Clinical overview
Antepartum haemorrhage (APH) is bleeding from the genital tract from 24 weeks of gestation until the birth of the baby. It complicates roughly 3–5% of pregnancies (standard teaching) and is one of the great obstetric emergencies: it threatens the mother through exsanguination and disseminated intravascular coagulation (DIC), and the fetus through abruption-related hypoxia and the consequences of iatrogenic preterm birth. In South Africa, obstetric haemorrhage — antepartum and postpartum combined — sits among the leading direct causes of maternal death in every triennium of the Saving Mothers report (NCCEMD), and a large proportion of those deaths are judged avoidable: late recognition, under-resuscitation, delayed transfer between levels of care, and failure to deliver in time.
The registrar's task in APH is fundamentally one of simultaneous triage: decide in the first minutes whether this is a stable, minor "spotter" who can be investigated calmly, or a haemodynamically compromising bleed that demands resuscitation and delivery now. The two diagnoses that kill — placenta praevia and placental abruption — must be actively excluded or confirmed, and the single most important rule of APH is burned into every obstetric curriculum: never perform a digital vaginal examination until placenta praevia has been excluded, because you can provoke catastrophic haemorrhage. This chapter treats APH as the HOTS-level integrative problem it is — recognise, resuscitate, diagnose the cause, and deliver or expectantly manage by gestation, maternal stability and fetal condition. See also postpartum-haemorrhage, pre-eclampsia-and-hellp (abruption association) and shock-management.
Core knowledge
Definition and causes
Figure J7.1 — Antepartum haemorrhage cause map contrasting abruption, praevia/PAS, vasa praevia and local causes, with the central safety rule to avoid digital vaginal examination until praevia is excluded.
APH = bleeding from or into the genital tract from 24⁺⁰ weeks until delivery. Bleeding before 24 weeks is classed as threatened miscarriage or early-pregnancy bleeding. The causes are conventionally grouped:
- Placental causes (the dangerous two):
- Placenta praevia — placenta wholly or partly implanted in the lower uterine segment. RCOG (GTG 27a) now favours describing the placenta as low-lying when the placental edge is <20 mm from the internal os on transvaginal scan after 16 weeks, and praevia when it covers the os.
- Placental abruption — premature separation of a normally sited placenta.
- Vasa praevia — fetal vessels running through the membranes over the internal os, unsupported by placenta or cord (RCOG GTG 27b). Rare but lethal to the fetus: rupture causes fetal exsanguination, classically painless bleeding with acute fetal compromise at membrane rupture.
- Local / lower genital tract causes — cervical ectropion, cervicitis, cervical polyp, cervical carcinoma, vaginal trauma, and infection. These are common and benign-to-serious; cervical cancer must be considered in any unexplained APH (link to cervical-screening-sa).
- Uterine rupture — see uterine-rupture; bleeding may be revealed or concealed, with pain, fetal compromise and collapse.
- "Indeterminate" / unexplained APH — a large group where no cause is found; still associated with adverse outcome and warrants surveillance.
A "heavy show" (blood-stained mucus at the onset of labour) is physiological and is a diagnosis of exclusion, not a label to apply prematurely.
Placental abruption
Abruption is haemorrhage at the decidua–placenta interface. Bleeding may be revealed (tracks down and out through the cervix), concealed (retained behind the placenta — the abdomen distends, the uterus is tense, and the visible blood loss grossly underestimates true loss), or mixed. The cardinal feature is pain: a continuously painful, tense, "woody-hard" uterus, often with uterine irritability and a non-reassuring or absent fetal heart. Concealed abruption is the trap — a woman can be in hypovolaemic shock with DIC and only a trickle of external bleeding.
Risk factors (standard teaching): previous abruption (the strongest), hypertensive disorders and pre-eclampsia, abdominal trauma (including assault/GBV — relevant in the SA setting), smoking and cocaine use, polyhydramnios with sudden decompression, multiple pregnancy, advanced maternal age and multiparity, thrombophilia, and preterm prelabour rupture of membranes. Abruption is a leading cause of DIC in pregnancy because thromboplastin from the disrupted decidua enters the circulation.
