see also [[postpartum haemorrhage]], [[placental abruption]], [[miscarriage and threatened miscarriage]] #tables > - The most common incidental cause of bleeding is from cervical erosion or ectropion, often presenting with post-coital bleeding. > - Sinister causes discussed below must first be considered > - If blood mixed with mucous released, consider whether this is actually [[pre-term labour#PPROM]] # Life threats to mum or bub | diagnosis | bleeding | pain | signs | complications | | ----------------------- | ---------------------------------- | ----- | -------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------- | | [[#Placenta praevia]] | bright blood, sudden and profuse | no | soft and non-tender uterus.<br>no foetal distress | - shock (worse for *mum* initially than bub)<br>- [[pre-term labour\|premature delivery]] | | [[placental abruption]] | dark blood (or, rarely, concealed) | *yes* | tender, contracted uterus.<br>maternal shock and fetal distress | fetal death, maternal shock and death, [[DIC]] | | [[#Vasa praevia]] | small amount | no | fetal distress *without maternal distress* | foetal death | | [[uterine rupture]] | variable | yes | usually due to severe mechanism. rare. maternal shock, abdo pain, palpable fetal anatomy, fetal demise | many; really only happens in [[Pregnant trauma\|trauma]] | **Other DDx** - cervical (ectropion, cervical incompetence) - polyps - vulvar varicies - trauma - infection - PROM - malignancy - lower GI tract incidental # General APH mgmt - urgent obstetrics referral / review - *PV exam contraindicated* until praevia excluded on USS - only done if active tx for bleeding available (eg in OT, under GA, have x-matched blood ready, ready for emergency C-section) - Don’t confuse praevia with abruption, for which USS has no use > **if shocked or significant bleeding** > - volume resus with blood # Placental abruption - separation of normally located placenta - causes: - *patient factors* - HTN - trauma - smoking - EtOH - coagulopathy - *obstetric factors* - short umbilical cord - premature rupture of membranes - fibroid - idiopathic - findings - PV bleeding - A retroplacental clot may form and accumulate with 2-4L of maternal blood *without* vaginal loss - abdo or back pain - uterine tenderness - abnormal uterine contractions - premature labour - Ix - [[CTG monitoring|CTG]] - FBC - coags and DIC screen - group and hold - USS -- cannot exclude abruption, this is a ==CLINICAL DIAGNOSIS== - **mgmt** - urgent Ob consult - deliver if unstable - IVF +/- blood - reverse coagulopathy - consider betamethasone - [[Anti-D]] if indicated # Placenta praevia - 2nd and 3rd trimester - implantation of placenta over or near internal os - total - internal os completely covered by placenta - partial - os partially covered - causes - prior C section - increased maternal age - smoking - Assisted reproduction - Multiparity - Prev abortion - complications - antipartum haemorrhage - placenta accreta spectrum and PPM - Ax - vaginal bleeding: sudden onset, **PAINLESS**, often settles and re-occurs - Ix - ==USS locates placenta in 95% of cases== - blood group and hold - feto-maternal haemorrhage test - **Mgmt** - ob consult - +/- steroids - +/- [[Anti-D]] # Vasa praevia - RARE - blood vessels in the placenta or umbilical cord are trapped btwn foetus and cervix/vagina - Ax - vaginal bleeding - umbilical vessels are torn at time of labour or during artifical rupture of membranes - bleeding is completely **foetal in origin** - ==no maternal haemodynamic changes== - **small bleeding can cause significna fetal compromise**; 75% mortality! - ==decelerations on [[CTG monitoring]]== - mgmt - emergency c-section