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Bleeding antepartum

Specialties > Emergency medicine and intensive care

Differential Diagnosis Schema 🧠

Placental Causes

  • Placenta previa: Painless bleeding, often occurs after 20 weeks, no uterine tenderness.
  • Placental abruption: Painful bleeding, associated with uterine tenderness and contractions, may have signs of foetal distress.
  • Vasa previa: Foetal vessels run across or close to the internal cervical os, painless bleeding, foetal heart rate abnormalities.

Cervical and Vaginal Causes

  • Cervical ectropion: Erosion of cervical tissue, post-coital bleeding, no pain.
  • Cervical polyps: Painless bleeding, often post-coital, visible on speculum examination.
  • Cervical cancer: Intermittent bleeding, may be associated with pelvic pain, abnormal cervix on examination.
  • Vaginal trauma: Often related to intercourse or examination, bleeding usually occurs immediately following trauma.

Uterine Causes

  • Uterine rupture: Intense abdominal pain, associated with history of previous caesarean section, may be life-threatening.
  • Subchorionic haemorrhage: Bleeding between the chorion and the uterine wall, may be detected on ultrasound.
  • Fibroids: Can cause bleeding, typically with associated uterine enlargement, diagnosed via ultrasound.

Infectious Causes

  • Chorioamnionitis: Associated with fever, uterine tenderness, and malodorous vaginal discharge, often follows prolonged rupture of membranes.
  • Cervicitis: Can be caused by sexually transmitted infections like Chlamydia or Gonorrhoea, presents with mucopurulent discharge.

Key Points in History 🥼

Bleeding Characteristics

  • Onset: Sudden onset may suggest placental abruption or uterine rupture, while gradual onset could suggest placenta previa.
  • Pain: Painful bleeding suggests placental abruption, uterine rupture, or vasa previa, while painless bleeding is more likely placenta previa.
  • Volume: Heavy bleeding may suggest a more severe cause such as placental abruption or uterine rupture.

Obstetric History

  • Previous caesarean section: Increases risk of placenta previa and uterine rupture.
  • History of placenta previa or abruption: Recurrence risk is higher in subsequent pregnancies.
  • Gestational age: Bleeding in the third trimester raises concern for placenta previa and placental abruption.

Background

  • Past medical history: History of hypertension or clotting disorders increases risk of placental abruption.
  • Drug history: Use of anticoagulants may exacerbate bleeding; smoking is a risk factor for placental abruption.
  • Family history: Family history of bleeding disorders might suggest a coagulopathy.
  • Social history: Domestic violence could lead to trauma and consequent bleeding; stress and substance abuse are also relevant.

Possible Investigations 🌡️

Imaging

  • Ultrasound: First-line imaging to assess placental location, foetal well-being, and rule out placenta previa or abruption.
  • MRI: May be used in complex cases to better assess placental attachment or uterine anatomy.

Laboratory Tests

  • Full blood count: To assess for anaemia or infection.
  • Coagulation profile: Important in cases where coagulopathy is suspected, especially with massive bleeding.
  • Kleihauer-Betke test: Assesses the extent of foetal-maternal haemorrhage.
  • Blood group and crossmatch: Essential for preparation in case of necessary transfusion.

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Emergency medicine and intensive care