AKT · Obstetrics & gynaecology/Late pregnancy & labour

Placental abruption

Premature placental separation

Overview

Premature separation of a normally sited placenta before delivery, causing PAINFUL antepartum bleeding and a tense tender uterus, with risk of fetal compromise and maternal DIC. Bleeding may be concealed (shock out of proportion to visible loss).

Recognise

PAINFUL constant abdominal pain with vaginal bleeding (may be concealed)
Tense, "woody"-hard, TENDER uterus; uterine irritability/contractions
Fetal distress/demise; maternal shock, possible DIC

Red flags

Concealed abruption (shock disproportionate to visible blood), fetal distress, DIC, Couvelaire uterus

Differentials & how to tell them apart

Placenta praeviaPAINLESS, soft non-tender uterus

Uterine ruptureprevious caesarean, loss of contractions, recession of presenting part

Vasa praeviafetal bleeding at ROM, painless

Labourintermittent pain without the woody tender uterus

Investigations

Clinical diagnosis (do not delay for imaging — USS can MISS abruption). Continuous CTG, FBC/coagulation (DIC), crossmatch, Kleihauer if rhesus-negative.

Management

Resuscitate + urgent delivery (caesarean if fetal/maternal compromise)

1ABC resuscitation, large-bore access, crossmatch/blood, continuous CTG, treat DIC.Gate: Fetal distress or maternal compromise → urgent (emergency) caesarean; if fetus has died and mother stable → aim for vaginal delivery
2Anti-D for rhesus-negative; corticosteroids if preterm and stable; watch for postpartum haemorrhage (atony).

Resuscitation + blood products — maternal priority; treat DIC

Anti-D — rhesus-negative

Corticosteroids — if preterm and stable

Key points

A normal USS does NOT exclude abruption — it is a clinical diagnosis. Concealed haemorrhage causes shock and DIC with little external bleeding.

Monitor & prognosis

Maternal haemodynamics/coagulation, fetal CTG, urine output, PPH risk.

Depends on severity and speed; risk of recurrence.

Source: RCOG Green-top 63