnancies. pregnancy, placenta praevia at term will not be encoun-
tered.
Classification Transvaginal ultrasound is safe in the presence of
placenta praevia, and is more accurate than transabdominal
ultrasound in locating the placental edge. Ultrasound has
Classification of placenta praevia is important in making
been used to observe and document the phenomenon of
management decisions because the incidence of morbidity
placental migration from the lower uterine segment. It is
and mortality in the fetus and mother increases as the grade
thought that this process is not a true migration of placental
increases. Classically, placenta praevia is divided in four
tissue but, rather, a degeneration of the peripheral
types or grades (Table 1). Types I and II are regarded as
placental tissue that receives a suboptimal vascular supply
minor, and types III and IV as major degrees of placenta
and has slow placental growth in better perfused uterine
praevia. Care must be taken not to confuse these grades
areas at the same time, so-called placental trophotropism.
with grades of placental maturity.
None of the cases presented with placenta praevia at
The classification is difficult to use in practice, because
term, unless the placental edge overlapped the internal os
the definition of lower uterine segment is more conceptual
at least by 1 cm at the mid-trimester scan. There was a
than anatomical. In any case, with the availability of
minimal placental migration rate of 0.1 mm/week in this
ultrasound, this classification has become obsolete. Cur-
group. In contrast, cases where the placenta eventually
rently, the condition is most commonly diagnosed on
migrated away from the internal os showed a mean rate of
ultrasound examination. Ultrasound remains the method of
migration of 4.1 mm/week. Placental edge overlapping the
choice because it is relatively cheap and readily available.
internal os at the mid-trimester scan, and a thick placental
edge (where the angle between the placental edge and the
Aetiology and associated factors uterine wall is o1351) are known to be associated with
reduced likelihood of placental migration. In addition, those
Placenta praevia is caused by implantation of the blastocyst cases, where the placentas failed to migrate were asso-
low in the uterine cavity. Factors associated with the ciated with increased rates of interventional Caesarean

Table 1 Classification of placenta praevia.

Type I The placenta encroaches into the lower uterine segment and lies within 5 cm of the internal cervical os
Type II The placenta reaches the cervical os but does not cover it
Type III The placenta covers the cervical os but the placental site asymmetric with most of the placenta being on one
side of the cervical os
Type IV The placenta is centrally located over the cervical os
 ARTICLE IN PRESS
82 N. Ngeh, A. Bhide

delivery and manual placental removal, and a higher operation theatre with known major placenta praevia
prevalence of placenta accreta. should be attended by an experienced obstetrician and
anaesthetist, with consultant presence available, especially
if these women have previous uterine scars, an anterior
Management placenta or are suspected to be associated with placenta
accreta. Four units of cross-matched blood should be kept
The management of placenta praevia depends upon clinical ready, even if the mother has never experienced vaginal
presentation, severity of bleeding and degree of praevia. bleeding. Delivery of women with placenta praevia should
Currently, the diagnosis of placenta praevia is made using not be planned in units where blood transfusion facilities are
ultrasound. Most cases presenting with APH would already unavailable. The choice of anaesthetic technique for
be known to have a low-lying placenta. Those cases, in Caesarean sections is usually made by the anaesthetist
which the placenta was low-lying at the time of routine conducting the procedure.
anomaly scan should receive a repeat ultrasound scan at 36
weeks to check placental location. Some of these cases will Placenta accreta
present with antepartum bleeding. Initial haemorrhages,
referred to as ‘warning haemorrhages’ are often small and
Although placenta accreta is very rare (0.004%) in women
tend to stop spontaneously. Delivery may be needed for
with a normally situated placenta, it occurred in 9.3% of
severe, intractable or recurrent bleeding. Fetal morbidity is
women with placenta praevia according to data from
associated with iatrogenic prematurity.
Southern California. Ultrasound features of placenta accreta
In the report of confidential enquiries into maternal
in second and third trimesters include visualization of
mortality over 2000–2002 in the UK (‘Why mothers die
irregular vascular sinuses with turbulent flow, abnormalities
2000–2002’), there were 17 maternal deaths due to
of the bladder wall on ultrasound inspection and possibly
haemorrhage. Four out of these 17 deaths were due to
myometrial thickness of less than 1 mm. Absence of the
placenta praevia.
sono-luscent space between myometrium and the placenta
Controversy surrounds the antepartum management of
is not a reliable sign. Colour Doppler and magnetic
those cases found to have a low-placenta at the anomaly
resonance imaging are not yet completely sensitive and
scan, particularly the ones who have never had antepartum
specific tests for the diagnosis of placenta accreta.
bleeding. Moreover, many women will be admitted with
When a probability of placenta accreta is raised, multi-
vaginal bleeding due to known low-lying placenta, but the
disciplinary input involving the patient and the family, the
bleeding would stop spontaneously, and not recur for several
anaesthetist, obstetrician and the sonographer should be
days. Current guidelines by the Royal College of Obstetri-
arranged. Advance planning should be made for manage-
cians and Gynaecologists (RCOG) recommend that such
ment of delivery. The options are subsequent hysterectomy
women be kept admitted to the hospital. This advice is
after delivery or leaving the placenta in-situ in order to
based on a small randomized trial that showed no difference
reduce surgical complications and blood loss. Of the four
between inpatient and outpatient management of cases
maternal deaths due to placenta praevia in the triennium
of placenta praevia. However, the authors of the RCOG
2000–2002, all had at least on previous Caesarean, and three
guideline felt that uncommon, but potentially serious,
had a history of placenta accreta.
maternal complications are unlikely to come to light with
a trial with small numbers. The recommendation for in-
hospital management is not based on the presence of Bleeding of uncertain origin
evidence of benefit of hospitalization, but due to absence of
large good quality trials. The exact cause of bleeding in late pregnancy is unknown in
Traditionally, Caesarean section has been the recom- about half of cases. The woman typically presents with
mended mode of delivery for major placenta praevia (type painless vaginal bleeding without ultrasound evidence of
III and IV), whereas for minor praevia (type I and II) an placenta praevia. Placenta praevia can be excluded by an
attempt at vaginal delivery was deemed appropriate. Until ultrasound scan, but the diagnosis of placental abruption is
recently, no evidence-based protocol was available for based on clinical signs and symptoms, and is difficult to
management of delivery guided by the findings of the confirm in mild cases. Approximately 15% of women with
ultrasound scan. We reported that when the placental edge unexplained APH will go into spontaneous labour within 2
was within 1 cm of the internal cervical os within 2 weeks of weeks of the initial haemorrhage. In the majority of cases,
delivery, all patients required a Caesarean delivery due to the bleeding is mild and settles spontaneously. Further
bleeding. We proposed that cases with placental edge to management will either be expectant or delivery will be
internal os distance of less than 2 cm be referred to as major expedited. If pregnancy is beyond 37 weeks gestation and
placenta praevia. An elective Caesarean section should be the bleeding is recurrent or associated with fetal growth
recommended. In contrast, if the placental edge to internal retardation, labour induction is the management of choice.
cervical os distance was 2–3.5 cm at the last ultrasound scan If episodes of bleeding are recurrent and significant, there
within 2 weeks of delivery, the likelihood of achieving a may be a need for immediate delivery even if the gestation
vaginal delivery was at least 60%. It is recommended that is below 37 weeks.
these cases be still referred to as low-lying placenta, If a policy of expectant management is adopted, fetal
because the risk of postpartum haemorrhage remains high well-being should be monitored. Once the bleeding has
in this group. An attempt at vaginal delivery is appropriate. settled and the woman has been observed as an inpatient for
RCOG guidelines recommended that any women going to the 24–48 h, it may be considered safe to allow her to be
 ARTICLE IN PRESS
Antepartum haemorrhage 83

