Green–top Guideline No. 63

1 Antepartum HaemorrhageGreen top Guideline No. 63 November 2011 RCOG Green-top Guideline No. 632 of 23 Royal College of Obstetricians and GynaecologistsAntepartum HaemorrhageThis is the first edition of this and scopeAntepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0weeks of pregnancy and prior to the birth of the baby. The most important causes of APH are placenta praeviaand placental abruption, although these are not the most common. APH complicates 3 5% of pregnancies andis a leading cause of perinatal and maternal mortality to one-fifth of very preterm babies areborn in association with APH, and the known association of APH with cerebral palsy can be explained bypreterm Guideline has been developed primarily for clinicians working in obstetric units in the UK;recommendations may be less appropriate for other settings where facilities, resources and routine practicediffer.

2 This Guideline does not include specific recommendations for the management of women who refuseblood transfusion. The Centre for maternal and Child Enquiries (CMACE)2and the RCOG3have publishedguidance regarding the management of pregnancy in women who decline blood products. The code ofpractice for the surgical management of Jehovah s Witness patients by the Royal College of Surgeons(England) and Management of Anaesthesia for Jehovah s Witnesses by the Association of Anaesthetists of GreatBritain and Ireland provide useful additional , and backgroundObstetric haemorrhage remains one of the major causes of maternal death in developing countries and is thecause of up to 50% of the estimated 500 000 maternal deaths that occur globally each the UK, deaths from obstetric haemorrhage are uncommon.

3 In the 2006 08 report of the UK Confidential Enquiriesinto maternal Deaths,7haemorrhage was the sixth highest direct cause of maternal death (9 direct deaths; deaths/million maternities) a decline from the 14 that occurred in the previous triennium ( deaths/million maternities).8 There were 4 deaths from APH in the more recent the 2005 07report of the Confidential Enquiries into maternal Deaths in South Africa, obstetric haemorrhage was the thirdmost common cause of death accounting for of all deaths; there were 108 deaths from APH and 74 ofthese ( ) were considered to be clearly emerges as the major cause of severematernal morbidity in almost all near miss audits in both developed and developing haemorrhage encompasses both antepartum and postpartum bleeding.

4 This green-top Guideline isrestricted in scope to the management of APH. The causes of APH include: placenta praevia, placentalabruption and local causes (for example bleeding from the vulva, vagina or cervix). It is not uncommon to failto identify a cause for APH when it is then described as unexplained APH . Green-top guidelines that are relevant to this topic and are cited in this Guideline include:RCOG Green-top Guideline No. 47 Blood Transfusions in Obstetrics3 RCOG Green-top Guideline No. 22 The Use of Anti-D Immunoglobulin for Rhesus D Prophylaxis11 RCOG Green-top Guideline No. 27 Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and Management12 RCOG Green-top Guideline No.

5 52 Prevention and Management of Postpartum Haemorrhage13 RCOG Green-top Guideline No. 56 maternal collapse in pregnancy and the Puerperium14 RCOG Green-top Guideline No. 55 Late Intrauterine Fetal Death and Stillbirth15 RCOG Green-top Guideline No. 7 Antenatal Corticosteroids to Reduce Neonatal Morbidity16 RCOG Green-top Guideline No. 1b Tocolysis for Women in Preterm Labour17 Royal College of Obstetricians and Gynaecologists3of 23 RCOG Green-top Guideline No. 63 RCOG Green-top Guideline No. 37b The Acute Management of Thrombosis and Embolism DuringPregnancy and the are no consistent definitions of the severity of APH. It is recognised that the amount of blood lost isoften underestimated and that the amount of blood coming from the introitus may not represent the totalblood lost (for example in a concealed placental abruption).

