EM · Obstetric, gynaecological and sexual-health emergencies

Antepartum haemorrhage

Also known as APH · Antepartum bleed · Third-trimester bleeding · Placenta praevia bleed · Placental abruption

Antepartum haemorrhage (APH) is bleeding from the genital tract from 24 weeks of gestation until the onset of labour or birth. The four major causes are placenta praevia (painless, bright-red, recurrent bleeding from a low-lying placenta), placental abruption (painful, dark bleeding with a rigid woody tender uterus and concealed or revealed retroplacental haemorrhage), vasa praevia (fetal bleeding at rupture of membranes with fetal distress and a stable mother), and uterine rupture. The physiological show and cervical or vaginal lesions are the benign mimics. Management is simultaneous maternal and fetal resuscitation — ABCDE, two large-bore cannulae, an early crossmatch, coagulation and fibrinogen, continuous CTG, Kleihauer-Betke with anti-D for the Rh-negative mother, speculum (never digital) examination until praevia is excluded, early obstetric referral, and Caesarean section for praevia covering the os. ACEM-primary, globally tagged.