Placenta praevia and the spectrum of accreta
Classically painless, causeless, recurrent fresh red bleeding, often with the fetal head high or a malpresentation because the placenta occupies the lower segment. Risk factors include previous caesarean section, previous praevia, advanced maternal age, multiparity, multiple pregnancy and assisted reproduction.
Crucially, praevia plus a previous caesarean scar raises the spectre of placenta accreta spectrum (PAS) — placenta accreta spectrum (accreta, increta, percreta) — which is a defining cause of massive obstetric haemorrhage and peripartum hysterectomy. RCOG GTG 27a stresses antenatal diagnosis by ultrasound (with MRI as an adjunct), planned delivery in a unit with surgical and transfusion capability, and a multidisciplinary "accreta pathway". The single most useful screening question is: is the placenta low AND is there a prior uterine scar? If yes, image deliberately for accreta.
Why APH harms the fetus
Acute blood loss and abruption reduce uteroplacental perfusion, causing hypoxia, acidaemia and, if severe, intrauterine death (link to placental-insufficiency-response and contractions-fetal-oxygenation). Recurrent or chronic low-grade bleeding is associated with growth restriction (see intrauterine-growth-restriction), oligohydramnios and preterm birth. Vasa praevia harms the fetus directly through loss of fetal blood.
Assessment
Assessment and resuscitation run in parallel, not in sequence. The first judgement is haemodynamic: is she stable or shocked? (See shock-management.)
Rapid history
- Onset, amount, colour of bleeding; relation to trauma, coitus, or rupture of membranes.
- Pain — its presence, character and constancy (abruption pain is continuous; labour pain is intermittent).
- Fetal movements (link to decreased-fetal-movements).
- Gestational age and the booking placental localisation — was a low-lying placenta already flagged at the anomaly scan? (link to antenatal-booking).
- Obstetric history — previous caesareans/uterine surgery (accreta risk), previous abruption or praevia.
- Risk factors — hypertension, smoking, substance use, trauma/assault.
- Rhesus status — every Rh-negative woman with APH may need anti-D (link to rh-isoimmunisation).
Examination
- Maternal vitals: pulse, BP, respiratory rate, capillary refill, conscious level. Remember young, healthy pregnant women compensate and maintain BP until late — tachycardia and a narrowing pulse pressure precede hypotension. Quantify visible loss but distrust it (concealed abruption).
- Abdomen: fundal height, tenderness, tone ("woody-hard" = abruption), contractions, fetal lie/presentation, and the fetal heart.
- Speculum examination is permissible and useful (to see local causes, assess the cervix and amount of bleeding) only once praevia is excluded by ultrasound and the woman is stable.
- DIGITAL VAGINAL EXAMINATION IS CONTRAINDICATED until placenta praevia is excluded. This is the central safety rule of APH — a finger through a praevia can precipitate torrential bleeding.
Investigations
- Bedside: continuous fetal monitoring / CTG appropriate to gestation (link to ctg-interpretation and fetal-monitoring-methods).
- Bloods: FBC, group and crossmatch (at least 2–4 units in significant bleeding), coagulation screen (PT/aPTT) and fibrinogen — a falling fibrinogen is an early and sensitive marker of abruption-related DIC and predicts severity. U&E and a Kleihauer–Betke test in Rh-negative women to quantify fetomaternal haemorrhage and titrate anti-D dose.
- Ultrasound: confirms placental site (praevia / low-lying) and is the test that "unlocks" the vaginal examination. Ultrasound is poor at diagnosing abruption — a normal scan does NOT exclude it, and abruption remains a clinical diagnosis. Scan also assesses fetal growth, presentation, liquor and viability, and screens for accreta where a scar + low placenta coexist.
Management
Figure J7.2 — APH emergency drill showing parallel resuscitation, blood-bank activation, investigation, TXA, monitoring and delivery-or-transfer decisions.
APH EMERGENCY DRILL — the shocked / actively bleeding woman
- CALL FOR HELP — shout for senior obstetric, anaesthetic and theatre/ midwifery help; activate the major obstetric haemorrhage protocol and alert the blood bank.
- AIRWAY / BREATHING — high-flow oxygen; left lateral tilt / manual uterine displacement to relieve aortocaval compression.