6 It is important therefore, when estimating theblood loss, to assess for signs of clinical shock. The presence of fetal compromise or fetal demise is animportant indicator of volume the purposes of this Guideline , the following definitions have been used:Spotting staining, streaking or blood spotting noted on underwear or sanitary protectionMinor haemorrhage blood loss less than 50 ml that has settledMajor haemorrhage blood loss of 50 1000 ml, with no signs of clinical shockMassive haemorrhage blood loss greater than 1000 ml and/or signs of clinical APH is the term used when there are episodes of APH on more than one and assessment of the evidenceThis Guideline was developed in accordance with standard methodology for producing RCOG 22 Cochrane reviews on interventions for suspected placenta praevia23and for treating placentalabruption have highlighted the lack of evidence to guide Search strategyThe Cochrane Library (including the Cochrane Database of Systematic Reviews, DARE and EMBASE), TRIP,Medline and PubMed (electronic databases)

7 Were searched for relevant randomised controlled trials,systematic reviews and meta-analyses. The search was restricted to articles published between 1966 andFebruary 2011. The databases were searched using the relevant MeSH terms, including all subheadings, andthis was combined with a keyword search. Search words included antepartum haemorrhage , placentalabruption , placenta praevia , placenta previa , vasa praevia , vasa previa , obstetric haemorrhage , obstetrichemorrhage , fetal haemorrhage , fetal hemorrhage , fetomaternal haemorrhage , fetomaternal hemorrhage , antenatal bleeding , pregnancy , disseminated intravascular coagulopathy , and the search limited to humansand the English National Library for Health and the National Guidelines Clearing House were also searched for relevantguidelines and reviews (with no results).

8 Guidelines and recommendations produced by organisations suchas NHS Health Trusts were therefore considered. Where possible, recommendations are based on availableevidence and the areas where evidence is lacking are annotated as good practice points . and prevention of antepartum haemorrhage? What are the risk factors for placental abruption? A number of clinical and epidemiological studies have identified predisposing risk factors for 31 The most predictive is abruption in a previous pregnancy . A large observational study fromNorway reported a incidence of recurrent abruption (adjusted OR , 95% CI ).32 Abruptionrecurs in 19 25% of women who have had two previous pregnancies complicated by riskfactors for placental abruption include: pre-eclampsia, fetal growth restriction, non-vertex presentations,polyhydramnios, advanced maternal age, multiparity, low body mass index (BMI), pregnancy following assistedreproductive techniques, intrauterine infection, premature rupture of membranes, abdominal trauma (bothaccidental and resulting from domestic violence), smoking and drug misuse (cocaine and amphetamines)during ,34 First trimester bleeding increases the risk of abruption later in the pregnancy .

9 A retrospective cohort studyfrom Denmark found that threatened miscarriage increases the risk of placental abruption from to (OR , 95% CI ).35A systematic review reported first trimester bleeding to be associated with anincreased risk of placental abruption (OR , 95% CI ); when an intrauterine haematoma is identifiedon ultrasound scan in the first trimester, the risk of subsequent placental abruption is increased (RR , 95%CI ).36 maternal thrombophilias have been associated with placental abruption. In a systematic review, Robertson seven studies that evaluated the association between thrombophilias and placental , thrombophilias were associated with an increased risk of placental abruption, but significantassociations were only observed with heterozygous factor V Leiden (OR , 95% CI ) andheterozygous prothrombin 20210A (OR , 95% CI ).

10 More recently, a systematic review andmeta-analysis of prospective cohort studies investigating the relationship between factor V Leiden, theprothrombin gene mutation and placental abruption reported only a weak association (pooled OR estimatefor placental abruption in women with factor V Leiden was [95% CI ], and prothrombin20210A was [95% CI ]).38 While these and other risk factors for placental abruption are recognised, causal pathways remain should be assessed for these factors at each antenatal contact. This information may beused to assign women to high-risk or low-risk antenatal What are the risk factors for placenta praevia?A number of risk factors for placenta praevia have been described, some of which are listed in Table 43,45 47In a comparison of maternal risk factors for placenta praevia and placental abruption, Yang et abruption is more likely to be related to conditions occurring during pregnancy and placenta praevia ismore likely to be related to conditions existing prior to Can APH be predicted?