O&G · Antenatal care — obstetric haemorrhage
Antepartum haemorrhage: undifferentiated approach
Also known as APH · Antepartum hemorrhage · Bleeding in late pregnancy · Third trimester bleeding · Antepartum haemorrhage of unknown origin · APHUO
Exam-exhaustive FRANZCOG reference on undifferentiated antepartum haemorrhage — the RCOG Green-top 63 severity grades, the causes with their discriminating features, the first-fifteen-minute resuscitation, why the digital vaginal examination is forbidden, anti-D and Kleihauer with ANZ doses, fetal assessment, and disposition by gestation and severity. RANZCOG-primary, globally tagged to MRCOG and ABOG.
Checked against its sources on 3 Sept 2026
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Target exams
Red flags
- A digital vaginal examination before the placental site is known — this is the one action that turns a bleed into a catastrophe
- Shock out of proportion to the visible blood — the concealed abruption is filling the uterus, not the pad
- A normal ultrasound used to exclude abruption — the scan rules the placenta in, it never rules abruption out
- Bleeding at rupture of membranes with immediate fetal bradycardia — vasa praevia, and that fetus has minutes
- An RhD-negative woman discharged without anti-D and a Kleihauer after any bleed past 20 weeks
- A term-range fibrinogen reported as normal — in pregnancy that value is already a warning
It is 23:40 and the triage midwife hands you a phone: 31 weeks, second bleed this week, "not much, maybe a cupful". You will make four decisions in the next fifteen minutes — is she stable, is the baby alive and coping, what is the cause, and does this pregnancy end tonight. The bleeding you can see is the least informative thing in the room.[3][18]
Overview and definition
Antepartum haemorrhage means bleeding from or into the genital tract after 20 weeks of pregnancy and before the baby is born. RCOG Green-top 63 sets its boundary at 24+0 weeks; ANZ maternity services and most Australian and New Zealand jurisdictional guidelines use 20 weeks, which matches the point at which fetomaternal haemorrhage quantification becomes mandatory in RhD-negative women. Below that line you are talking about threatened miscarriage; above it, you are talking about a fetus that can be delivered.[9][10]
Two numbers frame the problem. APH complicates roughly 3 to 5% of pregnancies, and it drags preterm birth, growth restriction, perinatal death and postpartum haemorrhage along behind it whatever the cause turns out to be.[2][18]
References21ShowHide
- [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]Bhandari S, Raja EA, Shetty A, Bhattacharya S Maternal and perinatal consequences of antepartum haemorrhage of unknown origin BJOG, 2014.PMID 24125550
- [3]Oyelese Y, Ananth CV Placental abruption Obstet Gynecol, 2006.PMID 17012465
- [4]Brandt JS, Ananth CV Placental abruption at near-term and term gestations: pathophysiology, epidemiology, diagnosis, and management Am J Obstet Gynecol, 2023.PMID 37164498
- [5]Silver RM Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta Obstet Gynecol, 2015.PMID 26244528
- [6]Sinkey RG, Odibo AO, Dashe JS #37: Diagnosis and management of vasa previa Am J Obstet Gynecol, 2015.PMID 26292048
- [7]Oyelese Y, Javinani A, Gudanowski B, et al. Vasa previa in singleton pregnancies: diagnosis and clinical management based on an international expert consensus Am J Obstet Gynecol, 2024.PMID 38494071
- [8]Oyelese Y, Catanzarite V, Prefumo F, et al. Vasa previa: the impact of prenatal diagnosis on outcomes Obstet Gynecol, 2004.PMID 15121568
- [9]Qureshi H, Massey E, Kirwan D, et al. BCSH guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn Transfus Med, 2014.PMID 25121158
- [10]Porter L, Hazell M, Eggington J, et al. BSH guideline for the estimation of fetomaternal haemorrhage Transfus Med, 2026.PMID 42286430
- [11]McGoldrick E, Stewart F, Parker R, Dalziel SR Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth Cochrane Database Syst Rev, 2020.PMID 33368142
- [12]Gyamfi-Bannerman C, Thom EA, Blackwell SC, et al. Antenatal Betamethasone for Women at Risk for Late Preterm Delivery N Engl J Med, 2016.PMID 26842679
- [13]Shepherd ES, Goldsmith S, Doyle LW, et al. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus Cochrane Database Syst Rev, 2024.PMID 38726883
- [14]Erez O, Mastrolia SA, Thachil J Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management Am J Obstet Gynecol, 2015.PMID 25840271
- [15]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
- [16]Glantz C, Purnell L Clinical utility of sonography in the diagnosis and treatment of placental abruption J Ultrasound Med, 2002.PMID 12164566
- [17]Treffers A, Reynoldson O, Beckmann M Risk Factors for Antepartum Haemorrhage in Women With Placenta Praevia Aust N Z J Obstet Gynaecol, 2025.PMID 39744804
- [18]Kitil GW, Shibabaw AA, Getachew E, et al. Fetal outcomes and associated factors of antepartum hemorrhage in Ethiopia: A systematic review and meta-analysis PLoS One, 2025.PMID 40036274
- [19]Neilson JP Interventions for suspected placenta praevia Cochrane Database Syst Rev, 2003.PMID 12804418
- [20]Bonanni G, Lopez MC, Tarchi SM, et al. Postpartum Hemorrhage in Patients With a Low-Lying Placenta: A Systematic Review and Meta-analysis Obstet Gynecol, 2025.PMID 40472373
- [21]Rouse DJ, Hirtz DG, Thom E, et al. A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy N Engl J Med, 2008.PMID 18753646