Antepartum haemorrhage: assessment and management

All clinicians should:

• know where to find all equipment for APH management in their service
• know their local escalation procedures
• understand which blood products are available at their service and how to access them
• know how to activate their local massive transfusion protocol (MTP)
• attend multidisciplinary obstetric emergency training annually (for example, PROMPT, MSEP).

APH with significant bleeding or haemodynamic instability is an obstetric emergency – SUMMON HELP IMMEDIATELY

• APH assessment and management flowchart

Practice points

• Stabilise the woman before assessing fetal condition
• Understand your health service capability:
  • Victorian Maternity & Newborn Capability Framework
• If required, aim for in-utero transfer if safe to do so:
  • within Victoria, seek assistance from PIPER: 1300 137 650.

Initial assessment

Assess blood loss

• Weigh blood loss
• Document ongoing blood loss
• Document history of blood loss in this pregnancy
• Consider possible causes of APH:
  • placenta praevia
  • placental abruption
  • show
  • post-coital bleed
  • trauma
  • cervical abnormalities
  • infection
  • vasa praevia.

Maternal examination

• Vital signs - heart rate, blood pressure, respiratory rate, O2 saturation, temperature
• Document a running total of blood loss
• Gentle abdominal palpation
• Assess pain, rigidity, fetal presentation, size and movement
• Avoid vaginal examination until placenta praevia is excluded.

Fetal surveillance

• Cardiotocograph (CTG) is indicated from 26 weeks
• CTG should be continued if there is:
  • ongoing bleeding
  • abdominal pain
  • uterine activity.

History

• Document obstetric, medical, surgical and social history.

Speculum

• Observe and document:
  • blood loss
  • cervical dilatation and length
  • membranes
  • presenting part.

Ultrasound

• Investigate for:
  • placental position and condition
  • fetal growth and wellbeing
  • cervical length.

Investigations

• Request:
  • full blood count (FBC)
  • group and hold, for minor APH (<50 ml)
  • group and cross match, for APH >50 ml and/or clinical shock
• Kleihauer, if:
  • Rhesus negative
  • abdominal trauma
  • abnormal CTG
• For blood loss >50 ml:
  • liver function tests
  • renal function tests
  • coagulation studies, including fibrinogen.

Immediate management

Resuscitation

• Summon help - consider MET Call, Code Blue or Code Pink
• Resuscitate and assess simultaneously
• IV access x 2 16 g
• Fluid replacement
• Oxygen 8 L/min
• In-dwelling catheter (IDC).

If immediate delivery is indicated

• Consult with obstetric and paediatric clinicians
• Prepare resuscitation equipment appropriate for gestation:
  • consider a rapid infusion of 20 ml/kg of Rh O-negative uncross-matched blood, for infants symptomatic of hypovolaemia secondary to blood loss 
• Notify SCN/NICU
• Counsel the woman and family about what to expect in terms of baby's condition and care.

Indications for caesarean section

• Previous CS
• Placenta praevia
• Vasa praevia.

Possible indications for caesarean section

• Breech and <32 weeks
• Multiple pregnancy and <26 weeks
• Maternal condition necessitating caesarean section

Corticosteroids

• Administration of corticosteroids should not delay delivery
• If ≤ 34 weeks:
  • Betamethasone 11.4 mg IM
    then
  • Betamethasone 11.4 mg IM in 24 hours
  • Consider second dose at 12 hours if birth likely within 24 hours
  • If risk of preterm birth remains ongoing in seven days, repeat dose
• Between 34+1 and 36+6 weeks, consider cortiscosteroids if the woman is having a pre-labour CS.

Tocolysis

• Contraindicated if woman is actively bleeding.

Magnesium sulfate (MgSO4)

• Contraindicated if woman is actively bleeding
• Indicated at <30 weeks for neuroprotection, if delivery is imminent
• Regimen:
  • loading dose MgSO4 4 g IV bolus over 20 minutes
  • maintenance dose MgSO4 1 g/hr IV for 24 hours or until birth - whichever is first.

