As part of our continued efforts towards protecting your privacy and personal information, we’ve made recent updates to our privacy policy. The public hospital system is currently under considerable pressure to meet the needs of public obstetric care. The development of guidelines involves more than the collation and reviewing of evidence. hospitalization with hemodynamic stabilization and continuous maternal and fetal monitoring. It can be associated with reduced fetal birth weight. The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site. Differentiate the clinical features of placenta previa, abruptio placenta and other possible causes. The level of evidence and the grade of the recommendations used in this guideline originate from the guidance by the Scottish Intercollegiate Guidelines Network (SIGN) Grading Review Group, which incorporates formal assessment of the methodological quality, quantity, consistency, and applicability of the evidence base. All rights reserved. Most antepartum haemorrhages (APH) usually occur because of either: Vaginal bleeding can be mild or severe. A policy of expectant management, pioneered by MacAfee,19 continues to be … The principles of fluid replacement and administration of blood products are the same for APH as they are for postpartum haemorrhage. This offer is for all new pregnancies booked after 1st April 2020 until 30th September 2020. Full text Full text is available as a scanned copy of the original print version. WHO recommendations for the prevention and treatment of postpartum haemorrhage 3 Executive summary Introduction Postpartum Haemorrhage (PPH) is commonly defined as a blood loss of 500 ml or more within 24 hours after birth. Prediction and Prevention of Antepartum Haemorrhage (APH). This guideline was developed in accordance with standard methodology for producing Royal College of Obstetricians and Gynaecologists (RCOG) Green-top guidelines. Any woman who is considered to be at high risk of haemorrhage and in whom continued heparin treatment is considered essential should be managed with intravenous, unfractionated heparin until the risk factors for haemorrhage have resolved. The primary goal of this guideline is to provide a foundation for the implementation of interventions shown to have been effective in reducing the burden of PPH. It can be associated with reduced fetal birth weight. D - In the non-sensitised RhD-negative woman in the event of recurrent vaginal bleeding after 20+0 weeks of gestation, anti-D Ig should be given at a minimum of 6-weekly intervals. All comments will be collated by the RCOG and tabulated for consideration by the guideline leads. This is the current release of the guideline. Sometimes it can be revealed but occasionally there may also be concealed internal bleeding. Once evidence has been collated and appraised, it can be graded. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2006 Nov. 4 p. Electronic copies: Available from the, Development of RCOG Green-top guidelines: producing a clinical practice guideline. Antepartum Haemorrhage Page 4 of 17 Obstetrics & Gynaecology 6. External Peer Review Internal Peer Review. What Investigations Should Be Performed in Women Presenting with APH? Placental abruption can increase perinatal morbidity and mortality. The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field). Where evidence is felt to warrant 'down-grading', for whatever reason, the rationale must be stated. The common causes of bleeding during pregnancy are cervical ectropion, vaginal infection, placental edge bleed, placenta praevia or placental abruption. Blood transfusions may be applied in cases of prolonged hemorrhage. Counseling Diagnosis Evaluation Management Prevention Risk Assessment Treatment, Anesthesiology Family Practice Internal Medicine Obstetrics and Gynecology Pediatrics Radiology, Advanced Practice Nurses Nurses Physician Assistants Physicians, To assist clinicians working in obstetric units in the UK in identifying the risk factors, diagnosis, and management of single or recurrent antepartum haemorrhage (APH), Pregnant women with antepartum haemorrhage (APH), occurring from 24+0 weeks of pregnancy and prior to the birth of the baby. Due to the continuing pandemic, we have elected to extend our offer until 31 December 2020. Up to 4 units of fresh frozen plasma (FFP) and 10 units of cryoprecipitate may be given whilst awaiting the results of the coagulation studies. D - Women receiving antenatal anticoagulant therapy (usually low molecular weight heparin or warfarin) should be advised that if they have any vaginal bleeding they should not take any more doses of anticoagulant medication. To get started, log in or create your free account Create Account, © Guideline Central 2021 | All Rights Reserved – Privacy, Terms, and Rights, CPT© copyright 2019 American Medical Association. Thirty percent of maternal deaths are caused by antepartum haemorrhage of which 50% are associated with avoidable factors.2 The causes of antepartum hemorrhage Any study with a high chance of bias (either 1– or 2–) will be excluded from the guideline and recommendations will not be based on this evidence. Antepartum bleeding, also known as antepartum haemorrhage or prepartum hemorrhage, is genital bleeding during pregnancy after the 28th week of pregnancy up to delivery.. 