REVIEW

Antepartum haemorrhage APH and post-partum haemorrhage (PPH) together, are the
leading cause of maternal death worldwide. In the UK, maternal
deaths have remained stable and the recent MBRRACE-UK report
Nektaria Varouxaki published in December 2017 showed that maternal mortality in
Sai Gnanasambanthan the UK was 8.7 per 100,000 in 2013e2015, compared with 8.5 per
100,000 between 2012 and 2014. This suggests that further
Shree Datta measures are required to continue to reduce maternal mortality
Nadia Amokrane rates in the UK. The report also highlighted a non-significant rise
in maternal deaths from haemorrhage of 99%, and this was due
to a small increase in deaths from abnormal placentation, one of
Abstract the causes of APH.
Antepartum haemorrhage (APH) is defined as bleeding from or into the The MBRRACE report reminds us that APH and PPH are not
genital tract occurring between 24þ0 weeks’ gestation until birth and only are an ongoing cause of maternal mortality but also of
seen in 3e5% of pregnancies. Moreover, up to 20% of preterm deliv- maternal and perinatal morbidity. Therefore the early recogni-
eries are associated with APH. In the UK, the 2013e1015 report of the tion and management of women presenting with any blood loss
UK Confidential Enquiries into Maternal Deaths showed that whilst is essential in preparing for potential sequelae and thorough
maternal mortality remained stable, there was a non-significant rise antenatal, intrapartum and postpartum planning is required.
in deaths due to haemorrhage. APH can be caused by a range of pa- The aim of this review is to define causes of APH and discuss
thologies and due its high prevalence and strong association with management as advised by recent guidelines and published
maternal mortality, maternal and perinatal morbidity, a thorough un- evidence.
derstanding of APH is essential for the practising obstetrician. The
objective of this review is to define the most common causes of
APH (placenta praevia, placental abruption and local causes), together Causes of APH
with its management.
Causes of APH include placenta praevia, placental abruption and
Keywords antepartum haemorrhage; obstetric haemorrhage; bleeding from the vulva, vagina or cervix. Whilst it is important
placenta accreta; placenta praevia; placental abruption to diagnose these pathologies, it is not uncommon to fail to
identify a cause for APH, which is then described as ‘unexplained
APH’. Clinicians should also be aware that domestic violence in
Introduction pregnancy can present this way and repeated presentations
Bleeding in pregnancy is a common reason for presentation to should prompt exploring the mother’s social history.
labour wards, maternity triage units, GP surgeries and early
pregnancy centres in the UK. Cervical and vaginal causes
The management of bleeding in pregnancy varies according to A common cause of APH is bleeding from the cervix. A cervical
gestation. In this review we specifically address antepartum ectropion or ’erosion’ is where the columnar epithelium that
haemorrhage (APH) which occurs in 3e4% of all pregnancies lines the cervical canal protrudes further onto vaginal surface of
and is defined as bleeding from the genital tract from 24 weeks’ the cervix. This is more common in pregnancy, thought to be
gestation onwards, after the arbitrary cut-off for viability of fetus related to the high oestrogen levels in the body at this time. The
has passed. Bleeding in early pregnancy is usually seen by tissue of the ectropion is very friable and contact or provoked
General Practitioners, accident & emergency departments and bleeding can occur, usually at sexual intercourse or even on
our gynaecology colleagues. Obstetricians may see women with passing hard stools. The ectropion can be easily diagnosed on
APH from 16 to 23 weeks’ gestation however, due to the fact that speculum examination of the cervix.
the pregnancy is not yet viable, management of this group of Cervicitis (inflammation or infection of the cervix) may be an
women may differ. under-diagnosed cause of vaginal bleeding in pregnancy, and
may be caused by sexually transmitted infections (STIs) such as
chlamydia and gonorrhoea, which can present in this way. A
simple swab test and screening for STIs should be undertaken at
every examination, as treatment is essential. STIs are associated
Nektaria Varouxaki Ptychion Iatrikes MRCOG Registrar in Obstetrics and with preterm labour and neonatal morbidity.
Gynaecology, Princess Royal University Hospital, King’s College,
An additional cause of APH is cervical polyps which are
London, UK. Conflicts of interest: none declared.
benign growths. If the bleeding is not compromising the mother
Sai Gnanasambanthan MBBS BSc (Hons) MRCOG, Specialist Registrar or foetus and the polyp appears non-suspicious then usually
in Obstetrics and Gynaecology, Guy’s and St Thomas’ NHS Trust, these do not have to be removed in pregnancy.
London, UK. Conflicts of interest: none declared.
Cervical carcinoma presenting in pregnancy is uncommon
Shree Datta MBBS LLM BSc (Hons) MRCOG, Consultant Obstetrician and and a detailed history at booking appointment should assess a
Gynaecologist, King’s College Hospital, London, UK. Conflicts of woman’s smear history and history of previous cervical treat-
interest: none declared. ments. If a cervical carcinoma is suspected on assessment of the
Nadia Amokrane MBChB Specialist Registrar, King’s College cervix then urgent referral to colposcopy is indicated. Smear tests
Hospital, London, UK. Conflicts of interest: none declared. are not indicated in pregnancy.

