Population Covered By The Guidance
This pathway provides guidance for investigating pregnant patients with antepartum haemorrhage.
Lead Researcher: Charlotte Humphries
Experts & Contributors: Emmeline Lee, Seonaid Mulroy
Editorial Panel: Core Membership
Date reviewed: October 2013
Date Published: November 2013
Low Lying Placenta Praevia
Low Lying Placenta Praevia
Partial Placenta Praevia
Partial Placenta Praevia
Complete Placenta Praevia
Complete Placenta Praevia
- The term antepartum haemorrhage (APH) typically refers to vaginal bleeding during the second half of pregnancy. The main causes are 1,2
- Normal ‘bloody show’
- Placenta Praevia
- Placental abruption
- Vasa praevia
- Transabdominal US is the standard method of evaluating patients with APH
- Resuscitation always takes priority over imaging
- Morrison EH. Common peripartum emergencies. American family physician. 1998;58(7):1593-1604. (Review article)
- Neilson JP. Interventions for treating placental abruption. Cochrane database of systematic reviews (Online). 2003 2003 (1):CD003247-CD003247. (Review article)
- Catanzarite V, Maida C, Thomas W, Mendoza A, Stanco L, Piacquadio KM. Prenatal sonographic diagnosis of vasa previa: ultrasound findings and obstetric outcome in ten cases. Ultrasound in obstetrics & gynecology. 2001;18(2):109-115. (Level III evidence)
- Farine D, Peisner DB, Timortritsch IE. Placenta previa - is the traditional diagnostic approach satisfactory. Journal of Clinical Ultrasound. 1990 May;18(4):328-330. (Level III evidence)
- Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 63: Antepartum Haemorrhage. 2011 [cited 2013 July 1]. Available from: http://www.rcog.org.uk/files/rcog-corp/GTG63_05122011APH.pdf (Evidence based guideline)
- Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 27: Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and managment. 2011 [cited 2013 July 1]. Available from: http://www.rcog.org.uk/files/rcog-corp/GTG27PlacentaPraeviaJanuary2011.pd (Evidence based guideline)
- Sherman SJ, Carlson DE, Platt LD, Medearis AL. Transvaginal ultrasound: does it help in the diagnosis of placenta previa? Ultrasound Obstet Gynecol. 1992 Jul 1;2(4):256-60. (Level II evidence)
- Leerentveld RA, Gilberts EC, Arnold MJ, Wladimiroff JW. Accuracy and safety of transvaginal sonographic placental localization. Obstet Gynecol. 1990;76(5):759-762. (Level III evidence)
- Smith RS, Lauria MR, Comstock CH, Treadwell MC, Kirk JS, Lee W, et al. Transvaginal ultrasonography for all placentas that appear to be low-lying or over the internal cervical os. Ultrasound Obstet Gynecol. 1997 Jan;9(1):22-4. (Level III evidence)
- Maher MA, Abdelaziz A, Bazeed MF. Diagnostic accuracy of ultrasound and MRI in the prenatal diagnosis of placenta accreta. Acta Obstet Gynecol Scand. 2013 May 28. (Level III evidence)
- Warshak CR, Eskander R, Hull AD, Scioscia AL, Mattrey RF, Benirschke K, et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. Obstet Gynecol. 2006 Sep;108(3 Pt 1):573-81. (Level III evidence)
- Shih JC, Palacios Jaraquemada JM, Su YN, Shyu MK, Lin CH, Lin SY, et al. Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques. Ultrasound Obstet Gynecol. 2009 Feb;33(2):193-203. (Level II/III evidence)
- Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment of placental abruption. Journal of ultrasound in medicine. 2002;21(8):837-840. (Level III evidence)
- Harlev A, Levy A, Zaulan Y, Koifman A, Mazor M, Wiznitzer A, et al. Idiopathic bleeding during the second half of pregnancy as a risk factor for adverse perinatal outcome. J Matern Fetal Neonatal Med. 2008 May;21(5):331-5. (Level II evidence)
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| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Ultrasound
Ultrasound
Transabdominal ultrasound is the standard method of assessing antepartum haemorrhage. If visualisation of the relationship of the placenta to the internal os is obscured, then transvaginal or transperineal US should be considered
- Ultrasonography (transabdominal and transvaginal) is the standard method of evaluating patients with antepartum haemorrhage (APH), but resuscitation takes priority over any form of imaging
- Transvaginal US was more accurate than transabdominal US in placental localisation and diagnosis of placenta praevia in one small randomised controlled trial. It appears safe and is not associated with an increase in the rate of haemorrhage, haemorrhagic complications or other adverse outcomes in prospective studies ,
- Transvaginal US is 87.5% sensitive and 98.8% specific for placenta praevia in the second and third trimester
- Transabdominal US is 79%-82% sensitive and 38%-97% specific for placenta praevia
- If the placenta is noted to be praevia earlier in pregnancy, a repeat ultrasound is recommended at 32 weeks gestation for asymptomatic women ,
- Transabdominal and transvaginal US (3D power Doppler > grey scale > colour Doppler,) can help detect placenta praevia accreta. MRI can provide additional information where ultrasound is inconclusive
- Ultrasound cannot exclude placental abruption, with reported sensitivity of just 24%. This remains a clinical diagnosis. However, when ultrasound suggests abruption the likelihood is high (96% specificity)
- Vasa praevia can be accurately diagnosed with transvaginal and transabdominal colour Doppler ultrasound, but in APH with fetal compromise or membrane rupture delivery should not be delayed to try and confirm diagnosis.6 Formal assessment of the region of the internal cervical os is with transvaginal colour Doppler
- Women with unexplained APH are at increased risk of adverse perinatal outcomes including intrauterine growth restriction (IUGR). They should be considered high risk and have increased fetal surveillance including serial ultrasound