24/7 Phone Available to all expecting mothers. Published on 20 December 2018; Presentation 3.8 MB, 33 slides; Overview. We believe that patients will value the experience of private obstetric care with an experienced obstetrician at Northpark private hospital with a significant reduction in costs. } fetal distress is marked with mild vaginal bleeding and good general condition of the mother} . 52, "Prevention and Management of Postpartum Haemorrhage" and are summarised in Appendix 2 in the original guideline document. DIC (coagulation problems resulting from consumption of blood clotting factors). The Cochrane Library (including the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews and Effects [DARE] and EMBASE), Turning Research into Practice (TRIP), Medline and PubMed (electronic databases) were searched for relevant randomised controlled trials, systematic reviews and meta-analyses. Note: This guideline does not include specific recommendations for the management of women who refuse blood transfusion. substandard care in the majority of fatal cases, obstetric haemorrhage must be considered as a priority topic for national guideline development. Dr. Steve Hatzikostas However, some exclusions apply. There are no notes to display. Should Corticosteroids Be Administered to Women who Present with APH Before Term? Clinical Governance Advice No 1a. Purpose and scope Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby. B - Consideration should be given to the use of ergometrine-oxytocin (Syntometrine® [Alliance, Chippenham, Wilts]) to manage the third stage of labour in women with APH resulting from placental abruption or placenta praevia in the absence of hypertension (see the Green-top guideline No. Observation, bed rest, regular control 1.2. In addition to these evidence-based recommendations, the guideline developer also identifies points of best clinical practice in the original guideline document. C - Ultrasound can be used to diagnose placenta praevia but does not exclude abruption. It is not uncommon to fail to identify a cause for APH, when it is then described as 'unexplained APH'. Dr Steven Hatzikostas is a top Melbourne Obstetrician with more than 20 years of high risk obstetric … Antepartum haemorrhage (APH) - single or recurrent. This summary was verified by the guideline developer on June 18, 2012. Electronic copies: Available from the Royal College of Obstetricians and Gynaecologists (RCOG) Web site. An objective appraisal of study quality is essential, but paired reviewing by guideline leads may be impractical because of resource constraints. The National Library for Health and the National Guideline Clearinghouse were also searched for relevant guidelines and reviews (with no results). In addition, suggested audit topics can be found in section 21 of the original guideline document. This will therefore introduce the need for consensus. It is hoped that this process of local ownership will help to incorporate these guidelines into routine practice. Oxytocin is the most effective treatment for postpartum hemorrhage, even if already used for labor induction or augmentation or as part of AMTSL. If there are signs of fetal or maternal compromise, consider immediate delivery. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes. Define antepartum hemorrhage. How Should the Woman with an Extremely Preterm Pregnancy (24+0 to 26+0 Weeks of Gestation) and APH Be Managed? D - A senior paediatrician/neonatologist should be involved in the counselling of women when extreme preterm birth is likely. From the 26th week of pregnancy the Lower Segment of the uterus will have formed and any placenta, which remains low and encroaches the lower segment will be called a Placenta Praevia. Management of APH in general There are few high quality clinical trials to guide the management of antepartum haemorrhage or abruption, where there is high quality evidence this is noted below. Hysterectomy is often the definitive treatment for PPH with the most common indications being uterine atony and placenta accreta. No definite cause is diagnosed in about 50% of all women who present with APH; however, placenta praevia and placental abruption are the major identifiable causes: 1. Get a printable copy (PDF file) of the complete article (295K), or click on a page image below to browse page by page. Following this review, the document will be updated and the GC will then review the revised draft and the table of comments. 