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As with non-pregnant women, bleeding or spotting can occur

from the vagina and vulva secondary to infections such as Risk factors
thrush, folliculitis and from trauma. Placenta praevia Multiple pregnancy
Advanced maternal age (>40 years)
Placental causes High parity
Placental abruption Deficient endometrium due to
Abruptio placenta is the premature separation of a normally sited Uterine scar (caesarean section, myomectomy)
placenta from the uterus. Placental abruption can lead to - previous caesarean section RR 2.6
maternal and fetal complications and ultimately fetal and Endometritis
maternal mortality. The bleeding occurs when the placenta starts Manual removal of placenta
to separate from the decidua basalis. The presentation usually Curettage
includes pain (50%) and bleeding (70e80%) however, a con- Fibroids
cealed abruption (20% of cases) can present with no pain or Previous placenta praevia
bleeding. Premature labour can be a feature of nearly a third of Smoking,
cases of abruption, however, the contraction pains may be Assisted Conception
atypical. Placental abruption Previous placental abruption
The incidence of placental abruption is reported between Hypertension
0.26% and 0.80% in literature depending on the type of study Pre-eclampsia
and population. The biggest risk factor for abruption is abruption Smoking, cocaine use
in a previous pregnancy, with a report incidence of 4.4% if there First trimester bleeding
has been an abruption in the previous pregnancy. The risk in- Premature rupture of membranes
creases to 19e25% if a woman has had two previous abruptions. Coagulopathies
Although no exact aetiology has been identified for placental Multiple pregnancy
abruption, a number of risk factors have been illicited. These Advanced maternal age
include hypertension and pre-eclampsia. Notably, chronic hy- Abdominal trauma
pertension has a stronger association with abruption (OR 3.13) Vasa praevia Placental anomalies:
than pre-eclampsia (OR 1.73) compared with normotension. - Velamentous insertion of umbilical cord
Smoking is associated with a 90% increase in abruption and a - Succenturiate lobes,
three times increased risk in pregnancies complicated by pro- - bi-lobe placenta
longed rupture of membranes (PROM). Cocaine use has also History of low lying placenta in the 2nd
been linked to a higher rate of placental abruption. trimester
First trimester bleeding or threatened miscarriage has been Multiple gestation
shown to increase the risk of placental abruption later in preg- IVF pregnancy
nancy from 1% to 1.4%. Risk of abruption is also noted to in- Uterine rupture Multiparity
crease if an intrauterine haematoma was identified with first Congenital uterine anomalies
trimester bleeding investigations (RR 5.6, 95% CI 2.8e11.1). Uterine scar (caesarean section, myomectomy)
Thrombophilias, especially heterozygous factor V leiden and Maternal age
heterozygous prothrombin have shown significant associations Abnormal placentation
with placental abruption occurrences. Uterine distension (multiple gestation,
However, despite numerous risk factors and associations polyhydramnios, macrosomia)
(Table 1), abruption is usually an unexpected event and 70% will Gestation > 40 weeks
occur in low risk pregnancies. While women should be encour- Uterine rupture Obstructed labour
aged to change modifiable risk factors such as smoking, there is
Table 1
limited evidence that this will prevent abruption.