Blood products

• Be familiar with blood products available at your service (Appendix 1)
• Consider cell salvage
• If a woman does not consent to blood transfusion, transfer her to a service with cell salvage
• Indications for blood transfusion* (from the National Blood Authority Guidelines - Obstetrics and Maternity module):
  • Hb concentration >90 g/L, Red blood cell (RBC) transfusion is usually inappropriate.
  • Hb concentration of 70-90 g/L, RBC transfusion not associated with reduced mortality. Decision to transfuse (with a single unit followed by reassessment) should be based on the need to relieve clinical signs and symptoms of anaemia, availability of other therapies for the treatment of anaemia, expected timeframe to giving birth, and individual risk factors for haemorrhage.
  • Hb concentration <70 g/L, RBC transfusion may be associated with reduced mortality and may be appropriate. However, transfusion may not be required in well-compensated patients or where other specific therapy is available.

*Direct evidence of the efficacy of RBC transfusion for treatment of anaemia is not available in maternity patients. This advice draws on evidence from other patient groups and CRG consensus.

Inpatient management

• Prolonged inpatient care can be associated with an increased risk of venous thromboembolism (VTE):
  • encourage mobility
  • use TED stockings
  • ensure adequate hydration.
• Prophylactic anticoagulation in women at high risk of bleeding can be hazardous and the decision to use it should be taken on an individual basis.
• Weekly FBE
• Treat anaemia:
  • prescribe elemental iron (100-200 mg daily) and monitor the response to therapy
  • if the response is inadequate, use IV iron
  • see the National Blood Authority Guidelines - Obstetrics and Maternity module for more information
• Administer Anti-D if indicated
• Plan for timing of birth.

Observation

• Frequency of observation depends on:
  • maternal condition
  • ongoing bleeding
  • other clinical findings
• Fetal monitoring daily and as clinically indicated
• Review by the paediatric/neonatal and anaesthetic teams
• Ultrasound (US) as clinically indicated.

Discharge

• Women with an APH have an increased risk of adverse perinatal outcomes: (Table 2)
  • Counsel the woman about the risk of adverse outcomes.
  • Refer the woman for serial US for growth (timing will depend on gestation).
  • Plan for active management of third stage
• Discharge criteria:
  • Spotting = if placenta clear of os and no further bleeding
  • Minor APH = 24 hours after last observation of fresh blood loss
  • Major or massive APH = as per obstetric team.

Outpatient management

• Home-based care requires:
  • the woman’s consent
  • the woman to be aware of signs and symptoms which mean she should attend hospital
  • a plan and method to attend hospital if needed.

Timing of birth

• Planning for birth should be tailored to the individual patient, based on:
  • gestation
  • ultrasound findings
  • history of bleeding
  • medical comorbidities
  • surgeon availability
  • patient preferences
• Patient counselling and consent form should include:
  • increased risk of post-partum haemorrhage (PPH)
  • risks associated with caesarean section
  • specific risks of placenta praevia in terms of massive obstetric haemorrhage
  • potential need for blood transfusion
  • risk of hysterectomy.
• A woman with a placental edge less than 2 cm from the internal os in the third trimester is likely to need delivery by caesarean section (after 34 weeks).
• Elective delivery by caesarean section in asymptomatic women is not recommended before 38 weeks of gestation.
• Placenta praevia without previous caesarean section carries a risk of massive obstetric haemorrhage and hysterectomy and should be carried out in a unit with a blood bank and facilities for high dependency care.
• Placenta accreta - maternal and neonatal outcome is optimised in stable patients with a planned delivery at 34–36 weeks gestation. The gestation for elective delivery should balance the neonatal risks of prematurity against the maternal risks of emergent delivery.
• At <30 weeks gestation, consider magnesium sulphate for neuroprotection (see - Preterm birth).
• Significant APH is an obstetric emergency:
  • Any woman going to theatre with suspected placenta praevia/accreta should be attended by a consultant obstetrician and anaesthetist.
  • If delivery is unexpected, alert out-of-hours consultant staff to attend as soon as possible.