3. In these cases the baby is at major risk will need to be delivered prematurely and usually by caesarean section. D - Placental abruption is a clinical diagnosis and there are no sensitive or reliable diagnostic tests available. If available, randomised controlled trials (RCTs) of suitable size and quality should be used in preference to observational data. In response to the extraordinary circumstances that our community is facing with the current COVID – 19 Pandemic, we have elected to adopt a proactive financial support approach to help families who are experiencing financial difficulties. They are associated with major risks to mother and baby’s health. 63). [Medline] . D - In the non-sensitised RhD-negative woman for all events after 20+0 weeks of gestation, at least 500 iu anti-D Ig should be given followed by a test to identify FMH greater than 4 ml red blood cells; additional anti-D Ig should be given as required. Antepartum Haemorrhage (APH)_2015-11-18.docx Page 5 of 9 6. 7. Nynke R. van den Broek, in Hunter's Tropical Medicine and Emerging Infectious Diseases (Tenth Edition), 2020 Hemorrhage. Most antepartum haemorrhages (APH) usually occur because of either Placental Abruption or a Low Lying Placenta. Spontaneous abortion occurs in less than 30% of these women. What Is the Role of Obstetric Skill Drills to Improve the Management of APH? Please call Northpark Reception 03 9468 0100 outside of normal business hours if you do not have this number. Treatment for postpartum hemorrhage may include: Medication (to stimulate uterine contractions) Manual massage of the uterus (to stimulate contractions) Removal of placental pieces that remain in the uterus. If the placental abruption is small it may have no apparent effect on the fetus but can subsequently be associated with fetal growth restriction. Antepartum haemorrhage is a relatively common entity with potentially serious implications for the mother and the fetus. 4. Tranexamic acid for the prevention and treatment of postpartum haemorrhage. 1. 27, Placenta Praevia, Placenta Accreta and Vasa Praevia: Diagnosis and Management). Placental abruption can also cause serious and life threatening problems for the mother as well through: A low-lying placenta is commonly found at the time of the 20-week ultrasound scan. 8, 23, 24 The choice of a … Antepartum haemorrhage is vaginal bleeding in pregnancy occurring from 24 weeks and above and prior to delivery(1). London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2011 Nov. 23 p. (Green-top guideline; no. 2018 UPDATE. Antepartum haemorrhage is defined as bleeding from the vagina after 24weeks. Half of all cases are small abruptions but 25% can be moderate or severe. How Should the Woman Presenting with an APH Who Develops a Coagulopathy Be Managed? 1.2 All staff must perform these guidelines in accordance with the Trust’s Health and Safety Policy. This prevents recommendations being based on poor-quality RCTs when higher-quality observational evidence is available. Get a printable copy (PDF file) of the complete article (295K), or click on a page image below to browse page by page. The best treatment for postpartum hemorrhage is to replace the lost blood and fluids. Antepartum vaginal bleeding may occur in as many as 25% of pregnant women; fortunately, only a fraction of these patients experience life-threatening hemorrhage. Equally, in contrast to other guideline groups, the topics chosen for development as Green-top guidelines are concise enough to allow development by a smaller group of individuals. Obstetric hemorrhage is the most commonly documented cause of maternal death. 1. Antepartum haemorrhages are identified as bleeding in pregnancy occurring after the 20th week of pregnancy. [Evidence level 4]. Register D - In women who are in preterm labour whose pregnancies have been complicated by major APH or recurrent minor APH, or if there has been any clinical suspicion of an abruption, then continuous electronic fetal monitoring should be recommended. See the separate Placenta and Placental Problemsarticle. Saturday-Sunday & Public Holidays: Closed D - Following APH from placental abruption or unexplained APH, the pregnancy should be reclassified as 'high risk' and antenatal care should be consultant-led. The databases were searched using the relevant MeSH terms, including all subheadings, and this was combined with a keyword search. Authors: Dr AJ Thomson MRCOG, Paisley, Scotland and Dr JE Ramsay MRCOG, Kilmarnock, Scotland; with input from Miss D Rich FRCOG, Wales at the scope and first draft stage, Peer Reviewers: Sir S Arulkumaran FRCOG, London; Mr KT Moriarty MRCOG, Northampton; Mr DI Fraser MRCOG, Norwich; Mr AK Ash FRCOG, London; Dr G Kumar FRCOG, BMFMS, RCGP, BCSH, Committee Lead Peer Reviewers: Dr P Owen MRCOG, Glasgow, Scotland; Dr K Harding FRCOG, London. Most antepartum haemorrhages (APH) usually occur because of either Placental Abruption or a Low Lying Placenta. