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.
Checked against its sources on 3 Sept 2026
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Target exams
Red flags
- Painless, bright-red, recurrent third-trimester bleeding is placenta praevia until imaging proves otherwise — NEVER perform a digital vaginal examination until praevia is excluded; speculum only
- A rigid, woody, tender uterus with severe constant pain and shock out of proportion to the visible dark bleed is a concealed placental abruption — the fibrinogen under 2 g/L heralds DIC
- Bleeding at the moment of rupture of membranes with fetal bradycardia or a sinusoidal CTG in a haemodynamically normal mother is vasa praevia — the fetus is exsanguinating; immediate Caesarean section
- Every Rh-negative woman with an APH needs anti-D immunoglobulin within 72 hours, dosed by the Kleihauer-Betke quantification of fetomaternal haemorrhage
- Abruption is the commonest cause of pathological DIC in pregnancy — send coagulation and fibrinogen early and repeat them
- Cessation of painful contractions with sudden severe constant pain, loss of fetal station and maternal shock is uterine rupture through a previous scar — immediate laparotomy
Meet the patient
A 34-year-old woman at 34 weeks, with two previous Caesareans, is brought in by ambulance after a sudden, painless, bright-red vaginal bleed that has soaked her clothes. She is pale and cold at 86/52 with a heart rate of 124; the abdomen is soft, relaxed and non-tender and the presenting part is high. The registrar reaches for a glove to perform a vaginal examination. That single act — a digital examination before the placental site is known — is how a warning praevia bleed becomes a catastrophe, and praevia plus two previous scars is placenta accreta until proven otherwise.[1]
Two questions decide her next hour and every APH: what is the cause? (the four-fingerprint read) and where is the placenta? (ultrasound before any digital examination). Hold those two and the obstetric emergency becomes systematic.[1]
References11ShowHide
- [1]Jauniaux E, Bhide A, Hussein AM, et al. Placenta Praevia and Placenta Accreta Spectrum: Diagnosis and Management: Green-Top Guideline No. 27a. BJOG, 2026.PMID 42374711
- [2]Jauniaux E, Bartels HC, Afshar Y Placenta accreta spectrum in the 21st century: Challenging dogma and redefining disorder. PLoS Med, 2026.PMID 42284360
- [3]Wright GL, Friedman A, Ananth CV, Wen T Placental Abruption: Temporal Trends, Risk Factors, and Associated Adverse Maternal Outcomes. Am J Perinatol, 2026.PMID 40940025
- [4]Ruiter L, Kok N, Limpens J, et al. Incidence of and risk indicators for vasa praevia: a systematic review. BJOG, 2016.PMID 26694639
- [5]Ruiter L, Kok N, Limpens J, et al. Systematic review of accuracy of ultrasound in the diagnosis of vasa previa. Ultrasound Obstet Gynecol, 2015.PMID 25491755
- [6]Oyelese Y, Ananth CV Placental abruption. Obstet Gynecol, 2006.PMID 17012465
- [7]WOMAN Trial Collaborators Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet, 2017.PMID 28456509
- [8]Crowther CA, Hiller JE, Doyle LW, Haslam RR Effect of magnesium sulfate given for neuroprotection before preterm birth: a randomized controlled trial. JAMA, 2003.PMID 14645308
- [9]Roberts D, Brown J, Medley N, Dalziel SR Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev, 2017.PMID 28321847
- [10]Charbit B, Mandelbrot L, Samain E, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost, 2007.PMID 17087729
- [11]Ruano R, Mihulka O, Hombal A, et al. Fetoscopic Laser Ablation of Type II Vasa Previa-Case Report and Systematic Review. Prenat Diagn, 2025.PMID 41024316