OG10.1 | Antepartum Haemorrhage — Summary & Reflection

KEY TAKEAWAYS

Antepartum Haemorrhage — Key Points:

• Definition: Bleeding from the genital tract after 20 weeks of gestation (pre-delivery). Major APH = ≥1000 mL or haemodynamic compromise.
• Classification: Placental causes (praevia 30–40%, abruption 30–40%, vasa praevia) vs extraplacental incidental causes (diagnosis of exclusion).
• Placenta praevia: Abnormal low implantation → painless, fresh, recurrent bleeding; soft uterus; malpresentation. Four types (I–IV); Types III–IV = mandatory CS. Risk of PAS in scarred uterus. USS (transabdominal/transvaginal) is diagnostic — never digital VE.
• Placental abruption: Premature separation of normally sited placenta → painful, dark bleeding; woody uterus; fetal distress; shock disproportionate to visible loss. Sher Grades 0–III. Grade IIIb = DIC — replace fibrinogen (cryoprecipitate), FFP, and deliver vaginally.
• Couvelaire uterus: Blood infiltrating myometrium; impairs contraction; may need hysterectomy.
• Vasa praevia: Fetal vessels at os → fetal exsanguination on membrane rupture; diagnose with colour Doppler; plan elective CS at 35–36 weeks.
• Investigations: USS first, FBC, group/cross-match, coagulation screen (fibrinogen critical), Kleihauer-Betke (Rh-negative mothers), CTG.
• Management principles: Stabilise mother, corticosteroids if <34 weeks, anti-D for Rh-negative, do not perform digital VE, grade/type-matched delivery plan.

REFLECT

Reflect on your learning using Kolb's cycle:

Concrete Experience: Imagine you are the first doctor to see Mrs Savitha from the opening scenario — 32 weeks, painless bright-red bleeding, haemodynamically borderline, uterus soft.

Reflective Observation: Walk through the sequence of your actions: what you would NOT do first (digital VE), what you would do immediately (establish IV access, bloods, CTG, call senior), and what investigation you would prioritise (USS).

Abstract Conceptualisation: Where does this case sit in the APH classification? What USS finding would change your management completely (Type IV praevia versus Type I)? What if she were Rh-negative?

Active Experimentation: Next time you are on the antenatal ward or labour room, ask the midwife or registrar how they confirm placental position before any vaginal examination in a patient with third-trimester bleeding. Observe how the CTG trace changes your assessment of urgency. Ask to review a real placenta praevia USS report and identify the placental edge-to-os distance.