Synopsis
Identify placental separation despite concealed blood loss, resuscitate maternal haemorrhage promptly, and coordinate delivery according to maternal stability and fetal condition.
- Abruption is premature separation of a normally situated placenta before birth, with revealed, concealed or mixed bleeding.
- The diagnosis is clinical; a normal ultrasound cannot reliably exclude placental abruption.
- Maternal shock may be disproportionate to the visible loss because blood can collect behind the placenta.
- Pain, uterine tenderness, frequent contractions and sustained tone are concerning, but milder cases may lack the complete classical picture.
- Send full blood count, group and crossmatch, coagulation screen and fibrinogen when significant abruption is suspected.
- Resuscitation and delivery planning proceed together; do not wait for imaging confirmation in an unstable patient.
- A viable fetus with sustained compromise usually requires urgent caesarean birth unless vaginal birth is imminent; fetal death changes the balance toward maternal safety and often vaginal birth.
Key red flags
Severe persistent abdominal pain with a tense uterus or worsening maternal physiology requires emergency assessment for concealed abruption.
An abnormal fetal trace, absent fetal movements or suspected fetal death can accompany extensive separation and should trigger immediate senior review.
Investigation priorities
Identify shock, uterine tenderness, tone and other causes of acute abdominal pain.
Management branches
Painful bleeding, concealed loss or maternal or fetal compromise suggests substantial separation.
- Summon consultant obstetrics, anaesthesia, senior midwifery and neonatal staff; establish intravenous access and request the obstetric major-haemorrhage pathway when indicated.
- Restore circulation with appropriate warmed resuscitation and blood products, measure ongoing loss, catheterise when necessary and track urine output and perfusion.
- Make an urgent delivery decision from maternal physiology, fetal assessment and stage of labour; do not postpone treatment for a negative or unavailable ultrasound.
Key medicines
Event-related anti-D immunoglobulinAfter an abruption-associated bleed beyond 20 weeks in a non-sensitised RhD-negative patient, give a minimum 500 IU within 72 hours by the preparation's authorised route, then supplement according to laboratory fetomaternal-haemorrhage measurement.Neither a negative Kleihauer test nor previous routine antenatal anti-D cancels the event-related indication; coordinate repeat testing and dosing if bleeding continues.
Haemorrhage blood-component replacementUse the activated obstetric major-haemorrhage protocol for warmed red cells and coagulation components, titrating to clinical loss, fibrinogen, platelet count and coagulation or viscoelastic results; this requires immediate transfusion-team prescription rather than a fixed outpatient dose.Monitor temperature, ionised calcium, acid-base status and fluid balance; excessive crystalloid without timely blood replacement can worsen dilution and tissue hypoperfusion.