Placenta praevia, placenta accreta, increta and

placenta percreta
Placenta praevia is the insertion of the placenta partially or The routine incidence of low lying placenta can be up to 28%
entirely within the lower segment of the uterus after 32 weeks. If of pregnancies at the 20 week anomaly ultrasound scan, but the
the placenta does not cover the internal os then it is described as majority of these will have migrated higher by the following
a minor praevia and if it partially or fully covers the os then it is scan, usually at 32 weeks or later. The incidence of true placenta
classified as a major praevia. A morbidly adherent placenta such praevia at term will be approximately 3%.
as a placenta accreta, increta or percreta invades through the There are several hypothesis about the aetiology of placenta
decidua basalis. In placenta accreta the chorionic villi attach to praevia. One theory is that the position of the placenta depends on
the myometrium. In placenta increta the myometrium is invaded the site of implantation of the discoid trophoblast when the
and in placenta percreta the placenta invades through the myo- pregnancy is developing and from where the placenta will arise.
metrium and breaches the uterine serosa. Placenta percreta may The other theory postulates that areas of deficient endometrium
then invade other organs such as the bladder. from procedures such as caesarean sections, surgical management

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of miscarriage and myomectiomies may affect how the placenta section the risk if 0.2e0.5% and after two the risk increases to
attaches in these cases. 1.36%. Uterine rupture is more likely to present with CTG ab-
The risk factors for placenta praevia include previous termi- normalities or pain first instead of APH but quick stabilisation of
nation of pregnancy, multiparity, multiple pregnancy, increasing the mother and baby is required as mortality and morbidity is
maternal age (>40 years), smoking, previous praevia, assisted high.
conception and causes of deficient endometrium (Table 1) The
number of previous caesarean sections also increases the risk Vasa praevia
ratio of a praevia and accreta (Table 2) Vasa praevia is another rare event where fetal vessels travel
In well-resourced settings such as in the UK, the majority of through the membranes between the fetal presentive part and the
placenta praevias may be picked up on ultrasound scan at 20 internal os. As the incidence is rare (between 1 in 2000 and 1 in
weeks. Currently the UK National Screening Committee does not 6000 pregnancies) it is not routinely screened for by ultrasound.
recommend screening for placenta praevia however, alongside The risk of APH mainly comes with rupture of the membranes or
the RCOG, they support most local practice of identifying women labour when the tearing of the vessels may occur. The fetus can
by ultrasound whose placenta lies near the internal os at the be compromised quickly and management if diagnosed or sus-
routine 20 week scan. Evidence shows that at the second pected is usually by immediate category 1 Caesarean section. The
trimester scan about 26e60% of women with a low lying mortality rate is 60%, however if diagnosed antenatally the