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2006 Nov. 6 p. Electronic copies: Available from the, Development of RCOG Green-top guidelines: producing a scope. If necessary, tocolysis (e.g., nifedipine, β2-adrenergic agonist) 1.2.3. Antepartum Hemorrhage. Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field. NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. b. – US Government Rights. Note: The causes of APH include placenta praevia, placental abruption and local causes (for example bleeding from the vulva, vagina or cervix). The causes of antepartum hemorrhage range from cervicitis to abnormalities in placentation, including placenta previa and placental abruption. It is envisaged that this will not detract from the rigor of the process but prevent undue delays in development. Weighting According to a Rating Scheme (Scheme Given), 1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias, 1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias, 1– Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias, 2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal, 2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal, 2– Case–control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal, 3 Non-analytical studies, e.g., case reports, case series, Review of Published Meta-Analyses Systematic Review. A propensity score and inverse probability treatment weighting was used to generate an odds ratio that corrects for differences in baseline characteristics. *By signing up I agree to the privacy terms listed here, Type of Evidence Supporting the Recommendations, Methods Used to Collect/Select the Evidence, Description of Methods Used to Collect/Select the Evidence, Methods Used to Assess the Quality and Strength of the Evidence, Rating Scheme for the Strength of the Evidence, Description of the Methods Used to Analyze the Evidence, Methods Used to Formulate the Recommendations, Description of Methods Used to Formulate the Recommendations, Description of Method of Guideline Validation, Composition of Group That Authored the Guideline, Financial Disclosures/Conflicts of Interest, *By signing up I agree to the privacy terms listed, Benefits/harms Of Implementing The Guideline Recommendations, Rating Scheme For The Strength Of The Recommendations, Institute Of Medicine (iom) National Healthcare Quality Report Categories, www.sign.ac.uk/methodology/checklists.html, Royal College of Obstetricians and Gynaecologists (RCOG) Web site, Placenta Praevia, Placenta Accreta and Vasa Praevia: Diagnosis and Management, http://www.guideline.gov/about/inclusion-criteria.aspx, Reduced pregnancy complications related to antepartum haemorrhage, Prevention of maternal or fetal morbidity and mortality. Use of aspirin before 16 weeks of pregnancy to prevent pre-eclampsia also appears effective at preventing antepartum bleeding.. D - The Kleihauer test should be performed in rhesus D (RhD)-negative women to quantify fetomaternal haemorrhage (FMH) in order to gauge the dose of anti-D immunoglobulin (anti-D Ig) required. 2. Objective: This study was to asses the outcome of threatened abortion following treatment. Get a printable copy (PDF file) of the complete article (301K), or click on a page image below to browse page by page. This may lead to death of the mother due to shock. Search words included 'antepartum haemorrhage', 'placental abruption', 'placenta praevia', 'placenta previa', 'vasa praevia', 'vasa previa', 'obstetric haemorrhage', 'obstetric hemorrhage', 'fetal haemorrhage', 'fetal hemorrhage', 'fetomaternal haemorrhage', 'fetomaternal hemorrhage', 'antenatal bleeding', 'pregnancy', 'disseminated intravascular coagulopathy', and the search limited to humans and the English language. Unlimited Access to Thousands of Summaries, Personalized Content Recommendations and Alerts, Access Saved Content on All Mobile Devices. You may be admitted to hospital for observation and assessment of the cause of your bleeding. In our capacity to accommodate the difficulties that some families are experiencing we have elected to reduce the out of pocket expenses for private