⚡ Massive APH (praevia/abruption)
1 RECOGNIZE
- Significant antepartum bleeding with instability or fetal compromise: resuscitate immediately; visible loss can underestimate concealed abruption.
- Pain/tender tense uterus suggests abruption; painless bleeding may indicate praevia. Bleeding after membrane rupture with sudden fetal deterioration also raises vasa praevia.
2 CALL FOR HELP
- Senior obstetrician, anaesthetist, blood bank, theatre and neonatal team; major-haemorrhage activation when required.
3 IMMEDIATE ACTION
- Resuscitate with two IV cannulae, crossmatch/blood, warming and continuous maternal monitoring. Quantify loss and assess shock rather than relying on the pad count.
- NO digital vaginal examination until placenta praevia is excluded or the senior team is prepared for immediate operative rescue.
- Continuous fetal assessment when appropriate; localise the placenta by ultrasound if it does not delay necessary birth. A normal ultrasound does not rule out abruption.
- If a preterm birth is likely and time/eligibility allow, choose ONE antenatal-steroid course and consider magnesium neuroprotection using the complete regimens below. Do not postpone urgent maternal/fetal delivery for their completion.
Drug doses & preparation
Choose the regimen for the stated indication. Alternatives are not instructions to give every medicine. Check prior doses, contraindications, concentration and the response before repeating.
Betamethasone — antenatal courseWHOsummary checked
Dose12 mg IM, then 12 mg IM 24 hours later
RouteIM
FrequencyTwo doses, 24 h apart
DurationOne 24 mg course. Consider only ONE repeat course under NICE criteria; not routine weekly courses
PreparationConfirm product strength: for 6 mg/mL, 12 mg = 2 mL; volumes differ by formulation. Use the obstetric IM preparation
Max dose24 mg/course; NICE permits no more than 2 courses in total under its repeat-course criteria
- Indication: Imminent preterm birth within the guideline gestational window; do not delay urgent maternal/fetal delivery
- NICE offers at 24+0–33+6 weeks, considers 34+0–35+6; individual discussion at 22+0–23+6. Repeat: <34 weeks, prior course >7 days ago and very high risk of birth in 48 h.
Monitoring
- Glucose monitoring and an insulin-adjustment plan in diabetes; assess infection and timing of birth
Contraindications: Do not delay lifesaving delivery to complete steroids; do not use a blanket “infection contraindication” without senior assessment
Dexamethasone — antenatal alternativeWHOsummary checked
Dose6 mg IM every 12 h for four doses
RouteIM
FrequencyEvery 12 hours, four doses
Duration24 mg total over 36 h; ONE course, subject to the same repeat-course restrictions
PreparationCheck the injectable product: if 4 mg/mL, 6 mg = 1.5 mL; other strengths require recalculation. Give IM for this antenatal regimen
Max doseFour 6 mg doses = 24 mg/course; do not combine with a full betamethasone course
- Indication: Alternative fetal-lung-maturation course when appropriate
Monitoring
- Maternal glucose, infection assessment and birth timing; diabetes team plan
Contraindications: Do not prolong an unsafe pregnancy to finish the course
Magnesium sulfate — fetal neuroprotectionNICE · NG25checked
Dose4 g over 15 min, then 1 g/hour
RouteIV infusion
FrequencyLoading once, then continuous infusion
DurationStop at birth or 24 hours, whichever occurs first
Preparation50%: 4 g = 8 mL diluted in compatible sodium chloride 0.9%; maintenance example 20 g made up to FINAL 100 mL, 5 mL/hour via pump
Max dose24 hours for neuroprotection; do not add to an eclampsia regimen already running
- Indication: Imminent preterm birth: NICE offers at 24+0–29+6 weeks and considers at 30+0–33+6 weeks; discuss 23+0–23+6 individually
Monitoring
- Record pulse, BP, respiratory rate and tendon reflexes at least every 4 h; more often if oliguria or renal impairment
Contraindications: Myasthenia gravis, heart block or magnesium toxicity · Renal impairment or oliguria requires reduced/withheld maintenance and more frequent assessment
4 INVESTIGATIONS (never delaying treatment)
- CBC/platelets, crossmatch, PT/APTT and fibrinogen; blood gas/lactate, calcium and renal function during major loss.
- Ultrasound placental localisation/fetal assessment when feasible; RhD status and fetomaternal-haemorrhage testing to guide anti-D under the local gestation-specific policy.
5 DEFINITIVE MANAGEMENT
- Ongoing major bleeding, maternal deterioration or fetal compromise requires urgent birth and haemorrhage control. Route depends on cause and circumstances; praevia commonly requires caesarean.
- Abruption with fetal death and a stabilised mother may favour vaginal birth, but coagulopathy/ongoing bleeding still needs active resuscitation and senior review.
- Suspected accreta requires senior specialist planning; avoid forcible placental separation.
6 ESCALATION
- Major transfusion, coagulopathy or persistent shock: theatre, blood-bank/haematology and ICU support immediately.
7 POST-EVENT CARE
- Monitor for recurrent bleeding/DIC, renal injury and anaemia; send placenta for indicated examination.
- Document RhD prophylaxis assessment, neonatal outcome, cause and future pregnancy/birth plan.
Admission & discharge after the acute event
Care setting: Emergency obstetric assessment; suspected acute abruption usually needs admission
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
This is recovery after major antepartum haemorrhage. Identify the actual cause: placenta praevia/PAS/vasa praevia and abruption need their own specialist surveillance, birth and postoperative plans.
When admission or continued hospital care is needed
- Admit suspected abruption with pain, tenderness, bleeding, maternal instability, coagulopathy or fetal compromise; arrange timely delivery and resuscitation when indicated.
When clinic, day care or home care may be suitable
- Abruption must not be dismissed because visible bleeding is small or absent. Home care is considered only after specialist reassessment of a resolved/uncertain presentation with a clear surveillance plan.
Before going home
- Acute bleeding/pain and obstetric risk have been addressed; maternal blood/renal/coagulation trends and fetal or post-birth assessment support recovery.
- No ongoing transfusion/organ-support need; the senior team has documented surveillance if the pregnancy continues.
Discharge medicines and treatment changes
- Reconcile anaemia treatment and any indicated post-birth VTE prevention against current bleeding risk. Acute haemorrhage medicines are not routine take-home treatment.
Tests, pending results and their reviewer
- Communicate blood loss, Hb/platelets/coagulation/renal findings and the plan for abnormal results.
Home care and counselling
- Explain recurrence risks, future-pregnancy specialist review and urgent-return symptoms; support bereavement if relevant.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Before discharge | Agree obstetric/fetal monitoring if still pregnant, or early postnatal and anaemia reviews after birth. |
Postnatal/future-pregnancy review | Review hypertension, placental-risk factors, recovery and prevention planning. |
Return urgently
- Recurrent bleeding, abdominal pain, reduced movements, collapse, dyspnoea or fever require immediate hospital care.
Sources
MSFcheckedNICE · NG25checkedWHOsummary checkedNICE · NG235, updated 9 June 2026checkedMSFcheckedNICE · NG194, recommendationscheckedIndia MoHFW / NHM · LaQshya district-hospital SOP, linked editioncheckedWHO · 2022 official recommendation summarycheckedRCOG · Current public recovery informationcheckedNICE · CG50, recommendationschecked