placenta on abdominal ultrasound would be reclassified with a survival rate is 97%. The risk factors for Vasa praevia (Table 1)
more accurate transvaginal scan. There have been no reports that include IVF where the incidence has been reported of up to 1 in
transvaginal scanning suspected placenta praevia cases is unsafe. 300.
Women with a low lying placenta at 20 weeks should be
followed up in the third trimester, usually at 36 weeks. However, Unexplained APH
if women have had a previous Caesarean section and have a low Some women will present with bleeding that cannot be attributed
lying placenta, then a placenta accreta should be suspected. If to any of the above causes. The RCOG Greentop Guideline has
major placenta praevia is suspected at this scan then this also reviewed a number of studies over the last four decades that
significantly raises the risk of morbidity and preterm delivery, demonstrate that pregnancies with unexplained APH are at
therefore, these women would benefit from earlier follow up at higher risk of preterm birth and stillbirth. A recent retrospective,
32 weeks. If identified at 32 weeks, 73% will remain low at term. observational study noted that they were at a higher risk of
If major placenta praevia is identified at 32 weeks, 90% will preterm birth, lower birthweight, induction of labour and their
persist. However, even with early ultrasound diagnosis, placenta babies were at a higher risk of admission to neonatal units.
praevia should be suspected in any patient who presents with Repeated presentations with unexplained APH in pregnancy
painless, fresh bleeding or bleeding after intercourse. should raise suspicion and the pregnancy should be monitored as
The most likely symptom from a placenta praevia is painless high risk.
bleeding in contrast to abruption where pain is likely to also co- Healthcare providers should be aware that trauma including
present. The bleeding is usually fresh, red and the amount of domestic violence can result in APH, possibly from placental
APH can vary. The patient may also present with fresh bleeding abruption. A third of domestic violence is known to start or
in early labour with the onset of labour and cervical dilatation escalate in pregnancy. A retrospective study of 2070 women
triggering the bleed or vice versa. 40% will deliver preterm and subjected to physical violence in pregnancy found an increased
the risk of massive haemorrhage at caesarean section is 12 times odds ratio of APH in this cohort, compared with controls, of 3.79
more likely. (95% CI 1.38e10.40). Women who present with APH and other
signs suggestive of domestic violence or, who disclose violence,
Uterine rupture should be identified and managed appropriately by a multidis-
Uterine rupture is a rare event that is defined as loss of the full ciplinary team who have been specially trained in domestic
thickness of the uterine wall integrity. It usually occurs during violence to safeguard these pregnant women.
labour in a woman with a previous caesarean section or myo-
mectomy but even within this group the risk is still small in the Diagnosis and management of APH
order of 7 per 10,000 planned VBACs. A previous uterine rupture Women who present with major or massive haemorrhage and
has a more than 5% risk of recurrence. After one caesarean signs of shock should be seen in a maternity unit with

