Suspected placental abruption
Pregnant 20 weeks or more with bleeding, constant pain, a tender uterus or an abnormal CTG. Bleeding can be concealed.
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Obstetrics & GynecologyEmergency
Placental Abruption Management
Placental Abruption Management: Suspected placental abruption → Recognise abruption: it is a clinical diagnosis → No digital vaginal exam or amniotomy u...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Recognise abruption: it is a clinical diagnosis
A normal ultrasound does not exclude abruption. Ultrasound misses about 3 in 4 cases.
- Constant abdominal or back pain; tense, tender or 'woody' uterus
- Vaginal bleeding; it can be small or absent when concealed
- Frequent contractions, abnormal CTG or fetal death
- Shock out of proportion to the visible blood loss
- Risk factors: previous abruption, pre-eclampsia, abdominal trauma (including domestic violence), cocaine or amphetamines, smoking
- Kleihauer test does not diagnose abruption
03Warning No digital vaginal exam or amniotomy until placenta praevia is excluded
Check earlier scan reports or do an ultrasound for placental site first. A digital exam on a praevia can cause severe bleeding.
- Speculum exam is safe to assess bleeding and the cervix
- Painless bleeding, a soft uterus or a high presenting part suggest praevia
- Also suspect vasa praevia if bleeding starts when membranes rupture
04Action Resuscitate the mother first, then assess the fetus
Call the senior obstetrician, anaesthetist and midwife. Tell the haematologist and blood bank if bleeding is major. On an anticoagulant: stop further doses and get haematology advice.
- Shocked or bleeding heavily: activate the major haemorrhage protocol
- 2 large-bore IV cannulas (14-16 G); manual uterine displacement or left lateral tilt
- Bloods: FBC, PT/INR, APTT, fibrinogen, crossmatch 4 units, U&E, LFT
- Give red cells early; limit crystalloid while blood is coming (it dilutes clotting factors)
- Group unknown and life-threatening bleeding: uncrossmatched group O Rh D negative red cells
- Fetal heart: auscultate or ultrasound; continuous CTG once the mother is stable, if birth for fetal reasons would be offered
- Indwelling catheter; hourly urine output; oxygen as needed
- Pre-eclampsia: a normal BP can hide shock; magnesium sulfate and BP control per pre-eclampsia protocol; careful fluids (pulmonary oedema risk)
- Abdominal trauma: trauma primary survey; viable fetus: CTG for at least 4 hours; ask about family violence in private
- Rh D negative, no anti-D antibodies: Rh D immunoglobulin 625 IU deep IM within 72 hours; do not wait for the FMH result
- Rh D negative after 20 weeks: Kleihauer or flow cytometry to size the FMH; give extra Rh D immunoglobulin if needed
05Decision Maternal or fetal compromise, or fetal death?
Judge severity by the mother's and the fetus's condition, not by visible blood loss. Visible loss underestimates concealed bleeding. An abnormal CTG counts as compromise only at a gestation where birth for fetal reasons is offered.
- Compromise: maternal shock, coagulopathy, or an abnormal CTG at a gestation where birth for fetal reasons is offered
- Fetal death: no fetal heart on ultrasound; shock and DIC are common
- No compromise: mother stable and coagulation normal; CTG normal, or fetus pre-viable
- Maternal or fetal compromise
06Warning Compromise: deliver urgently while you resuscitate
Birth stops the bleeding and removes the source of DIC. The mother's life comes first at any gestation. Pre-viable fetus: deliver only for the mother's condition.
- Fetus viable: usually caesarean, unless vaginal birth is imminent in established labour
- Pre-viable fetus, mother stable: no caesarean for fetal reasons; conservative care, senior obstetrician and neonatologist counsel
- No tocolysis
07Action Check for coagulopathy now, and repeat
Send FBC, PT/INR, APTT and fibrinogen now. Repeat after every 4 units of red cells. In massive bleeding, give products before results.
- Fibrinogen under 2 g/L
- PT or APTT over 1.5 x normal, or INR over 1.5
- Low or falling platelet count
- Blood loss without clots
- No coagulopathy: go on to plan the birth
08Action If coagulopathy: replace blood products and deliver
Correct coagulopathy while you arrange birth. Do not delay birth to correct it. Get haematologist advice.
- Major haemorrhage protocol: red cells:FFP:platelets at least 2:1:1
- Fibrinogen under 2 g/L: 3-4 g fibrinogen = cryoprecipitate 9 units (whole blood or split apheresis) or 3 units (apheresis), adult
- Platelets under 50 x10^9/L: 1 adult unit of platelets
- PT or APTT over 1.5 x normal: FFP
- Keep temperature over 35 C, ionised calcium over 1 mmol/L, pH over 7.2
- Cell salvage at caesarean if available
09Decision Fetus alive: caesarean or vaginal birth?
Decide on the mother's condition, the CTG and labour progress. A senior obstetrician decides.
- Compromise, unstable or not in advanced labour
10Action Caesarean: viable fetus with compromise, unstable mother, or birth not imminent
Resuscitate during surgery. Unstable or coagulopathic, or recent anticoagulant dose: general anaesthetic, no spinal or epidural.