- CIRCULATION — two large-bore IV cannulae (14–16 G); draw FBC, crossmatch (≥4 units), coagulation + fibrinogen, U&E, Kleihauer. Begin warmed crystalloid resuscitation and activate massive transfusion — give blood early; use O-negative / group-specific if crossmatched blood is not yet available. Aim to replace red cells, plasma (FFP) and platelets, guided by near-patient testing where available; keep fibrinogen >2 g/L, platelets and warmth (avoid the lethal triad of hypothermia, acidosis, coagulopathy).
- TRANEXAMIC ACID — has an established mortality benefit in established obstetric haemorrhage (WOMAN trial); give early per local protocol once significant bleeding is confirmed.
- MONITOR — continuous maternal observations, urine output (catheterise), and continuous fetal monitoring if the fetus is alive and delivery is not already proceeding.
- DELIVER — if the mother is unstable, or the fetus is alive and compromised, expedite delivery: emergency caesarean for the compromised live fetus; consider vaginal delivery only when birth is imminent and the fetus has died with a stable mother. Anticipate and prevent postpartum haemorrhage — abruption and praevia both predispose to PPH (link to postpartum-haemorrhage).
- TRANSFER — at a district hospital, stabilise and arrange urgent transfer to a regional/tertiary unit with theatre, blood and neonatal care only if the mother is stable enough to move; if she is exsanguinating, deliver where she is rather than transferring an unstable patient.
Principles by cause and gestation
Figure J7.3 — Cause-specific APH management dashboard using maternal stability, fetal condition and gestational age to choose urgent delivery, planned caesarean, expectant care, transfer or local-cause treatment.
The decision pivots on three axes: maternal stability, fetal condition, and gestational age. An unstable mother or a compromised live fetus mandates delivery regardless of gestation. A stable mother with a stable preterm fetus may be managed expectantly to gain maturity.
Placental abruption
- Major abruption with maternal compromise or non-reassuring/absent fetal heart → resuscitate and deliver immediately (caesarean if the fetus is alive and vaginal birth not imminent). If the fetus has died, vaginal delivery is often achievable and preferable provided the mother is stable, because labour is frequently rapid; manage coagulopathy aggressively throughout.
- Minor abruption, preterm, stable mother and fetus → admit, monitor closely, give antenatal corticosteroids between 24⁺⁰ and ~34 weeks (RCOG GTG 74) for fetal lung maturity, consider magnesium sulphate for fetal neuroprotection at early gestations, and individualise timing of delivery. Anti-D for Rh-negative women.
Placenta praevia
- Stable, preterm, controlled bleeding → inpatient expectant management with corticosteroids, crossmatched blood available, and a clear plan; many units keep women with significant praevia bleeds in hospital. Avoid PV examination and intercourse.
- Planned delivery → elective caesarean is the route for major praevia, typically in the late preterm to early term window (RCOG GTG 27a guides timing around 36–37 weeks for praevia and earlier — ~35–36⁺⁶ — where accreta is suspected; confirm exact local timing against the current guideline). Deliver in a unit with senior surgical, anaesthetic, transfusion and neonatal support; consultant presence and a PAS pathway if accreta is suspected.
Vasa praevia
- If diagnosed antenatally, plan elective caesarean before labour (around the preterm–term border, with steroids). If it presents acutely with membrane rupture and fetal bradycardia, it is a category-1 caesarean — minutes count for the fetus.
Local causes — treat the lesion: cervicitis/STI per SA STI guidelines, refer suspicious cervical lesions urgently for colposcopy/biopsy (do not assume an ectropion).
South African context
- The NDoH National Integrated Maternal and Perinatal Care Guideline, 5th ed (2024) is the SA source of truth; it structures APH management around the levels of care — recognise and resuscitate at the clinic/CHC, refer appropriately, and deliver major praevia/accreta at facilities with theatre, blood and neonatal capacity. Know your own facility's blood-bank turnaround and the realistic transfer time to the next level — these constraints shape whether you transfer a stabilised woman or deliver on site.
- Blood products can be scarce in district hospitals; this raises the threshold for early activation of the emergency-blood protocol and for not moving an unstable patient.
