In addition to these evidence-based recommendations, the guideline developer also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
Prediction and Prevention of Antepartum Haemorrhage (APH)
Can APH Be Predicted?
C - APH has a heterogeneous pathophysiology and cannot reliably be predicted.
What Investigations Should Be Performed in Women Presenting with APH?
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.
C - The Kleihauer test is not a sensitive test for diagnosing abruption.
C - Ultrasound can be used to diagnose placenta praevia but does not exclude abruption.
D - Placental abruption is a clinical diagnosis and there are no sensitive or reliable diagnostic tests available. Ultrasound has limited sensitivity in the identification of retroplacental haemorrhage.
D - Ultrasound should be carried out to establish fetal heart pulsation if fetal viability cannot be detected using external auscultation.
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. 27, Placenta Praevia, Placenta Accreta and Vasa Praevia: Diagnosis and Management).
Should Corticosteroids Be Administered to Women who Present with APH Before Term?
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.
Should the Antenatal Care of a Woman Be Altered Following APH?
D - Following APH from placental abruption or unexplained APH, the pregnancy should be reclassified as 'high risk' and antenatal care should be consultant-led. Serial ultrasound for fetal growth should be performed.
Labour and Delivery
What Intrapartum Fetal Monitoring Should Be Employed for Women Whose Pregnancies Were Complicated by APH?
D - Women in labour with active vaginal bleeding require continuous electronic fetal monitoring.
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.
What Is the Appropriate Management of the Third Stage of Labour in Women with APH?
A - Women with APH resulting from placental abruption or placenta praevia should be strongly recommended to receive active management of the third stage of labour.
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. 52, "Prevention and Management of Postpartum Haemorrhage").
Should Women Presenting with APH Who Are RhD-Negative Be Given Anti-D Ig?
B - Anti-D Ig should be given to all non-sensitised RhD-negative women after any presentation with APH, independent of whether routine antenatal prophylactic anti-D has been administered.
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.
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.
What Blood Products Should Be Ordered and Made Available for Women with APH?
The principles of fluid replacement and administration of blood products are the same for APH as they are for postpartum haemorrhage. These are presented in detail in the RCOG Green-top guideline No. 52, "Prevention and Management of Postpartum Haemorrhage" and are summarised in Appendix 2 in the original guideline document.
How Should the Woman Presenting with an APH Who Develops a Coagulopathy Be Managed?
D - In women who have experienced a massive blood loss or a major abruption, the development of a disseminated intravascular coagulation (DIC) should be considered. Clotting studies and a platelet count should be urgently requested and advice from a haematologist sought. 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.
How Should the Woman Presenting with an APH Who Is Taking Anticoagulant Therapy Be Managed?
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. They should attend hospital urgently, be assessed on admission and further doses should only be administered after consultation with medical staff.
If a woman develops a haemorrhagic problem while on anticoagulant therapy, the treatment should be reviewed urgently and expert haematological advice sought. 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. [Evidence level 4]
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.
What Is the Role of Obstetric Skill Drills to Improve the Management of APH?
C - Management of a major APH should be included in obstetric skill drills.
Grades of Recommendations
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++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Classification of Evidence Levels
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
4 Expert opinion