Antepartum Hemorrhage

InCheat Sheets / Obstetrics and Gynaecology

Updated on April 25, 2025

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Antepartum Hemorrhage

Antepartum Hemorrhage

Antepartum hemorrhage is bleeding from late 2nd trimester to delivery (around 20-24 weeks and beyond). All causes of antepartum hemorrhage risk the complications of preterm delivery and fetal death.

Differentials for antepartum hemorrhage

Classification	Differentials
Cervical	Cervicitis, cervical polyps, cervical cancer
Vagina	Lacerations
Uterus	Uterine rupture
Placenta	Abruption placentae, pplacenta previa, vasa previa
Others	Hemorrhoids

Obstetric causes of Antepartum hemorrhage

Cause	Bleeding	Blood	Diagnosis (NB: NO pelvic exam)	Complications
Abruptio placentae	Painful	Maternal	Ultrasound, abnormal fetal heart rate	DIC, maternal shock/death
Uterine rupture	Painful	Maternal	Loss of station, abnormal uterine contracitons, abnormal fetal heart rate	Hysterectomy
Placenta previa	Painless	Maternal	Ultrasound, abnormal fetal heart rate	Malpresentation
Vasa previa	Painless	Fetal	Ultrasound with doppler, bright red blood per vagina, abnormal fetal heart rate	High risk fetal death
Abnormal placentation	Painless	Maternal	Ultrasound	Hysterectomy, maternal shock/death

Risk factors for antepartum hemorrhage

Risk factor	Predisposes to
Hypertension, trauma	Abruptio placentae
Uterine scarring	Abnormal placentation
Multiple gestation, Artificial reproductive technology	Placenta previa
Classical incision, overstimulation	Uterine rupture
Multiple gestation, succenturiate lobe, villametous cord	Vasa previa

Investigations
- Obstetrics ultrasound
- Complete blood count with peripheral smear: to rule out DIC (hemolysis)
- PT/PTT
- D-dimer
- Fibrinogen
- Group and crossmatch: to prepare for blood trasnfusion
- Kleihauer-Betke if Rh negative: to estimate RhoGAM dosage
- Apt test: to differentiate between fetal and maternal blood
  - Fetal blood → pink
  - Maternal blood → yellow-brown
Immediate Treatment (ABCs)
- Insert 16-gauge IV catheter, start IV fluid drip
- Foley catheter for urine output
- Gentle speculum exam if possible(to rule out differentials)
- Intermittent auscultation of fetal heart rate (with external Doppler)

Dr. Jeffrey Kalei

Author and illustrator for Hyperexcision. Interested in emergency room medicine. I have a passion for medical education and drawing.

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Biochemistry

Adrenocorticotrophic hormone	P: <80 ng/L
Alanine aminotransferase (ALT)	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alkaline phosphatase	P: 30–130 U/L (adults)
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
Antidiuretic hormone (ADH)	P: 0.9–4.6 pmol/L
Aspartate transaminase	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
C-reactive protein	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol	P: AM 450–700 nmol/L, Midnight 80–280 nmol/L
Creatine kinase (CK)	P: ♂ 25–195 U/L, ♀ 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P/S: 2–8 U/L ♂ (luteal); >25 U/L menopause
Gamma-glutamyl transpeptidase	P: ♂ 11–51 U/L, ♀ 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron	S: ♂ 14–31 μmol/L, ♀ 11–30 μmol/L
Lactate	P: Venous 0.6–2.4 mmol/L, Arterial 0.6–1.8 mmol/L
Lactate dehydrogenase (LDH)	P: 70–250 U/L
Lead	B: <1.8 mmol/L
LH	P: 3–16 U/L (luteal)
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
Parathyroid hormone (PTH)	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin	P: ♂ <450 U/L, ♀ <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin	P: Erect 2.8–4.5, Recumbent 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
Thyroxine (T4)	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
Total iron-binding capacity	S: 54–75 μmol/L
Triglycerides (fasting)	P: 0.50–2.3 mmol/L
Triiodothyronine (T3)	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate	P: ♂ 210–480 μmol/L, ♀ 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol creatinine
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids	♂ 28–30 μmol/24h, ♀ 21–66 μmol/24h
17-Oxosteroids (neutral)	♂ 17–76 μmol/24h, ♀ 14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
Red cell count	♂ 4.5–6.5 ×10¹²/L, ♀ 3.9–5.6 ×10¹²/L
Haemoglobin	♂ 130–180 g/L, ♀ 115–160 g/L
PCV / Haematocrit	♂ 0.4–0.54 L/L, ♀ 0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelet count	150–400 ×10⁹/L
Reticulocyte count	0.8–2.0% / 25–100 ×10⁹/L
ESR	Depends on age
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (beats per minute)
Neonate (<1 month)	140–160
Infant (<1 year)	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Temperature
Normal range	36.6–37.2 °C
38.0 °C	Fever (infant)
38.5 °C	Fever (>3 months)
Respiratory Rate (tachypnoea)
Neonate (0–2 months)	≥60 breaths/min
2–12 months	≥50 breaths/min
1–5 years	≥40 breaths/min
>5 years	≥30 breaths/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Head Circumference
Term	35 cm ± 2
1 year	+1 cm/month
2–3 years	+2 cm/year
4–5 years	+1 cm/year
5 years	~53 cm
10 years	56–57 cm
Height
Term	52–55 cm
1 year	75 cm
2–12 years	6a + 77 cm
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Blood Transfusion
Whole blood	20 mL/kg
pRBC	10 mL/kg
Formula	6 × (weight in kg) × Hb deficit
Normal Paediatric Lab Values
Haemoglobin (g/dL)	Hematocrit (%)
Term newborn: 13–20	40–58
1 month: 11–18	32–54
2 months: 10–15	28–44
1–2 years: 10–13	32–40
>2 years: 11–14	33–42
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Antepartum Hemorrhage

Dr. Jeffrey Kalei

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