Risk associated with the number of caesarean sections and placenta praevia, and placenta accreta
Number of caesarean sections Placenta praevia Placental accreta Chance of placenta accreta if placenta praevia

0 0.24% 3%
1 1% 0.31% 11%
2 1.7% 0.57% 40%
3 1.8% 2.13% 61%
>4 2.33% 67%

Table 2

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involvement of a multidisciplinary team including a senior

obstetrician, anaesthetist, senior midwife and also blood trans- Assessment and management
fusion technicians, haematologists, neonatalogists and porters. Assesment Management
Obstetric units will usually have fixed protocols for the man-
agement of Massive Obstetric Haemorrhage that should be acti- A(irway) Check patency
vated if a woman presents or develops major or massive B(reathing) Respiratory rate
haemorrhage and these should be utilised and rehearsed to Oxygen saturations
prepare for such cases. There is no clear advice on where women 10e15 L via non rebreathing mask
who have minor haemorrhage or spotting and who are haemo- C(irculation) Heart rate
dynamically stable can be managed but in current practice it Capillary refill time
would seem sensible that these women are seen in maternity Blood pressure
triage units that can transfer the patient to a labour ward or Iv access consider x 2 16 gauge cannulae
inpatient antenatal ward, if necessary. IV fluid resuscitation crystalloid/colloid/blood
The Greentop Guideline defines the severity of APH (Table 3). Assess Blood loss
The initial assessment of a woman with APH should include Consider catheterisation (input/output
the ABC approach to stabilising the patient (Table 4). As well as monitoring)
stabilising the woman, it is important to gain an overview of D(isabilty) Glasgow coma score.
likely blood loss. However, it is important to note that not all E(xposure) Abdominal examination
blood loss is revealed, so the clinical features of blood loss are Speculum
extremely important to base management. Vaginal examination
Patients with major or massive obstetric haemorrhage should F(etus) CTG Method used
be managed in left lateral tilt to avoid exacerbatory hypotension Auscultation FHR gestation dependent
secondary to uterine compression of the inferior vena cava. If an Ultrasound
adequate history cannot be provided due to maternal compro-
mise, then resuscitation and stabilization of the mother is the key Table 4
priority. Following the initial survey and commencement of
resuscitation, the cause and extent of the APH should be illicited
also have liver and renal function blood tests and a coagulation
by carrying out a full examination.
screen including klauss fibrinogen. They also may benefit from a
Abdominal examination may illicit a ’woody’ or tense uterus
bedside blood check such as a Hemacue since the FBC may not
that is characteristic of an abruption or it may show the patient is
give an accurate immediate estimate of blood loss.
contracting and could be in labour.
Even with bedside haemoglobin checks and laboratory FBC, it
If a patient with known placenta praevia presents with
should be noted that after acute major blood loss these tests can
bleeding, then a digital examination is not indicated. The diag-
be misleading. Therefore, initial diagnosis and management of
nosis of vasa praevia should be considered when the APH has
APH should be based on clinical criteria and observations.
been associated with rupture of membranes. All women pre-
After stabilizing the mother, the fetal heart rate should be
senting with APH should have their pulse and blood pressure
checked. There is no clear guidance or evidence to support
recorded.
monitoring fetuses during APH as there may be transient ab-
normalities with the CTG. Clinical judgement is essential to make
Investigations
a decision regarding mode and timing of delivery based on likely
The RCOG guideline recommends that all patients with APH diagnosis and the maternal and fetal status. For example, if an
should have a full blood count (FBC) and a group and save. A abruption is suspected and there is an abnormal CTG then the
Kleihauer test is also necessary for all Rhesus negative women. CTG findings are likely to be associated with fetal hypoxia and so
Women who present with major or massive haemorrhage should delivery would be indicated to save the fetus.
Ultrasound is the primary investigation, used to exclude a
placenta praevia or to check fetal growth if bleeding has settled.
Severity of APH It is not recommended as a diagnostic tool to diagnose abruption
as the reported sensitivity is only between 25 and 50%.
Description Blood volume Generally most clinicians currently do not recommend tocol-
ysis if a patient is actively bleeding. NICE guideline advises the
Spotting staining, streaking or blood spotting noted on
following regarding steroids if a woman is at high risk for pre-
underwear or sanitary protection
term delivery:
Minor haemorrhage blood loss less than 50 ml that has settled
23-23þ6 weeks: discuss with the woman
Major haemorrhage blood loss of 50e1000 ml, with no signs of
24-25þ6 weeks: consider steroids
clinical shock
26-33þ6 weeks: offer steroids
Massive haemorrhage blood loss greater than 1000 ml and/or signs
34-35þ6 weeks: consider steroids
of clinical shock
However, if delivery is indicated, this shouldn’t be delayed for
Table 3 steroid administration.

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Management blood components would be acceptable to the woman in the

