What is the impact of antepartum hemorrhage (APH) on early pregnancy?

From the Guidelines

Perigestational hemorrhage can significantly increase the risk of pregnancy complications, including antepartum hemorrhage, placenta abruption, and preclampsia or eclampsia, as evidenced by a large-scale meta-analysis of 43,611 deliveries 1. The impact of perigestational hemorrhage on early pregnancy is a critical concern, as it may indicate serious complications. Key points to consider include:

• The odds ratio for antepartum hemorrhage is not provided in the study, but other complications such as placenta abruption (2.28,95% CI 1.58-3.29) and preclampsia or eclampsia (1.85,95% CI 1.52-2.25) are significantly increased 1.
• Threatened preterm labor (2.91,95% CI 1.57-5.40) and gestational diabetes (2.35,95% CI 1.57-3.52) are also more common in pregnancies with perigestational hemorrhage 1.
• Immediate medical evaluation is essential to determine the cause and appropriate management of perigestational hemorrhage, including transvaginal ultrasound to confirm intrauterine pregnancy and assess fetal viability.
• Serial quantitative hCG measurements may be necessary to distinguish between viable and non-viable pregnancies, and progesterone supplementation may be beneficial in reducing miscarriage risk in cases of threatened miscarriage with confirmed viable intrauterine pregnancy.
• Patients should be monitored for signs of hemodynamic instability, and the underlying pathophysiology often involves implantation issues, placental formation problems, or hormonal imbalances affecting the endometrial lining 1.

From the Research

Impact of Perigestational Hemorrhage on Early Pregnancy

• Perigestational hemorrhage, also known as first trimester bleeding, is a common complication of early pregnancy, affecting approximately one-fourth of pregnant women 2.
• The differential diagnosis of first trimester bleeding includes threatened abortion, early pregnancy loss, and ectopic pregnancy, with pain and heavy bleeding associated with an increased risk of early pregnancy loss 2.
• Treatment of threatened abortion is typically expectant management, with no evidence to support the use of bed rest or progestins 2.
• Trends in quantitative ß subunit of human chorionic gonadotropin (ß-hCG) levels can provide useful information in distinguishing normal from abnormal early pregnancy, with a discriminatory level of 1,500 to 3,000 mIU per mL above which an intrauterine pregnancy should be visible on transvaginal ultrasonography 2.

Diagnosis and Management of Postpartum Hemorrhage

• Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide, with accurate diagnosis and treatment crucial to preventing adverse outcomes 3, 4, 5.
• Visual estimation of blood loss has been shown to have low sensitivity for diagnosing PPH, with a diagnostic approach using a calibrated drape to objectively measure blood loss plus clinical observations showing high sensitivity and specificity 5.
• Other index tests, such as haemoglobin levels and shock index, have shown low to moderate sensitivities in diagnosing PPH and severe PPH 5.

Ultrasound Assessment of Premenopausal Bleeding

• Ultrasound evaluation combined with a quantitative beta human chorionic gonadotropin test is an established diagnostic tool for assessing premenopausal bleeding, with a thorough knowledge of the normal sonographic appearance of intrauterine gestation essential to understanding the manifestations of an abnormal gestation 6.
• Ectopic pregnancy should be suspected and excluded in all patients presenting with first trimester bleeding, as it is associated with significant maternal morbidity and mortality 6.