Antepartum Haemorrhage — SAQ

Stem

A 31-year-old woman (G3P2) at 34 weeks gestation with one previous lower-segment caesarean section is brought to the labour ward with sudden-onset severe constant lower abdominal pain that started 30 minutes ago. She has had some dark vaginal bleeding. On arrival: BP 96/64 mmHg, pulse 118/min, respiratory rate 24/min; the uterus is tense, tender, and woody hard with poor relaxation between palpation; the CTG shows recurrent late decelerations with reduced variability. ^[1]

Questions

a) What is the most likely diagnosis and the single most important differential to exclude before any pelvic examination? (2 marks)

Diagnosis: placental abruption (concealed in part) — sudden severe constant abdominal pain, a tense tender woody-hard uterus, dark vaginal bleeding, maternal tachycardia with a narrowed pulse pressure, and fetal distress (recurrent late decelerations) are the classical tetrad. The history of a previous caesarean adds an accreta/rupture dimension but the clinical picture is abruption. Differential to exclude before any examination: placenta praevia — until ultrasound localises the placenta, a digital vaginal examination must NOT be performed because it can provoke catastrophic haemorrhage from the praevia edge. The clinical picture is not praevia (which is painless and bright red with a soft relaxed uterus) but the rule is absolute. ^[1]

b) Outline your immediate management. (4 marks)

Resuscitate in parallel with assessment and prepare for delivery:

1. Call for help — senior obstetrician, anaesthetist, haematology, neonatal team, alert theatre; activate the massive haemorrhage protocol.
2. ABC — high-flow oxygen (GTG 63 massive protocol: 10–15 L/min), two 14-gauge cannulae, left lateral tilt, keep warm; until blood arrives infuse up to 3.5 L warmed crystalloid (Hartmann’s 2 L and/or colloid 1–2 L) as rapidly as required (Green-top 63 appendix).
3. Bloods — FBC, coagulation screen, 4 units of blood cross-matched (Green-top 63 for major/massive APH). Cryoprecipitate if fibrinogen <1 g/L in the GTG 63/52 appendix — do not quote an unsourced 2 g/L APH target.
4. Continuous CTG — already showing late decelerations; prepare for emergency delivery.
5. Tranexamic acid 1 g IV is WOMAN-trial evidence for postpartum haemorrhage (repeat once after 30 minutes if bleeding continues); using it in major APH is an extrapolation, not a Green-top 63 APH recommendation.
6. Anti-D: if non-sensitised RhD-negative and ≥20+0 weeks, give at least 500 iu and send Kleihauer to detect FMH >4 mL red cells (Green-top 63).
7. Ultrasound to localise placenta (rule out praevia) — but do not delay delivery for the scan if the mother or fetus is compromised.
8. Urinary catheter for hourly output. ^[1]

Decision: this is massive APH (clinical shock) with fetal compromise → emergency caesarean section under general anaesthesia (regional contraindicated in shock and coagulopathy); correct coagulopathy before and during surgery. ^[1]

c) Why is this woman at higher risk of this complication, and what coagulopathy should you anticipate? (2 marks)

Higher risk: Chen 2025 found placenta previa (AOR 7.31) and previous abruption (AOR 2.72) the largest independent associations; hypertensive disorders are also independent factors and should be excluded in this shocked patient, along with trauma, smoking, and cocaine. Anticipate DIC: Erez’s pregnancy-specific score uses fibrinogen, PT difference, and platelet count (≥26 points: 88% sensitivity, 96% specificity). Deliver to remove the trigger and replace clotting factors; GTG 63 appendix: cryoprecipitate if fibrinogen <1 g/L. ^[1]

d) Name two maternal complications of severe abruption beyond acute haemorrhage and one specific postpartum endocrine complication. (2 marks)

• Acute kidney injury (acute tubular or cortical necrosis from prolonged hypotension).
• Peripartum hysterectomy (from a Couvelaire/atonic uterus or accreta) or Sheehan syndrome.
• Sheehan syndrome: anterior pituitary infarction from profound hypovolaemic shock — failure to lactate (low prolactin), amenorrhoea (low FSH/LH), hypothyroidism (low TSH), adrenal insufficiency (low ACTH); requires lifelong hormone replacement. ^[1]

References3ShowHide

1. [1]Royal College of Obstetricians and Gynaecologists Antepartum Haemorrhage: Green-top Guideline No. 63 RCOG, 2011.Source
2. [2]Chen D, Gao X, Yang T, et al. Independent risk factors for placental abruption: a systematic review and meta-analysis BMC Pregnancy Childbirth, 2025.PMID 40140972
3. [3]WOMAN Trial Collaborators Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial Lancet, 2017.PMID 28456509