event of severe blood loss and also if autologous transfusion in
Women presenting with spotting who are no longer bleeding and
the form of cell salvage can be used. There should be a signed
where placenta praevia has been ruled out can go home after the
advanced directive and all discussions clearly documented.
initial clinical assessment. All women with antepartum hae-
Antenatally, any woman who would refuse blood transfusion or
morrhage which is more severe than spotting, as well as women
blood products should have their haemoglobin levels optimised.
with ongoing bleeding should remain in hospital until the
In the event of major APH or indeed PPH, a consultant obste-
bleeding has stopped.
trician, anaesthetist and haematologist should be informed. If a
Conservative management of placenta praevia woman who would refuse donor blood is diagnosed antenatally
Women with placenta praevia were previously advised to remain with placenta accreta or this is suspected, it is recommended that
as inpatients from 34 weeks until elective delivery. Currently delivery is planned in a facility with access to interventional
there is limited evidence to support either hospital-based or radiology. There is insufficient evidence on whether prophylactic
home-based care in the third trimester. Women with placenta catheter placement for balloon occlusion or embolisation is
praevia who have APH which resolves spontaneously without advantageous.
requiring immediate delivery are likely to remain in hospital until
Delivery techniques and postpartum
bleeding has completely ceased. With recurrent APH in the third
Women who are in labour and have ongoing vaginal bleeding
trimester for any pathology, it is common practice for patients to
require continuous electronic fetal monitoring. Moreover, active
be hospitalised until elective delivery although there is no evi-
management of 3rd stage should be discussed due to the
dence to support this. In accordance with the RCOG guideline on
increased risk of postpartum haemorrhage.
APH women with placenta praevia in the third trimester should
Bleeding should be managed in the normal way with utero-
be counselled about the risks of preterm delivery and obstetric
tonic agents and failing that with interventions such as the Rusch
haemorrhage and care should be individualised to meet the pa-
or Bakri balloon, B-Lynch suture, uterine artery embolization
tients needs. If care is at home, the woman should be within
and hysterectomy. In cases of placenta accreta managed by
close proximity to the hospital, have a constant companion at
Caesarean section, where the placenta fails to separate, leaving it
home and be aware of when she should attend hospital
in situ and proceeding to either elective hysterectomy or con-
immediately.
servative management are options. There are no randomised
Tocolysis and elective cerclage have not been shown to pro-
control trials to compare approaches directly but case series have
vide any benefit to women with placenta praevia.
been published that show successful outcomes in both.
Blood products If the placenta is left in situ and the uterus is spared, con-
Managing severe antepartum haemorrhage may require using servative management involves prophylactic antibiotics and
blood transfusion and considering delivery with surgical in- lengthy follow-up with beta-HCG blood levels and imaging to
terventions to arrest the bleeding. If women require blood ensure resolution. Women should be counselled about the like-
transfusion then group-specific, cross-matched blood is ideal. lihood of bleeding and infection.
Rarely, if blood loss is so excessive that the processing time for
this would be clinically unacceptable then O Rhesus D negative K Conclusion
negative red cells should be utilised. Commencing red cell APH can be a traumatic event in the life of a woman at a
transfusion is based on clinical evaluation and haematological vulnerable time. Early recognition and management is therefore
investigations, if available. Fresh frozen plasma should be vital, together with the relevant debrief postnatally. The
administered if PT or APTT are prolonged with ongoing hae- MBRRACE reports remind us that whilst APH is common, hae-
morrhage or haemorrhage is ongoing after four units of morrhage is still a significant contributor to maternal morbidity
RBCs.Haematological investigation and specialist advice should and mortality. Local audits and reviews can help individual units
guide the further use of FFP, cryoprecipitate, and platelets in to learn through previous experiences and near-misses as well as
massive obstetric haemorrhage. Guidance from the British ensuring that the multidisciplinary team are regularly updated in
Committee for standards in Haematology summarises the main the massive obstetric haemorrhage protocol. A
therapeutic goals of the management of massive blood loss as
maintaining:
Hb > 80 g/L FURTHER READING
PLT > 50  109/L Anath CV, Savitz DA, Williams MA. Pracental abruption and its asso-
PT < 1.5 times normal ciation with hypertension and prolonged rupture of membranes: a
APTT < 1.5 times normal methodologic review and meta-analysis. Obstet Gynecol 1996
Fibrinogen > 2 g/L Aug; 88: 309e18.
It is important that women who will refuse blood products in Antepartum haemorrhage RCOG green top guideline 63. 2011, https://
an emergency, including Jehovah’s witnesses, are identified in www.rcog.org.uk/globalassets/documents/guidelines/gtg_63.pdf.
the antenatal period and referred to consultant-led care. These Blood tranfusion in obstetrics RCOG green top guidline 47: https://
women are at higher risk of morbidity and mortality in the case www.rcog.org.uk/globalassets/documents/guidelines/
of APH. The healthcare provider and patient should discuss what gt47bloodtransfusions1207amended.pdf.

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