🔑 Key Learning

  • Antepartum haemorrhage (APH) = bleeding after 24 weeks gestation and before delivery.
  • Three key causes: placental abruption (painful, firm 'woody' uterus), placenta praevia (painless, visible bleeding), vasa praevia (rupture → fetal distress).
  • Placental abruption = emergency; often concealed bleed and maternal compromise.
  • Placenta praevia = painless bleeding; managed with serial TVUS and elective C-section.
  • Vasa praevia = painless bleed + fetal bradycardia post-ROM; requires C-section at 34–36 weeks.

🧬 Placental Abruption

🧠 Pathophysiology

Separation of the placenta from the uterine wall, leading to haemorrhage:

  • Revealed: PV bleeding is visible.
  • Concealed: Cervical os closed → blood trapped in uterus → abdominal pain and shock.
Placental abruption. Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436, via Wikimedia Commons

⚠️ Risk Factors

  • Previous abruption
  • Pre-eclampsia
  • Multiple pregnancy
  • Maternal age
  • Smoking

👀 Clinical Features

  • Sudden, severe continuous abdominal pain
  • PV bleeding (remember - bleeding may be absent if concealed)
  • Tender, woody uterus
  • Shock: hypotension, tachycardia

🧪 Investigations

  • Diagnosis is clinical
  • Ultrasound to rule out placenta praevia
  • CTG: fetal monitoring

💊 Management

  • Maternal resuscitation and transfusion
  • Foetal distress → emergency C-section
  • No foetal distress:
    • > 37 weeks → induce labour
    • < 37 weeks → admit, give corticosteroids

📍 Placenta Praevia

🧠 Pathophysiology

  • Placenta praevia: placenta covers the cervical os
  • Low lying placenta: placenta within 20mm of os but not covering
Placenta praevia. BruceBlaus, CC BY-SA 4.0, via Wikimedia Commons

⚠️ Risk Factors

  • Previous C-section
  • Uterine abnormalities e.g. fibroids

👀 Clinical Features

  • Painless, visible PV bleeding
  • Usually presents after 35 weeks

🧪 Investigations

  • Transvaginal ultrasound (TVUS) = diagnostic test of choice

💊 Management

  • If identified during routine scanning, TVUS follow-up is recommended at 32 and 36 weeks
  • Planned C-section at 36–37 weeks to reduce risk of severe bleeding
  • Corticosteroids for fetal lung maturation

🩸 Vasa Praevia

🧠 Pathophysiology

  • Fetal vessels traverse membranes near cervical os → at risk of bleeding, particularly when there is rupture of membranes during labour. 
Two forms of Vasa Previa - a disease in which fetal blood vessels cross or run near the internal opening of the uterus. Sigrid de Rooij, CC BY-SA 4.0, via Wikimedia Commons

👀 Clinical Features

  • Triad:
    • Following rupture of membranes
    • Painless vaginal bleeding
    • Foetal bradycardia/distress

💊 Management

  • Planned C-section at 34–36 weeks
  • Corticosteroids for fetal lung development

📝 Exam Clues & Clinchers

  • Woody uterus, severe pain, concealed bleed → placental abruption
  • Painless PV bleeding, 36 weeks → placenta praevia
  • ROM + painless bleeding + fetal distress → vasa praevia
  • Abruption + fetal distress → emergency C-section
  • Placenta praevia diagnosed at 20-week scan → repeat TVUS at 32 and 36 weeks
    • Planned C-section at 36–37 weeks

🔗 Useful Links & References