Antepartum Haemorrhage
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Direct answer
Antepartum haemorrhage is bleeding from or into the genital tract after the threshold of viability — commonly taken as 20-24 weeks, with Indian texts often using 28 weeks — and before the birth of the baby. Placenta praevia and placental abruption together cause the majority of cases, with vasa praevia, local genital lesions and uterine rupture completing the list. The universal first response is assessment and resuscitation with strict avoidance of vaginal (speculum beyond visual inspection, or digital) examination until an ultrasound has localised the placenta, because one digital examination on a praevia can precipitate torrential bleeding.
What you must remember
- Definition and causes: bleeding after 20-24 weeks (viability-based definitions vary; 28 weeks in traditional Indian teaching) and before delivery; roughly two-thirds follow praevia or abruption, with the remainder split among vasa praevia, cervical or vaginal lesions, uterine rupture and unclassified bleeding.
- Immediate management: ABC assessment with two large-bore intravenous lines, crystalloid resuscitation, crossmatched blood, monitoring of pulse, blood pressure, fundal height and fetal heart; ask about pain, leaking liquor, trauma and fetal movements.
- The golden rule: no digital or speculum palpation of the placental site before ultrasound localisation; a gentle speculum inspection to see the cervix is acceptable once praevia is excluded.
- Ultrasound (transabdominal, supplemented by transvaginal which is safe and more accurate) localises the placenta, checks fetal wellbeing and estimates gestation; cardiotocography assesses the fetus once the mother is stable.
- Maternal measures: anti-D immunoglobulin for Rh-negative women within 72 hours, correction of anaemia and coagulopathy (fibrinogen, platelets, fresh frozen plasma in abruption), and corticosteroids for fetal lung maturity if delivery before 34 weeks is likely.
- Disposition: heavy bleeding, maternal instability or fetal compromise deliver promptly; light bleeding with a preterm pregnancy and reassuring status allow inpatient or carefully selected outpatient expectant care.
- Documentation and debriefing: record estimated blood loss and the working diagnosis, counsel about recurrence risk of abruption and the implications for future pregnancies.
Common confusion
The bedside distinction between the two majors decides everything: praevia bleeds painlessly, repeatedly and bright red with a soft, non-tender, usually high or malpositioned fetus; abruption bleeds dark blood with constant severe pain, a tense tender "woody" uterus, fetal distress and shock out of proportion to visible loss. The second trap is the examination itself — the instinct to perform a vaginal examination on any bleeding woman must be overridden until the placenta is localised, historically replaced by the "double set-up" examination in theatre, now abandoned for imaging.
Exam-focused takeaway
Next-step stems dominate: a woman at 32 weeks with painless bleeding gets an ultrasound (not a vaginal examination), Rh-negative women get anti-D, and unstable mothers deliver. Expect praevia-versus-abruption discrimination tables in clinical vignettes, timing thresholds for corticosteroids, and definition one-liners on the viability cut-off. The crossmatched-blood and two-IV-line discipline is the safety answer for heavy first bleeds.
Frequently asked questions
How is antepartum haemorrhage defined?
Bleeding after the period of viability — commonly 20-24 weeks, or 28 weeks in traditional Indian texts — and before the birth of the baby.
Why is vaginal examination avoided initially?
Because digital or speculum examination of a placenta praevia can provoke massive haemorrhage; the placenta must first be localised by ultrasound.
Which two causes account for most cases?
Placenta praevia and placental abruption; vasa praevia, local lesions and uterine rupture cause the remainder.
What is given to Rh-negative women?
Anti-D immunoglobulin within 72 hours of the bleeding episode, with fetomaternal haemorrhage quantification where indicated.
When is expectant management appropriate?
With minimal bleeding, maternal stability, a preterm fetus and reassuring surveillance — delivered under hospital supervision with steroids for lung maturity when early delivery is anticipated.