ANTEPARTUM HAEMORRHAGE

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Antepartum Haemorrhage — Recognition & Management

Antepartum haemorrhage (APH) is bleeding from the genital tract in the second half of pregnancy, before delivery (exact gestational cut-off varies by textbook and region — commonly 20–28 weeks onward). The two major causes — placenta praevia and abruptio placentae — are managed very differently, so the first task is always to work out which pattern you're dealing with, and to do it without making things worse.

🩸 AT A GLANCE — TWO PATTERNS TO TELL APART

Placenta praevia: painless, bright-red bleeding, often recurrent; uterus soft and non-tender; fetal heart usually normal; malpresentation common

Abruptio placentae: painful bleeding, often dark; uterus tender, tense, or "woody hard"; fetal distress or demise common; bleeding may be partly or wholly concealed

Overall Severity

GREEN: spotting/minor bleed, mother and fetus stable, no red-flag features

AMBER: confirmed minor praevia or mild suspected abruption, stable — needs admission and close observation

RED: major bleed, haemodynamic instability, or fetal distress — obstetric emergency

📋 KEY RISK FACTORS

Placenta Praevia

Previous caesarean section or other uterine surgery

Multiparity, multiple pregnancy, previous praevia

Assisted reproduction, smoking, advanced maternal age

Abruptio Placentae

Hypertensive disorders / pre-eclampsia

Abdominal trauma, previous abruption

Smoking, cocaine use, sudden uterine decompression (e.g., after ruptured membranes with polyhydramnios)

🧭 INITIAL ASSESSMENT — DO IT IN THIS ORDER

1

Airway, breathing, circulation — maternal vitals first, always

2

Two large-bore IV lines; send FBC, group & crossmatch, coagulation profile

3

Ultrasound before any digital vaginal exam — confirm placental location

4

Continuous fetal monitoring (CTG) once the mother is stable

5

Assess uterine tone, tenderness, fetal lie and presentation

🚨 SIGNS OF MAJOR HAEMORRHAGE — ESCALATE NOW

Maternal tachycardia, hypotension, or signs of shock

Woody-hard, tender, tense uterus (suggests abruption)

Absent or abnormal fetal heart rate / fetal distress

Heavy, continuous, or rapidly increasing bleeding

Signs of coagulopathy — poor clotting, oozing from puncture sites

🧪 DIAGNOSTIC WORKUP

Ultrasound (transabdominal ± gentle transvaginal by an experienced operator) to localize the placenta — transvaginal scanning is safe and more accurate for praevia than commonly assumed

Ultrasound is insensitive for abruption — a normal scan does not exclude it; abruption remains a largely clinical diagnosis

CTG for ongoing fetal wellbeing once mother is stable

Kleihauer–Betke test if the mother is Rh-negative, to quantify fetomaternal haemorrhage

Coagulation profile when abruption is suspected — watch for evolving DIC

Golden rule: never perform a digital vaginal examination until placenta praevia has been excluded by imaging — it can trigger torrential, life-threatening bleeding.

🛠️ MANAGEMENT PRINCIPLES

Minor bleed, stable, preterm: admit for observation; give corticosteroids for fetal lung maturity if <34 weeks; avoid intercourse and vaginal examinations; plan elective caesarean at term for confirmed major praevia

Major bleed, maternal instability, or fetal distress: emergency caesarean delivery, regardless of gestation

Abruption with a live, distressed fetus: expedite emergency caesarean

Abruption with fetal demise: vaginal delivery is often preferred if the mother is stable — expedite delivery and actively manage coagulopathy

Resuscitate the mother first — a stable mother gives the fetus the best chance, even when the fetus is the visible concern.

Placenta Praevia

Placenta implanted low, covering or near the internal os

Painless, recurrent, bright-red bleeding

Abruptio Placentae

Premature separation of a normally-implanted placenta

Painful bleeding; may be partly concealed

Vasa Praevia

Fetal vessels run unprotected across/near the os

Rare but catastrophic for the fetus if vessels rupture — often at membrane rupture

Local / Other Causes

Cervical polyp, erosion, infection, or malignancy

"Show" of labour; a proportion remain unexplained

Golden Safety Rule

No PV Exam Before Imaging

0

DIGITAL VAGINAL EXAMS
BEFORE PLACENTA IS LOCALIZED

A digital examination performed before praevia is excluded can disrupt a low-lying placenta and provoke sudden, severe haemorrhage — this single rule prevents one of the most avoidable disasters in obstetrics.

Secure IV access and send blood for grouping & crossmatch early — even if the bleed looks minor at first

Give Anti-D immunoglobulin to every Rh-negative woman after any APH episode

Give corticosteroids if <34 weeks and immediate delivery is not required

Reassess frequently — bleeding, especially from abruption, can progress rapidly

Reminder: "minor" bleeding today does not guarantee a stable course tomorrow — admit, observe, and keep a low threshold to escalate.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary for structured teaching and triage; gestational-age cut-offs and management thresholds vary by protocol — follow local and institutional guidelines.