Placenta praevia

• Refer the woman for follow-up imaging if a low-lying placenta is identified at the 20/40 US.
• Have a high index of suspicion for placenta accreta if placenta praevia is diagnosed in a woman with a history of caesarean section.
• Counsel the woman about the risks of preterm birth and obstetric haemorrhage.
• The woman with placenta praevia who is admitted with an APH not requiring immediate delivery should remain in hospital until 24 hours after bleeding has ceased.
• Recurrent APH in the third trimester may be an indicator for inpatient management.

Placenta accreta

• All diagnoses of placenta accreta should be flagged with the appropriate Level 6 service, as future potential transfers.
• Morbidly adherent placentation may be suspected when placenta praevia is diagnosed in a woman with a history of caesarean section or other uterine surgery.
• Diagnosis is by COGU US and occasionally confirmed by MRI.
• Ideally, placenta accreta will be diagnosed before 20–24 weeks gestation.
• Care planning and management must be undertaken by a multidisciplinary team, led by a senior registrar or consultant obstetrician.
• The woman with diagnosed placenta accreta must have a plan and method to attend hospital in the event of PV bleeding.
• If a woman presents with bleeding and a diagnosis of placenta accreta, organise transfer to a Level 6 service for ongoing care, if/when her condition is stable.

Vasa praevia

• Vasa praevia can be accurately diagnosed with colour Doppler US.
• See RANZCOG’s statement on Vasa praevia for more information.
• Bleeding in the context of known vasa praevia is an indication for a RANZCOG Category 1 caesarean section.
• A diagnosis of vasa praevia at term is an indication for caesarean birth:
  • RANZCOG recommends considering delivery by 35 weeks.
• If vasa praevia is diagnosed in the third trimester, antenatal admission to a unit with appropriate neonatal facilities is recommended.
• If vasa praevia is diagnosed in the second trimester, repeat imaging in the third trimester.

Audit and performance improvement

All maternity services should have processes in place for:

• auditing clinical practice and outcomes
• providing feedback to clinicians on audit results
• addressing risks, if identified
• implementing change, if indicated.

Auditable standards:

• adherence to standard of care for assessment and management.

For further information or assistance with auditing, please contact us on maternityehandbook@safercare.vic.gov.au.

• Department of Health, Government of South Australia 2013. Antepartum haemorrhage or bleeding in the second half of pregnancy. Retrieved from http://www.sahealth.sa.gov.au/wps/wcm/connect/b1c672004ee1d5a9ac15add150ce4f37/2013_04_29_antepartum+haemorrhage+or+bleeding+in+the+2nd+half+of+pregnancy.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-b1c672004ee1d5a9ac15add150ce4f37-lKRbKKW
• King Edward Memorial Hospital (KEMH) 2018. Placenta: Abnormally invasive. Retrieved from https://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/2/b2.22.pdf
• National Blood Authority (2015) Patient Blood Management Guidelines: Module 5 – Obstetrics and Maternity. Retrieved from https://www.blood.gov.au/system/files/documents/20180426-Module5-WEB.pdf
• Royal College of Obstetricians and Gynaecologists (RCOG) 2011. Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and Management. Green-top Guideline No.27. Retrieved from https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg27a/
• Royal College of Obstetricians and Gynaecologists (RCOG) 2015. Blood Transfusion in Obstetrics. Green-top Guideline No. 47. Retrieved from https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-47.pdf
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2015. Placenta Accreta. Retrieved from https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Placenta-Accreta-(C-Obs-20)-Review-March-2014,-Amended-November-2015_1.pdf?ext=.pdf
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2016. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2016. Vasa praevia. Retrieved from: https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Vasa-praevia-(C-Obs-47)-Review-July-2016.pdf?ext=.pdf

1. Blood product availability

2. Definitions