Bleeding during pregnancy is a cause for concern in many pregnant women and most often requires expert clinical management to prevent serious complications that may include death.

What is antepartum haemorrhage?
Antepartum haemorrhage is bleeding from the genital tract between 28 completed weeks of pregnancy and the onset of labour. Many of the causes of antepartum haemorrhage may exist before this time and may occur as early as 20 weeks gestation. The placental bed is the commonest site for antepartum bleeding.In a few cases bleeding is from local causes in the genital tract, while in a large number of cases no obvious cause is found.

Placental abruption
This is also called premature separation of the placenta. It is defined as the separation of a normally implanted placenta (afterbirth) from its uterine site before the delivery of the fetus. The are many ways to classify this condition. Placental abruption may entail only a small area of placental separation, but in some cases the separation may be very extensive. The patient’s pain and shock depend on the amount of tissue damage rather than on the volume pf bleeding. The amount of spasm in the blood vessel together with the amount of bleeding will both contribute to fetal death.

What are the causes of placental abruption?
The exact cause for placental abruption is not known. There are several predisposing factors and these include:
Previous placental abruption
Chronic hypertension or pregnancy - induced hypertension
Advanced maternal age
Over distension of the uterus - multiple pregnancy
Cigarette smoking
Fibroids
Trauma

What are the signs and symptoms of placental abruption?
These include the following:
Sudden severe abdominal pain or back pain
Hyperactive uterine contractions
Uterus very tender
Fainting or collapse
Shock
Vaginal bleeding

Management
A woman with placental abruption has a potentially dangerous condition that requires referral to a hospital immediately. A senior obstetrician should manage such cases.
Severe abruption may lead to severely disordered blood clotting, which must be managed expertly to prevent further complications.

Placenta praevia
This condition occurs in one out of 200 pregnancies. In this condition the placenta attaches to the uterine wall in the lower portion of the uterus and cover all or part of the cervix (mouth of the womb). About one-tenth of all antepartum haemorrhages are due to placenta praevia. In the lasts weeks of pregnancy the lower segment of the uterus stretches whereas the placenta is comparatively inelastic. In consequence, the placenta is peeled off the uterine wall with bleeding from the placental bed.

What are the causes of placenta praevia?
The cause of placenta praevia in not known. Associated factors include:
Previous Caesarean section (C-section)
Multiparty
Advanced maternal age (over 35 years)
Multiple gestations

Diagnosis
A woman with placenta praevia may have bright red, painless vaginal bleeding. It comes unexpectedly and the patient does not usually go into shock. Indeed, many women may want to ignore the bleeding because they feel normal. An ultrasound scan will confirm the diagnosis.

Management
Any woman experiencing vaginal bleeding in late pregnancy should be seen by a qualified and experienced obstetrician. No vaginal examination should be performed on any woman who bleeds in late pregnancy until a placenta praevia has been excluded by ultrasonography. If this principle is not followed, further separation of the placenta may occur with very heavy, and sometimes fatal, haemorrhage.
Once placenta praevia is diagnosed, the aim of treatment is to maintain the pregnancy until the fetus is mature enough to be delivered. An elective Caesarean section will be performed unless the placenta praevia is a minor one.

Other causes of bleeding
A heavy show may be confused with antepartum bleeding. A show is the consequence of dilation of the cervix with tearing of small veins.
Other non-obstetric causes of bleeding include the following:
Cervicitis
Cervical erosion
Cervical polyp
Cervical cancer
Vaginal candidiasis
Vaginal varicose veins
Vaginal lacerations

Bleeding of unknown origin
A definite cause of antepartum haemorrhage is unknown in a large number of women. Even if the cause is unknown, the woman should not be dismissed lightly. The risk to her baby at subsequent labour is high.

Conclusion
Women presenting with bleeding late in pregnancy must be assessed to rule out life threatening conditions such as placental abruption and placenta praevia. These conditions can lead to death of the pregnant mother and the fetus. An experience obstetrician must manage all cases of vaginal bleeding in late pregnancy. Cases must be admitted to hospital and, in most cases, remain in hospital until delivery. In the majority of cases of placenta praevia, once the correct diagnosis is made and correct management instituted the outcome is good. This is not the case with severe placenta abruption where the fetus may be dead prior to the patient seeking medical care. Pregnant women in late pregnancy must not ignore bleeding in late pregnancy and must seek medical advice.

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