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Referral and warning signs
When to refer
Urgent Referral/Transfer to Hospital (H/RR) for ALL APH cases. Ensure facility capable of blood transfusion and emergency C/S.
Red flags
- Heavy vaginal bleeding
- Signs of shock
- Severe abdominal pain / Tense uterus
- Fetal distress / Absent FHR
- Signs of DIC
Signs and symptoms
- Placenta Praevia: Painless, bright red vaginal bleeding. Often recurrent. Uterus soft, non-tender. FHR usually present. Malpresentation common.
- Abruptio Placentae: Vaginal bleeding (often dark, may be concealed). Abdominal pain (constant, severe). Uterus tender, firm, 'woody'. Fetal distress/absent FHR common. Maternal shock may exceed visible loss.
- Local Causes: Lighter bleeding, often post-coital. Identified on speculum.
Risk factors
- Praevia: Previous C/S, previous praevia, multiparity, AMA, multiple gestation, smoking.
- Abruption: Hypertension/PET, previous abruption, trauma, smoking, cocaine, PROM, multiple gestation, polyhydramnios.
Diagnosis
Clinical assessment
History (bleeding onset, amount, colour, pain, trauma). Abdo exam (tone, tenderness, SFH, FHR). Speculum exam (gentle) to rule out local causes. AVOID Digital Vaginal Exam until Praevia excluded by ultrasound.
Investigations
- Ultrasound Scan: Essential to locate placenta (diagnose/exclude Praevia). May show retroplacental clot (Abruption).
- FBC (anaemia).
- Blood Group & Cross-match.
- Coagulation Screen (esp. if Abruption).
- Cardiotocography (CTG - assess fetal well-being).
Diagnostic criteria
Clinical presentation (painful vs painless bleed, uterine tone) + Ultrasound (placental location).
Management
Non-pharmacological management
- Immediate Assessment & Resuscitation (ABC).
- Establish large-bore IV access (x2).
- Oxygen.
- Continuous maternal/fetal monitoring.
- Hospital Admission for ALL APH.
- Bed rest.
- Decision on delivery mode/timing.
Pharmacological treatment
- IV Fluids (Crystalloids).
- Blood Transfusion (PRBCs/WB).
- FFP/Cryo/Platelets (if DIC).
- Antenatal Corticosteroids (<34 weeks if delivery not imminent).
- Anti-D Immunoglobulin (Rh-negative).
- Tocolysis CONTRAINDICATED in significant APH.
- Management by Cause:
- - Praevia: Minor bleed/preterm -> Conservative in hospital, steroids <34w, elective C/S 36-37w. Major bleed/labour/term -> Emergency C/S.
- - Abruption: Fetal distress/Maternal compromise/Term -> Urgent Delivery (usually C/S). Fetus dead/Preterm/Stable -> May consider IOL with close monitoring.
Monitoring
Maternal vitals, blood loss, uterine tone. FHR (CTG). Serial FBC, coagulation.
Complications
- Maternal: Shock, Anaemia, DIC, AKI, Sheehan's, PPH, Hysterectomy, Death.
- Fetal/Neonatal: Distress/hypoxia, Stillbirth/Death, Prematurity, IUGR, Anaemia.
Prevention
- Manage risk factors (hypertension, smoking).
- Avoid trauma.
- Manage multiple pregnancies appropriately.
Patient education
- Explanation of cause.
- Need for admission/monitoring.
- Potential risks.
- Possible need for transfusion/urgent delivery (likely C/S).
- Report further bleeding/pain immediately.
Uganda-specific notes
Major cause of mortality. Access to ultrasound, blood, emergency C/S critical but often delayed. Clinical differentiation key if no ultrasound. AVOID VE if Praevia suspected.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.3.6