Antepartum Haemorrhage — Viva

Q1: Definition and classification (2 min) ^[1]

"Define antepartum haemorrhage and give the major causes."

• Definition (RCOG Green-top 63): bleeding from or into the genital tract from 24+0 weeks of pregnancy and prior to the birth of the baby. Below 24+0 it is classified as threatened miscarriage.
• Causes (PAVE mnemonic):
  • Praevia — placenta over/within 2 cm of internal os
  • Abruption — premature separation of normally-sited placenta
  • Vasa praevia — fetal vessels across the os
  • Else — uterine rupture, placenta accreta spectrum, local cervical/vaginal causes, unexplained APH (the largest single group)
• By severity (GTG 63): spotting (staining on underwear); minor (<50 mL that has settled); major (50–1000 mL, no shock); massive (>1000 mL and/or shock).

Q2: Praevia vs abruption — the discriminator (3 min)

"Distinguish placenta praevia from placental abruption at the bedside."

• Praevia: painless, bright-red, recurrent bleeding; soft, relaxed, non-tender uterus; lie often transverse/oblique; head not engaged; fetal heart usually normal; risks: previous LSCS (dose-response and accreta), multiparity, age, multiple, IVF, smoking. Diagnose by transvaginal ultrasound. NEVER digital VE until praevia excluded. Major praevia → planned caesarean before labour (timing per Green-top 27a/unit protocol).
• Abruption: painful (constant severe abdominal/back pain); tense, tender, woody-hard uterus with hypertonus; dark or concealed bleeding; fetal distress or intrauterine death; shock disproportionate to visible loss; risks: placenta previa AOR 7.31, previous abruption AOR 2.72 (Chen); after two prior abruptions recurrence 19–25% (GTG 63); trauma, smoking, cocaine. Clinical diagnosis — ultrasound misses about three-quarters of cases (GTG 63). Resuscitate and deliver.
• The 2 cm rule: placental edge within 2 cm of os at term = caesarean; more than 2 cm = may trial vaginal.

Q3: Vasa praevia (2 min)

"What is vasa praevia, and how do you recognise it?"

• Fetal vessels running unprotected through the membranes across the internal os (velamentous cord insertion or bilobed placenta). Risks: low placenta, bilobed/succenturiate placenta, IVF pregnancy.
• Presentation: painless bleeding at rupture of membranes + sudden fetal compromise (classically a sinusoidal CTG or bradycardia); the mother is haemodynamically normal because it is fetal blood being lost.
• Diagnosis: transvaginal ultrasound with colour Doppler (fetal vessels across the os, arterial waveform matching fetal heart). Apt test on vaginal blood (alkali denaturation — fetal Hb resists and stays pink = fetal blood).
• Management: planned caesarean before membrane rupture (all 58 prenatally diagnosed Australian cases were delivered by caesarean with no perinatal deaths); emergency caesarean if presenting with acute bleeding at ROM. Pooled survival 98.6% with prenatal diagnosis vs 72.1% without (Zhang); undiagnosed case fatality 40% in the Australian cohort.

Q4: Resuscitation bundle (2 min) ^[1]

"Walk me through the immediate management of a major APH."

• RAPID mnemonic (numbers from GTG 63 / named trials):
  • Resuscitate — ABC, oxygen 10–15 L/min if massive, two 14-gauge cannulae, left lateral tilt; until blood arrives up to 3.5 L warmed crystalloid (Hartmann’s 2 L ± colloid 1–2 L)
  • Alert — senior obstetrician, anaesthetist, haematology, neonatal; activate massive haemorrhage protocol
  • Prepare bloods — FBC, coagulation, 4 units cross-matched if major/massive; Kleihauer if RhD-negative
  • Investigate & monitor — continuous CTG, ultrasound to localise placenta; NO digital VE until praevia excluded
  • Drugs & delivery — anti-D ≥500 iu after 20+0 plus FMH test for >4 mL; TXA 1 g IV is WOMAN PPH evidence; steroids 24+0–34+6 if preterm-birth risk; BEAM magnesium 6 g then 2 g/h at 24–31 weeks if neuroprotection is indicated
• Decision node: spotting that has settled with reassuring tests may go home; heavier/ongoing — stay in until bleeding stops; massive or shock — protocol and deliver if compromised.

Q5: Abruption, DIC, and the Couvelaire uterus (2 min) ^[1]

"What coagulopathy complicates severe abruption, and what is the Couvelaire uterus?"

• Disseminated intravascular coagulation: the disrupted placenta releases tissue factor (thromboplastin) → consumption of platelets, fibrinogen, and clotting factors. Erez pregnancy-specific score: fibrinogen, PT difference, platelets — ≥26 points: 88% sensitivity, 96% specificity. Deliver to remove the trigger; GTG 63 appendix: cryoprecipitate if fibrinogen <1 g/L.
• Couvelaire uterus (uteroplacental apoplexy): in concealed abruption, blood extravasates through the myometrium to the serosa, giving a purplish, copper-bruised appearance; the uterus is contracted but atonic — fails to retract after delivery, a cause of refractory postpartum haemorrhage, often forcing hysterectomy.

Q6: Uterotonics and their contraindications (2 min) ^[1]

"Give the uterotonic ladder and the key contraindication for each."

• Rankings are from the Cochrane PPH-prevention network meta-analysis (140 trials), not an APH dose table: ergometrine plus oxytocin RR 0.69, carbetocin RR 0.72, misoprostol plus oxytocin RR 0.73 vs oxytocin for PPH ≥500 mL; ergometrine plus oxytocin RR 0.77 for PPH ≥1000 mL. Ergometrine combinations have more hypertension (RR 1.77); misoprostol plus oxytocin more fever (RR 3.18). Do not quote milligram uterotonic doses here — they were not in the fetched abstracts.
• If uterotonics fail: tranexamic acid 1 g IV (WOMAN, PPH), balloon tamponade, compression sutures, vessel ligation, hysterectomy (Rossi: mortality 2.6%, morbidity 56% of 981 emergency postpartum hysterectomies).

References3ShowHide

1. [1]Royal College of Obstetricians and Gynaecologists Antepartum Haemorrhage: Green-top Guideline No. 63 RCOG, 2011.Source
2. [2]Chen D, Gao X, Yang T, et al. Independent risk factors for placental abruption: a systematic review and meta-analysis BMC Pregnancy Childbirth, 2025.PMID 40140972
3. [3]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