In obstetrics

Obstetrics

Obstetrics is the medical specialty dealing with the care of all women's reproductive tracts and their children during pregnancy , childbirth and the postnatal period...

, antepartum haemorrhage (APH), also prepartum hemorrhage, is bleeding from the vagina

Vagina

The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the...

 during pregnancy

Pregnancy

Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...

 from the 24th (22nd in Malaysia), (28th in India) week (sometimes defined as from the 20th week) gestational age

Gestational age

Gestational age relates to the age of an embryo or fetus . There is some ambiguity in how it is defined:*In embryology, gestational age is the time elapsed since conception. This interval is also termed fertilisation age....

 to term.

It can be associated with reduced fetal birth weight.

Treatment

It should be considered a medical emergency

Medical emergency

A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...

 (regardless of whether there is pain

Pain

Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...

) and medical attention should be sought immediately, as if it is left untreated it can lead to death

Death

Death is the permanent termination of the biological functions that sustain a living organism. Phenomena which commonly bring about death include old age, predation, malnutrition, disease, and accidents or trauma resulting in terminal injury....

 of the mother and/or fetus

Fetus

A fetus is a developing mammal or other viviparous vertebrate after the embryonic stage and before birth.In humans, the fetal stage of prenatal development starts at the beginning of the 11th week in gestational age, which is the 9th week after fertilization.-Etymology and spelling variations:The...

.

Bleeding without pain is most frequently bloody show

Bloody show

Bloody show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It can occur just before labor or in early labor as the cervix changes shape, freeing mucus and blood that occupied the cervical glands or cervical os. Bloody show is a...

, which is benign; however, it may also be placenta previa (in which both the mother and fetus are in danger). Painful APH is most frequently placental abruption (which may also lead to adverse fetal and/or maternal outcomes).

As with other forms of hemorrhage, the patient may be at risk of hypovolemic shock, and volume restoration may be a priority.

Differential diagnosis of APH

• Obstetric
  • Placenta
    • Maternal blood
      • Bloody show
        Bloody show
        Bloody show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It can occur just before labor or in early labor as the cervix changes shape, freeing mucus and blood that occupied the cervical glands or cervical os. Bloody show is a...
        
         (benign) - most common cause of APH
      • Placental abruption
        Placental abruption
        Placental abruption is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth...
        
         - most common pathological
        Pathology
        Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
        
         cause
      • Placenta previa - second most common pathological cause
    • Fetal blood (can be distinguished with Apt test
      Apt test
      The Apt test is a medical test used to differentiate fetal or neonatal blood from maternal blood.-History:The test was developed by Leonard Apt, an American pediatric ophthalmologist. The test was originally used to identify the source of bloody stools in newborn infants...
      
      )
      • Vasa previa - often difficult to diagnose, frequently leads to fetal demise
  • Uterus
    • Uterine rupture
      Uterine rupture
      Uterine rupture is a potentially catastrophic event during childbirth by which the integrity of the myometrial wall is breached. In an incomplete rupture the peritoneum is still intact. With a complete rupture the contents of the uterus may spill into the peritoneal cavity or the broad ligament...
      
      

avoid manual examination as it may lead to further damage and bleeding

• Nonobstetric
  • Bleeding from the lower genital tract
    • Cervical bleeding - cervicitis
      Cervicitis
      Cervicitis is inflammation of the uterine cervix. Cervicitis in women has many features in common with urethritis in men and many cases are caused by sexually transmitted infections...
      
      , cervical neoplasm, cervical polyp
      Cervical polyp
      A cervical polyp is a common benign polyp or tumour on the surface of the cervical canal. They can cause irregular menstrual bleeding but often show no symptoms. Treatment consists of simple removal of the polyp and prognosis is generally good. About 1% of cervical polyps will show neoplastic...
      
      
    • Bleeding from the vagina itself - trauma, neoplasm
  • Bleeding that may be confused with vaginal bleeding
    • GI bleed - haemorrhoid
      Hemorrhoid
      Hemorrhoids or haemorrhoids , are vascular structures in the anal canal which help with stool control. They become pathological or piles when swollen or inflamed. In their physiological state they act as a cushion composed of arterio-venous channels and connective tissue that aid the passage of...
      
      s, inflammatory bowel disease
      Inflammatory bowel disease
      In medicine, inflammatory bowel disease is a group of inflammatory conditions of the colon and small intestine. The major types of IBD are Crohn's disease and ulcerative colitis.-Classification:...
      
      
    • Urinary tract bleed - urinary tract infection
      Urinary tract infection
      A urinary tract infection is a bacterial infection that affects any part of the urinary tract. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli...
      
      

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