Antepartum Haemorrhage (APH) – GCC Nurse Clinical Guide

Overview

Placenta Praevia

Placental Abruption

Emergency Management

GCC Context

MCQ Practice

🩸 Antepartum Haemorrhage — Overview

Antepartum Haemorrhage (APH) is defined as bleeding from or into the genital tract after 24 weeks of gestation and before delivery of the baby.

APH is a leading cause of maternal and perinatal mortality worldwide. All APH should be treated as an emergency until the source is identified and bleeding controlled.

Classification by Volume

Category	Blood Loss	Action
Spotting	<50 mL	Staining on pad only
Minor	50–1000 mL	No shock signs
Major	1000–2000 mL	Shock possible
Massive	>2000 mL	Life-threatening haemorrhagic shock

Common Causes

Placenta Praevia (~30%)

Placenta overlies or is near the internal cervical os
PAINLESS, bright red bleeding
Soft, non-tender uterus

Placental Abruption (~30%)

Premature separation of normally-sited placenta
PAINFUL, concealed or revealed bleeding
Tense, woody-hard uterus

Other causes: vasa praevia, uterine rupture, cervical ectropion, cervical/vaginal pathology (~40% unidentified/local)

NEVER perform a digital vaginal examination (DVE) in APH until placenta praevia has been excluded by ultrasound. Digital examination in praevia can cause catastrophic haemorrhage from dislodging the overlying placenta.

🔵 Placenta Praevia

Definition and Grades

Grade	Position
Grade I (Low-lying)	Lower uterine segment but not reaching os
Grade II (Marginal)	Reaches edge of internal os but doesn't cover it
Grade III (Partial)	Partially covers internal os
Grade IV (Complete/Central)	Completely covers internal os

Presentation

Painless bright red vaginal bleeding — hallmark feature
Bleeding often spontaneous or provoked by intercourse or examination
Soft, non-tender uterus (no abruption)
Foetal presentation often abnormal (transverse/oblique/breech) — foetal head cannot engage due to placenta blocking lower segment
May present with normal vital signs even with significant bleeding

Risk Factors

Previous caesarean section (increases risk of praevia AND accreta with each section)
Previous uterine surgery (myomectomy)
Multiparity (≥4 pregnancies)
Previous APH
Multiple pregnancy
Smoking and cocaine use
Advancing maternal age

Diagnosis

Ultrasound (transabdominal + transvaginal) — gold standard; TV scan safe and more accurate for os relation
MRI — if accreta suspected (invasion of myometrium/bladder)

Placenta Accreta Spectrum

Placenta Accreta Spectrum (PAS): Abnormally adherent or invasive placenta.

Accreta (most common): superficial invasion of myometrium
Increta: deep invasion into myometrium
Percreta (most severe): invasion through uterine wall ± into bladder/bowel

Risk increases dramatically with each prior caesarean section + placenta praevia. May require caesarean hysterectomy. Pre-op planning with interventional radiology/urology essential.

Management

Admit if symptomatic (bleeding) or >36 weeks with grade III/IV praevia
Corticosteroids (betamethasone) if preterm (<34–36 weeks) — foetal lung maturation
Caesarean section — mandatory for grade III/IV praevia; elective at 36–37 weeks or emergency if uncontrolled bleeding
Blood available cross-matched; IV access × 2; senior obstetric/anaesthetic/haematology team notified

🔴 Placental Abruption

Pathophysiology

Premature separation of the normally-sited placenta from the uterine wall before delivery. Blood accumulates between placenta and uterine wall causing pressure, DIC, and foetal compromise.

Types

Revealed (External) Abruption

Blood tracks down between membranes and uterine wall to escape via cervix
Vaginal bleeding visible
Blood loss may underestimate actual retroplacental haemorrhage

Concealed Abruption

Blood trapped behind placenta — no external bleeding
Most dangerous — degree of shock may exceed visible blood loss
Often presents with pain and sudden foetal distress without obvious bleeding

Presentation

PAINFUL bleeding — constant, severe abdominal/back pain (vs praevia = painless)
Woody-hard, tense uterus — uterus does not relax
Foetal distress / absent foetal movements
Haemodynamic instability disproportionate to visible blood loss (concealed)
DIC — severe abruption can release thromboplastins causing consumptive coagulopathy

Risk Factors

Hypertension / pre-eclampsia (most significant risk factor)
Previous abruption (10× recurrence risk)
Abdominal trauma (road traffic accident, domestic violence)
Smoking, cocaine use
Rapid uterine decompression (PPROM, polyhydramnios)
Thrombophilia (antiphospholipid syndrome, thrombophilia)

Kleihauer-Betke test: In Rh-negative mothers with APH — determine amount of foetal-maternal haemorrhage to calculate anti-D immunoglobulin dose required. Anti-D 500 IU IM for all Rh-negative women within 72 hours of APH.

