Antepartum Haemorrhage (APH) and the causes
An APH is bleeding from the vagina that occurs after the 20th week of pregnancy and before the birth of your baby. The common causes of bleeding during pregnancy are cervical erosion, vaginal infection, placental edge bleed, placenta praevia or placental abruption.
The cells on the surface of the cervix often change in pregnancy and make the tissue more likely to bleed, particularly after sex. This is called cervical erosion. This condition does not affect the pregnancy at all.
Vaginal infections can also cause a small amount of vaginal bleeding (eg severe Thrush) and you may be very uncomfortable. It is important to seek treatment from your Dr for this condition.
Placental Edge Bleed
In the second half of your pregnancy, the lower-segment of the uterus begins to stretch and grow which can lead to the edge of the placenta separating from the wall of the uterus. In most cases bleeding will stop after a few hours. It is important for you to contact the hospital to arrange assessment when you first notice the bleeding.
Placenta praevia is when the placenta grows in the lower segment of the uterus and is found near the edge or covering the cervix. We classify placenta praevia into four types:
Type I – The placenta is near the cervix.
Type II – The placenta reaches the edge of the cervix.
Type III – The placenta covers the cervix when it is closed, but not completely when it is open.
Type IV – The placenta completely covers the cervix even when it is open.
Causes of placenta praevia
The cause of placenta praevia is often unknown but these are some of the factors that put women more at risk:
- Previous Caesarean Section or uterine surgery
- Previous Placenta Praevia
- Multiple pregnancy (twins/triplets)
- Age (above 35 years)
- Multiple previous pregnancies
- Closely spaced pregnancies
- Placental abnormalities
- Abnormalities in the baby
If you have an ultrasound scan (USS) around 18-20 weeks the site of the placenta is identified. Approximately 1 in 5 women will have a low-lying placenta at this time. A repeat USS will be done at 32 to 34 weeks of pregnancy and by then only 2% of women will still have a low-lying placenta. Your doctor or midwife will discuss ongoing management and care. Most women with Type III and IV placenta praevia will need to give birth by Caesarean section.
Placental abruption occurs when the placenta separates from the wall of the uterus and a large amount of vaginal blood loss usually occurs. Some of the blood may however remain in the uterus and this can lead to a blood clot forming behind the placenta. The amount of vaginal blood loss is therefore not an accurate measurement of actual bleeding.
If you have any blood loss or abdominal pain it is important to contact your doctor or midwife immediately. Some causes of vaginal bleeding are more serious than others so it is important to find out the reason as soon as possible.
If you have any bleeding in pregnancy there is an increased risk of the baby's blood crossing into your blood stream. This may be of concern depending on your blood group. For example if you have a rhesus negative blood group you may need to have an injection of Anti D immunoglobulin. This should be discussed with your doctor or midwife.
You may be admitted to hospital for observation and assessment of the cause of your bleeding. The midwives will monitor the amount of blood loss, you may have a CTG (tracing of your baby's heart beat) and an ultrasound. Depending on how much bleeding has occurred, you may need to have an intravenous (IV) drip inserted and may require IV fluids. In severe circumstances you may require a blood transfusion or the baby may need to be born early. Most importantly, you will be encouraged to rest in bed.
If you are less than 35 weeks pregnant and your condition has stabilised you may be transferred to Mater Mothers' Private Hospital at South Brisbane for ongoing care and management.
Until your baby is born, it is important that you:
- Change sanitary pads at least every four hours while you have any blood loss (personal hygiene is very important to reduce the risk of infection).
- Do not use tampons
- Wipe from front to back after going to the toilet
- Do not go swimming
- Do not have baths or use a spa (please shower)
- Do not take part in any form of sexual activity
- Do not use any vaginal medications / creams
We recommend you discuss the plans for the rest of your pregnancy with your doctor.
Please telephone Birth Suites for advice at any time on 07 3163 7444.
References: Milliman Care Guidelines 11th Edition 2007
Mater Private Hospital Redland
Telephone: 3163 7444
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Mater acknowledges consumer consultation in the development of this patient information.
Last modified 13/11/2015.