APH — