Placental Abruption
Admission & discharge
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.
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.
Treatment
① Immediate stabilization — first minutes
- Resuscitate aggressively — visible loss underestimates total
- Blood EARLY (not crystalloid-only): target SBP>90, Hb>80 pending full picture
- Prepare theatre + neonatal team simultaneously
③ First-line treatment & drug regimens
- VIABLE fetus + Category II/III CTG or maternal instability → EMERGENCY CAESAREAN
- Viable fetus, Grade I stable, CTG normal: close observation; steroids <34+6; induction reasonable once stable (vaginal often achievable quickly with abruption-induced labour)
- PRE-VIABLE (<24 wks) or fetal death: aim VAGINAL birth (safer with DIC) — augment labour; avoid caesarean in coagulopathic mother unless obstetric necessity
- MgSO4 neuroprotection if <30–32 wks birth imminent
- Steroids <34+6 if birth not imminent within hours
④ Drug treatment detail (3 agents)
- 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.
- Glucose monitoring and an insulin-adjustment plan in diabetes; assess infection and timing of birth
- Indication: Alternative fetal-lung-maturation course when appropriate
- Maternal glucose, infection assessment and birth timing; diabetes team plan
- 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
- Record pulse, BP, respiratory rate and tendon reflexes at least every 4 h; more often if oliguria or renal impairment
Definitive treatment
Birth empties the uterus and removes the procoagulant trigger — speed matters more than mode except where DIC tips balance toward vaginal route.
Monitoring
| Domain | Schedule |
|---|---|
Coags incl. fibrinogen | On admission + hourly until stable (DIC evolves fast) |
Urine output | Hourly (>0.5 mL/kg/h target) |
CTG | Continuous until birth |
Fundal height marking | Hourly (concealed expansion) |
Hb | Serial q1–2h |
Response assessment
- Pain settling post-birth
- Uterus contracting; bleeding controlled
- Coags stabilising; urine output recovering
Treatment failure
- Persistent bleeding post-birth → atony (couvelaire uterus responds POORLY to uterotonics — proceed early to balloon/compression sutures)
- Coagulopathy worsening → MTP ratios; cryoprecipitate/fibrinogen concentrate
- Anuria >6 h → ICU/nephrology
Second-line treatment
- Interventional radiology embolisation for refractory uterine bleeding (stable enough)
- Hysterectomy for uncontrollable atonic haemorrhage
Rescue treatment
Massive haemorrhage protocol + tranexamic acid 1 g IV (within 3 h of birth) per PPH bundle; renal replacement if indicated.
Procedure / surgery
- Caesarean: anticipate couvelaire uterus + PPH; active third stage mandatory; consider internal iliac identification early
- Avoid regional anaesthesia if coagulopathy suspected pending results
Escalation
- ICU for organ failure/coagulopathy
- Peripheral centres: stabilize (volume+blood if any)+transfer WITH escort; do not await viability debates when mother bleeding
⑮ Complications & their management
DIC
Ratio components; fibrinogen ≥2 g/L; platelets >50–75; recheck hourly
Acute tubular necrosis/renal cortical necrosis
Fluid resuscitation first; nephrology; dialysis indications AEIOU; long-term BP/proteinuria follow-up
Couvelaire uterus + PPH
Escalate directly: balloon → compression sutures → hysterectomy ladder
Stillbirth/neonatal encephalopathy
Bereavement care; neonatal cooling pathway where available; debrief + autopsy offer
Recurrence
Next-pregnancy: aspirin if hypertensive risk, earlier growth surveillance, timed birth discussion
Post-treatment care
- Renal function + BP checks at discharge and 6 weeks
- Iron replacement; thromboprophylaxis once secure
- Bereavement/psychological support pathways
- Documentation for medico-legal clarity (trauma cases: safeguarding referral)
Classification
| Grade | Features | Action implication |
|---|---|---|
I (mild) | Mild pain/bleeding; uterus irritable; CTG normal | Observe closely; steroids; individualise |
II (moderate) | Moderate-severe pain; uterus tense; fetal distress present | Deliver (caesarean usually) |
III (severe) | Severe pain ± shock; fetal death or profound distress ± DIC/renal failure | Emergency birth; massive coagulation support |
Diagnosis & assessment
- Abnormal CTG/decelerations → birth NOW
- Maternal shock with small visible loss
- Oozing from puncture sites (DIC established)
- No fetal heart → stillbirth pathway + coagulopathy vigilance
- Renal failure signs
Definition: Premature separation of a normally situated placenta before birth. Revealed/concealed/mixed patterns; grades I–III (clinical severity).
Risk factors
Presentation
- Constant abdominal/back PAIN + woody tender uterus
- Dark venous bleeding (may be concealed — shock out of proportion to visible loss)
- Reduced movements/abnormal CTG
- Idiopathic preterm labour
- Rare: couvelaire uterus found at surgery
Initial assessment
- Call senior help; declare abruption
- Left lateral tilt + O₂; two IV lines; crossmatch ×4 + coags INCLUDING fibrinogen
- CTG immediately (viability) — category determination
- Estimate fundal height trend + palpate tonicity
- Kleihauer if Rh-negative (anti-D)
- Urinary catheter — hourly output
- Decision clock starts: deliver or stabilise-and-deliver
Investigations
| Test | Looking for |
|---|---|
CTG | Category III patterns mandate immediate birth |
Fibrinogen (most sensitive OB-DIC marker) + PT/APTT + platelets | Coagulopathy BEFORE oozing visible |
CBC (Hb misleading acutely) | Serial trend |
US | Usually NORMAL — do not exclude abruption sonographically; excludes praevia |
Creatinine + LFTs | End-organ injury; differentiate PE-driven abruption |
Principles & follow-up
Management principles
Sources (10)
2025-10 · checked 2026-10-17 · verified-summary
Open source ↗
Targeted recheck: WHO 2025 recognition/treatment trigger (≥500 mL or ≥300 mL with abnormal haemodynamics), concurrent first-response bundle and refractory-haemorrhage fibrinogen target ≥2 g/L if replacing a level <2 g/L. Primary recommendation chapter/table indexed at https://www.ncbi.nlm.nih.gov/bo…
· checked 2026-10-17 · verified-summary
Open source ↗
Recommendation 1.9/type-and-regimen evidence: IM dexamethasone or betamethasone total 24 mg; four 6 mg dexamethasone doses 12 hours apart or two 12 mg betamethasone doses 24 hours apart. NICE NG25 supplies gestational and repeat-course criteria.
20 November 2015 · updated 10 June 2022 · checked 2026-10-18 · verified-live
Open source ↗
Scope: additional clinical-detail explanation for ptl-threatened, ptl-established. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module. Additional admi…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary PDF downloaded; term prelabour rupture, selected expectant care and induction around 24 hours, temperature/return precautions, maternal post-birth assessment and newborn observation after prolonged membrane rupture checked. This is scoped to the implemented admission/transfer recommenda…
· checked 2026-10-18 · verified-live
Open source ↗
4Ts assessment, atonic-PPH oxytocin, additional uterotonic choice, compression, source control, tamponade and urgent surgical escalation. WHO 2025 supplies the newer treatment-recognition trigger. Additional admission/discharge check 18 October 2026 (limited to the following): Haemorrhage resuscitat…
· checked 2026-10-18 · verified-live
Open source ↗
Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.
· checked 2026-10-18 · verified-live
Open source ↗
Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.
· checked 2026-10-18 · verified-live
Open source ↗
Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.