🚨 Emergency APH Management

Initial Assessment and Resuscitation

Activate obstetric emergency team — call senior midwife, obstetrician, anaesthetist, haematologist
IV access × 2 (large bore, 14–16G)
Bloods: FBC, coagulation screen, U&E, group and crossmatch (6 units minimum)
Crystalloid fluid resuscitation — 1–2L Hartmann's while awaiting blood
Activate massive transfusion protocol if >2L estimated blood loss or shock
Continuous CTG monitoring — foetal wellbeing assessment
Catheterise — monitor urine output (>30 mL/hour target)
O₂ via face mask — maintain maternal and foetal oxygenation

Massive Obstetric Haemorrhage Protocol:
Blood transfusion: target ratio FFP:RBC 1:1 (or 4 FFP: 6 packed red cells)
Platelets: transfuse if <75 × 10⁹/L
Fibrinogen: if <2 g/L — Cryoprecipitate or Fibrinogen concentrate
Tranexamic acid 1 g IV (within 3 hours of bleeding onset) — reduces mortality
Consider recombinant Factor VIIa in refractory haemorrhage

Praevia vs Abruption — Key Management Differences

Aspect	Placenta Praevia	Placental Abruption
DVE	NEVER (catastrophic haemorrhage)	Avoid until praevia excluded
Delivery route	Caesarean section (grade III/IV)	May allow vaginal if minor + stable + foetus well
Uterine tone	Normal (soft)	Woody, hypertonic
DIC risk	Lower	High (especially severe abruption)
Pain	Painless	Painful

Anti-D Administration

All Rh-negative mothers with APH must receive anti-D immunoglobulin within 72 hours
Standard dose: 500 IU IM
Larger doses may be needed if Kleihauer-Betke test shows significant foeto-maternal haemorrhage

🌍 GCC-Specific Context

High Caesarean Rates and PAS Risk in GCC ▼

GCC countries have among the highest caesarean section rates globally (KSA ~27%, UAE ~31%, Qatar ~30%)
High C-section rates significantly increase placenta praevia and accreta risk in subsequent pregnancies
Placenta accreta spectrum is increasingly recognised as a major obstetric challenge in GCC tertiary centres
Multidisciplinary PAS teams (obstetrics, interventional radiology, urology, haematology) established at KFSH, Cleveland Clinic Abu Dhabi, HMC Doha
Uterine balloon tamponade and interventional radiology balloon occlusion used pre-operatively for suspected PAS

Grand Multiparity and APH Risk in GCC ▼

Grand multiparity (≥5 pregnancies) is associated with placenta praevia and postpartum haemorrhage risk
GCC countries historically have higher birth rates with some populations having >5 pregnancies
Pre-pregnancy counselling for high-parity women should include placenta praevia/accreta risk discussion
Domestic violence is underreported in GCC but is a recognised cause of blunt abdominal trauma and placental abruption
Nurses should follow safeguarding protocols and know referral pathways for domestic violence in their institution

SCFHS / DHA / QCHP Exam Focus ▼

APH definition: bleeding from/into genital tract after 24 weeks before delivery
Placenta praevia: PAINLESS bright red bleeding + soft uterus + abnormal foetal lie
Placental abruption: PAINFUL bleeding + woody-hard uterus + foetal distress + DIC risk
NEVER perform digital vaginal examination until praevia excluded by USS
Anti-D for ALL Rh-negative mothers with APH — within 72 hours
Kleihauer-Betke test: determines foeto-maternal haemorrhage volume → guides anti-D dose
Massive haemorrhage: ratio FFP:RBC 1:1; platelets if <75; fibrinogen if <2 g/L; tranexamic acid within 3 hours
Placenta accreta: abnormal adherence — accreta (myometrium) → increta (into) → percreta (through wall)
Risk of accreta: increases with each prior C-section + praevia
Grade IV praevia (complete): always caesarean section delivery

📝 MCQ Practice

1. A 32-week pregnant woman presents with sudden painless bright red vaginal bleeding. The uterus is soft and non-tender. What is the MOST likely diagnosis and what investigation is MOST urgently required?

✅ B — Painless bright red bleeding + soft uterus at 32 weeks = placenta praevia until proven otherwise. The critical action is USS to confirm placental position BEFORE any digital examination. DVE in praevia can cause catastrophic haemorrhage by dislodging the placenta.

2. A 36-week pregnant woman with known hypertension presents with severe abdominal pain, a tense woody-hard uterus, and vaginal bleeding. The CTG shows foetal bradycardia. What is the MOST likely diagnosis?

✅ B — Painful bleeding + woody-hard uterus + hypertension + foetal bradycardia = major placental abruption with acute foetal compromise. This requires immediate emergency delivery (caesarean section). Activate massive haemorrhage protocol. DIC is a significant risk with severe abruption.

3. A Rhesus-negative mother with placenta praevia loses 600 mL of blood and is stabilised. What additional treatment is required?

✅ C — All Rh-negative mothers with ANY APH must receive anti-D immunoglobulin (500 IU IM) within 72 hours to prevent Rh sensitisation. Kleihauer-Betke test determines the volume of foeto-maternal haemorrhage and whether additional anti-D doses are needed (large FMH may require >500 IU).

4. A patient with APH is bleeding heavily despite IV fluids. The massive haemorrhage protocol is activated. Her coagulation screen shows fibrinogen of 1.2 g/L. What should be administered?

✅ C — In obstetric haemorrhage with coagulopathy, fibrinogen levels must be maintained ≥2 g/L. Cryoprecipitate (10 units) or fibrinogen concentrate raises fibrinogen significantly. Fibrinogen <2 g/L in obstetric haemorrhage is an independent predictor of severe PPH. FFP alone provides insufficient fibrinogen to correct levels effectively.