- Immediate caesarean for maternal compromise, or fetal compromise at a viable gestation
- Consultant obstetrician and anaesthetist involved
- Blood and products in theatre
- Expect PPH from uterine atony
- Neonatal team at the birth: the baby may be anaemic and need transfusion
- Preterm and birth not immediate: magnesium sulfate under 30+0 weeks and corticosteroids if they do not delay birth
11Outcome After birth: expect PPH and ongoing DIC
Active management of the third stage. PPH: give tranexamic acid early. Hypertension or pre-eclampsia: no ergometrine (it can cause severe hypertension).
- Uterotonics per local PPH protocol; oxytocin first
- PPH: tranexamic acid 1 g IV over 10 min, within 3 hours of birth; second 1 g if bleeding continues after 30 min (adult)
- Repeat FBC, coagulation and fibrinogen until stable
- HDU or ICU care; watch urine output and renal function
- Rh D negative: if baby Rh D positive or group unknown, FMH test and Rh D immunoglobulin
- Bleeding controlled: VTE risk assessment; LMWH when safe (mechanical prophylaxis until then); restart antenatal anticoagulant with haematology advice
- Consultant-led care in the next pregnancy: abruption can recur
- Stable, established labour
12Action Vaginal birth: mother stable, established labour, CTG acceptable
Continuous CTG. Move to caesarean if the CTG or the mother's condition worsens.
- Amniotomy only after placenta praevia is excluded
- Assisted vaginal birth to shorten the second stage if needed
- Active management of the third stage
- Path rejoins step 11Shared downstream outcome
- Fetal death
13Action Fetal death: stabilise the mother, then plan vaginal birth
Shock and DIC are common. Previous caesarean or uterine scar: no set prostaglandin regimen after 28 weeks; a senior obstetrician plans induction.
- Confirm fetal death by ultrasound
- Check coagulation now and repeat; correct it while you arrange birth (see Coagulopathy step)
- Vaginal birth for most women; caesarean for maternal reasons
- Induction method per senior obstetrician and local stillbirth protocol
- Bereavement care; offer placental histology and postmortem
- Path rejoins step 11Shared downstream outcome
- No compromise
14Action No compromise: admit and plan by gestation
Stay in hospital at least until bleeding stops. Continuous CTG while there is bleeding, pain or contractions.
- Pre-viable fetus: conservative care while the mother is stable; senior obstetrician and neonatologist counsel
- 37+0 weeks or more: plan induction of labour, aim for vaginal birth
- Under 37 weeks and bleeding settled: expectant care with close monitoring
- Birth likely before 35 weeks (24+0 to 34+6): single course of antenatal corticosteroids
- Birth likely before 30+0 weeks: magnesium sulfate for fetal neuroprotection per local protocol
- Tocolysis only if a senior obstetrician decides; never with major bleeding, instability or fetal compromise; avoid nifedipine
- New bleeding, pain, abnormal CTG or coagulopathy: treat as compromise and deliver
- Rh D negative: 625 IU Rh D immunoglobulin for each new bleed (FMH test after 20 weeks), and every 6 weeks if bleeding continues
- Later: consultant-led care and serial growth scans
- Path rejoins step 11Shared downstream outcome
Guideline Source
RCOG Green-top Guideline No. 63: Antepartum Haemorrhage
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Abruption is a clinical diagnosis: a normal ultrasound or Kleihauer does not exclude it, and visible blood loss underestimates concealed bleeding
- Blood product doses and thresholds follow Australian NBA and RANZCOG guidance; follow your local major haemorrhage protocol
- RCOG GTG 63 dates from 2011; newer evidence may change details
- Women who decline blood products need an individual senior plan early
Contraindicated Populations
Suspected placenta praevia: no digital vaginal exam or amniotomy until excludedHypertension or pre-eclampsia: no ergometrineCoagulopathy, instability or recent anticoagulant dose: no neuraxial anaesthesia
Applicable Regions
AUNZUKGlobal
AU: Rh D immunoglobulin 625 IU after 12+6 weeks and FMH testing after 20 weeks per NBA 2024. Cryoprecipitate: 9 units whole-blood or split apheresis, or 3 units apheresis, gives 3-4 g fibrinogen (NBA critical bleeding GPS5, updated Sep 2025). Local guideline example: KEMH (WA) Antepartum Haemorrhage 2025.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Placental Abruption Management?
The Placental Abruption Management is a emergency clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on RCOG Green-top Guideline No. 63: Antepartum Haemorrhage.
What guideline is the Placental Abruption Management based on?
This algorithm is based on RCOG Green-top Guideline No. 63: Antepartum Haemorrhage.
What are the limitations of the Placental Abruption Management?
Known limitations include: Abruption is a clinical diagnosis: a normal ultrasound or Kleihauer does not exclude it, and visible blood loss underestimates concealed bleeding; Blood product doses and thresholds follow Australian NBA and RANZCOG guidance; follow your local major haemorrhage protocol; RCOG GTG 63 dates from 2011; newer evidence may change details; Women who decline blood products need an individual senior plan early. Individual patient factors may require deviation from these recommendations.
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