managed as an outpatient. If the gestational age is below  Unless the placental edge overlaps the internal os
34–36 weeks, antenatal steroids should be administered in by at least 1.0 cm at 21–23 weeks scan, placenta
view of the risk of preterm delivery. praevia at term will not be encountered. A repeat
In a small proportion of cases where placenta praevia and scan at 34–36 weeks should be organized.
placental abruption have been excluded, a cause may still  Caesarean section for placenta praevia should
be found. They include ‘show’, cervicitis, trauma, vulval involve the most senior available staff in the
varicosities, genital tumours, haematuria, genital infections anaesthetic and obstetric service. At least 4 units
and vasa previa. Many of these conditions are evident on the of blood should be cross-matched.
initial speculum examination.  The possibility of placenta accreta should be kept in
mind in cases of placenta praevia. Absence of an
echo-luscent line behind the placenta is not a
Vasa praevia
reliable sign. Sonographic visualization of irregular
sinuses with turbulent flow in the placenta is the
Vasa praevia is the presence of unsupported fetal vessels most reliable sign.
below the fetal presenting part, where the cord insertion is  Antepartum identification of vasa praevia leads to
velamentous. It is rare, but consequences are disastrous, if significant improvement in perinatal mortality.
not prenatally diagnosed. Vasa praevia has an incidence of  A multi-disciplinary massive obstetric haemorrhage
approximately one per 6000 deliveries. Classically, vaginal protocol should be available in all units. It should be
bleeding follows amniotomy with subsequent fetal brady- regularly updated and rehearsed in conjunction
cardia suggests vasa praevia. The diagnosis of this condition with the blood bank.
before these events is difficult but the experienced observer
may be able to feel vessels on digital examination below the
presenting part. A speculum examination may also reveal
the vessels on inspection. An Apt test on the blood can be
performed to demonstrate the presence of fetal blood.
Immediate Caesarean delivery is needed if fetal blood is
confirmed to be present in the vaginal bleeding. Further Reading
Oyelese et al. demonstrated the importance of prenatal
diagnosis. In the group where prenatal diagnosis had been 1. Placenta praevia: diagnosis and management. Clinical green top
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Guideline No. 27, January 2000.
the diagnosis had not been made before birth. Echogenic
2. Bhide A, Thilaganathan B. Recent advances in the management
parallel or circular lines near the cervix representing the of placenta praevia. Curr Opin Obstet Gynecol 2004;16:
umbilical cord, seen by grey-scale ultrasound, should raise 447–51.
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can be confirmed by Doppler and endovaginal ultrasound abruption and adverse perinatal outcomes. JAMA 1999;282:
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 Diagnosis of placental abruption is clinical, whereas 15–23.
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