obstetric and antenatal care. Safely, Screening and diagnosing Gynaecological cancers. Postpartum haemorrhage is a major cause of death during pregnancy and early motherhood, accounting for 25% of maternal deaths worldwide,1 and is the second leading direct cause of maternal deaths in the UK.2 It is defined as blood loss of more than 500 mL from the female genital tract after delivery of the fetus (or >1000 mL after a caesarean section). Placental abruption results from bleeding following partial separation of a placenta, which is in a normal position inside the uterus. C - Management of a major APH should be included in obstetric skill drills. Antepartum or pre-partum haemorrhage is bleeding from the birth canal which occurs after 24 weeks of gestation. 3. 35 Peripartum hysterectomy is estimated to occur ∼0.8 per 1000 deliveries. The Planning and Management of Pregnancy fee covers most Private Health Funds. If there are signs of fetal or maternal compromise, consider immediate delivery. Antepartum haemorrhage An antepartum haemorrhage (APH) is bleeding from the vagina that occurs after the 20th week of pregnancy and before the birth of your baby. Once the evidence has been collated for each clinical question it needs to be appraised and reviewed (refer to section 3 in "Development of RCOG Green-top guidelines: producing a clinical practice guideline" for information on the formulation of the clinical questions; see the "Availability of Companion Documents" field). Postpartum hemorrhage, the loss of more than 500 mL of blood after delivery, occurs in up to 18 percent of births and is the most common maternal … Antepartum vaginal bleeding may occur in as many as 25% of pregnant women; fortunately, only a fraction of these patients experience life-threatening hemorrhage. This NGC summary was completed by ECRI Institute on May 14, 2012. Placenta Praevias are divided into four categories (Grade I – IV). Guidelines and recommendations produced by organisations such as NHS Health Trusts were therefore considered. Any woman who is considered to be at high risk of haemorrhage and in whom continued heparin treatment is considered essential should be managed with intravenous, unfractionated heparin until the risk factors for haemorrhage have resolved. Standard management of symptomatic patients with PP. Poor blood flow to vital organs such as kidneys resulting in organ damage. Ultrasound has limited sensitivity in the identification of retroplacental haemorrhage. Results: Aspirin use was registered in 4088 (1.3%) women during pregnancy. Finally, the definitive management of an antepartum haemorrhage, depending on the cause, must be given. Title: Management of Ante-Partum Haemorrhage (APH).MDI Author: TSI Created Date: 8/2/2007 4:26:53 PM Threatened abortion had been shown to be associated with increased incidence of antepartum haemorrhage, preterm labour and intra uterine growth retardation. D - Women in labour with active vaginal bleeding require continuous electronic fetal monitoring. Not applicable: The guideline was not adapted from another source. The RCOG acknowledges that formal consensus methods have been described, but these require further evaluation in the context of clinical guideline development. In many cases the placenta will migrate upwards later in the pregnancy and will cause no problems. Please call our rooms on 0394679444 to confirm the fees. Postpartum hemorrhage becomes very serious if not taken into consideration very quickly. Development of RCOG Green-top guidelines: policies and processes. This Green-top guideline is restricted in scope to the management of postpartum haemorrhage (PPH). Complications of postpartum hemorrhage Due to excessive loss of blood the blood pressure may drop. Management of APH (Antepartum haemorrhage) and ManagementPlacenta previa (PP) Management. } ECV (turning babies in breech presentation around), Haemorrhage and Hypotension (low blood pressure). With grades I & II the placenta will enter the lower segment and can reach the cervical opening but will not cover the cervix. Dr. Steven Hatzikostas has been a Melbourne resident all his life. Sentilhes L, Lasocki S, Ducloy-Bouthors AS, et al. Attention is drawn to areas of clinical uncertainty where further research may be indicated. 