- HIV is highly prevalent; ensure ART continuity (TLD) peripartum and follow PMTCT and infection-control practice during operative delivery. APH itself does not change the antiretroviral plan, but anaemia of chronic disease and the population burden mean baseline reserves may be lower.
- Anti-D for Rh-negative women, dosed to the Kleihauer result, per the SA EML / NDoH guidance (link to rh-isoimmunisation).
- Saving Mothers repeatedly identifies substandard care in haemorrhage deaths — delays in recognition, transfusion and surgery. The registrar's contribution to avoidability is early senior involvement and decisive delivery.
Red flags / pitfalls
- Performing a digital VE before excluding praevia — the single most dangerous error in APH. Speculum only, and only once stable and praevia excluded.
- Trusting the visible blood loss — concealed abruption hides litres behind the placenta. Judge by maternal physiology (tachycardia, pulse pressure, conscious level), uterine tone and fetal status, not by what is on the pad.
- Mistaking compensation for stability — young pregnant women hold their BP until they crash. A persistently rising heart rate is an ominous sign; do not wait for hypotension to act.
- Forgetting coagulopathy — abruption causes DIC. Send fibrinogen early, repeat it, and replace clotting factors before the patient is frankly coagulopathic.
- Forgetting the next bleed (PPH) — both praevia and abruption strongly predispose to postpartum haemorrhage and, with accreta, to hysterectomy. Have uterotonics, TXA, extra blood and a senior surgeon ready before delivery (link to postpartum-haemorrhage).
- Missing accreta — a low placenta over a previous caesarean scar is accreta until proven otherwise; failing to image and plan for it converts an elective procedure into an unplanned massive haemorrhage.
- Omitting anti-D in a Rh-negative woman after any APH.
- Transferring an unstable woman — stabilise and deliver where you are if she is exsanguinating; do not send a shocked patient down a long road.
- Forgetting steroids and neuroprotection in a stable preterm bleed — and, conversely, delaying delivery to "complete steroids" in an unstable patient.
- Anchoring on a benign cause — calling it a "show" or an ectropion and missing early abruption or a cervical malignancy.
Evidence anchors
- RCOG Green-top Guideline No. 63 — Antepartum Haemorrhage — the principal reference for definitions, assessment and management of APH.
- RCOG Green-top Guideline No. 27a — Placenta Praevia and Placenta Accreta Spectrum, and No. 27b — Vasa Praevia — diagnosis, surveillance, timing and the multidisciplinary accreta pathway.
- RCOG Green-top Guideline No. 52 — Prevention and Management of Postpartum Haemorrhage — for the anticipated PPH that follows APH, and massive transfusion principles; RCOG GTG 47 — Blood Transfusions in Obstetrics.
- WOMAN trial (Lancet 2017) — tranexamic acid 1 g IV given early in obstetric haemorrhage reduces death due to bleeding; underpins early TXA in established APH/ PPH.
- RCOG GTG 74 — Antenatal Corticosteroids — fetal lung maturation in anticipated preterm delivery.
- NICE NG133 — Hypertension in Pregnancy — relevant to the pre-eclampsia / abruption association and to magnesium sulphate use.
- South African NDoH National Integrated Maternal and Perinatal Care Guideline, (NDoH, 2024) — the SA source of truth: levels of care, referral pathways, emergency-blood and anti-D practice.
- Saving Mothers (NCCEMD) triennial report — obstetric haemorrhage as a leading avoidable cause of SA maternal death; recurrent themes of late recognition, under-transfusion and delayed delivery.
- South African EML (Hospital Level, Adults) and South African HIV/ART Consolidated Guidelines (2023, TLD) — for anti-D, uterotonics, transfusion practice and peripartum ART continuity.
Specific praevia/accreta delivery-timing windows (≈36–37 weeks; earlier for accreta), the "fibrinogen >2 g/L" target, the <20 mm transvaginal cut-off for "low-lying", and exact transfusion ratios should be confirmed against the current RCOG GTG 27a/63/52 and the NDoH 5th-edition Maternity Guideline at the point of care, as thresholds are periodically revised.