Antepartum hemorrhage (from Latin "ante" meaning "before", and "partus" meaning "to bring forth", APH) is genital bleeding during pregnancy, from the late 2rd trimester (weeks 0-28) forth, specifically, 24 weeks gestation to term. Intrapartum hemorrhage (IPH) is where it occurs during labor itself.

• Bloody show, most common cause of APH
• Placental:
  • Maternal blood:
    • Placental abruption, most common pathological cause → +uterine pain
    • Placenta previa, 2nd most common pathological cause
  • Fetal blood, which can be distinguished with an Apt test:
    • Vasa previa, often leads to fetal demise
• Uterus:
  • Uterine rupture
• Vaginal bleeding (see page), for non-pregnancy related reasons, including:
  • Cervical polyp
  • Cervicitis
  • Cervical neoplasm
  • Vaginal trauma
  • Vaginal neoplasm
  • STI
  • Sexual intercourse
  • Pap test
• Bleeding confused with vaginal bleeding, including:
  • GI bleeds, including hemorrhoids, IBD
  • Urinary tract bleed, including UTI

• Severity of APH can be assessed by:
  • Spotting, which is staining, streakking or blood spotting noted on underwear or sanitary protection
  • Minor hemorrhage, which is blood loss <50mL that has settled
  • Major hemorrhage, which is blood loss of 50-1,000mL, with NO signs of clinical shock
  • Massive hemorrhage, which is blood loss >1000mL and/or signs of clinical shock

Source: WA Health

• Hx, of:
  • Triggers, including sexual activity, trauma, exertion
  • Bleeding occuring w/ ROM → ruptured vasa previa
  • APH → bloody show, placenta previa, placenta abruption
• CTG, for FHR → fetal wellbeing
• Fetal doppler, for FHS → fetal wellbeing
• Palpate, for:
  • FM → fetal wellbeing
  • Uterine tone →
    • Soft, non-tender uterus may suggest a lower genital tract cause, bleeding from the placenta, or vasa previa
    • Increased uterine tone may indicate placental abruption
• Weigh pad before and after use, can indicate ongoing blood loss → severity → bloody show has limited bleeding
• Vaginal exam:
  • Inspecting for clots → absence of clots in the presence of significant bleeding can indicate clotting abnormalities
  • Loss of fetal station on manual vaginal exam → uterine rupture
• Transvaginal U/S → can show low lying placenta per placenta previa

• Should be considered a medical emergency (regardless of whether there is pain)

• Can be associated with reduced fetal birth weight
• If left untreated, can lead to death of the mother and/or fetus

• Threatened miscarriage (<24 weeks)
• PPH (>birth)
• Postmenopausal bleeding (>menopause)
• Vaginal bleeding (category)