19 The majority of cases occur during the first trimester. Up to the 34th week of pregnancy 1.2.1. Oxytocin (Pitocin ®) is the first-line treatment for both the prophylaxis and treatment of uterine atony; 20 to 60 U/L is administered at a rate up to 1 L/hr. After Hours / Emergency: Closed What Blood Products Should Be Ordered and Made Available for Women with APH? An implementation strategy was not provided. They present recognised methods and techniques of clinical practice, based on published evidence, for consideration by obstetricians and gynaecologists and other relevant health professionals. Antepartum haemorrhages are identified as bleeding in pregnancy occurring after the 20th week of pregnancy. Antepartum haemorrhage. Dr Steven Hatzikostas is a top Melbourne Obstetrician with more than 20 years of high risk obstetric … A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++, and directly applicable to the target population; or, A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results, B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or, Extrapolated evidence from studies rated as 1++ or 1+, C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or, Extrapolated evidence from studies rated as 2++, Extrapolated evidence from studies rated as 2+, Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group. The aim of treatment of postpartum hemorrhage is to find and stop the cause of the bleeding as quickly as possible. Tocolytic therapy is contraindicated in placental abruption and is 'relatively contraindicated' in 'mild haemorrhage' due to placenta praevia. When these episodes of bleeding are minor they may only require close supervision. C - In the context of suspected vasa praevia various tests exist that can differentiate between fetal and maternal blood, but are often not applicable (see the National Guideline Clearinghouse [NGC] summary of Green-top guideline No. Grade III & IV will usually stay low and in these cases the baby will need to be born by caesarean section. Br J Anaesth . Serial ultrasound for fetal growth should be performed. The mother may require significant resuscitation as well. By updating our privacy policy with clearer language, our goal is to help you better understand what data we collect and how we use that information. Fetal lung maturity induction with corticosteroids (e.g., betamethasone) 1.2.2. Laboratory studies should be ordered. 2.0 Equality and Diversity Describe an appropriate management plan based on the probable cause. A judgement on the quality of the evidence will be necessary using the grading system (see the "Rating Scheme for the Strength of the Evidence" field). A - Clinicians should offer a single course of antenatal corticosteroids to women between 24+0 and 34+6 weeks of gestation at risk of preterm birth. Appendix 1 of the original guideline document contains principles of management of massive antepartum haemorrhage; Appendix 2 contains the principles of fluid replacement and administration of blood products. Please visit our privacy policy page for more information. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2010 Feb. 9 p. Electronic copies: Available from the, Kleihauer test in rhesus D (RhD)-negative women to quantify fetomaternal haemorrhage (FMH) to gauge the dose of anti-D immunoglobulin (anti-D Ig) required, Ultrasound for diagnosis of placenta praevia and to establish fetal heart pulsation, Fetal investigations to detect fetal heart rate and exclude intrauterine fetal death, Use of point-of-care tests for differentiating between fetal and maternal blood, Single course of antenatal corticosteroids to women at risk of preterm birth, Reclassification of pregnancies as 'high risk' following antepartum haemorrhage (APH) from placental abruption or unexplained APH, Use of continuous electronic fetal monitoring or intermittent auscultation during labour, Management of third stage of labour with consideration given to the use of ergometrine-oxytocin (Syntometrine®), Administration of anti-D Ig to all non-sensitised RhD-negative women, Management of suspected disseminated intravascular coagulation (DIC) with urgent clotting studies and a platelet count, advice from a haematologist, fresh frozen plasma, and cryoprecipitate, Avoidance of anticoagulant therapy in women with APH, Counselling by a senior paediatrician/neonatologist when extreme preterm birth is likely, Obstetric skill drills in management of a major APH, Perinatal and maternal morbidity and mortality, Risk factors for abruption and placenta praevia, Sensitivity and specificity of tests for abruption. Specific contraindications to regional anaesthesia relevant to antepartum haemorrhage include maternal cardiovascular instability and coagulopathy. Treatment is by immediate caesarean section} It is one form of ante partum haemorrhage in which the bleeding occurs due to the premature separation of normally situated placentae . Logistic regression was used to assess the risk of antepartum, intrapartum, and postpartum hemorrhage. Where comments are rejected then justification will need to be made. This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.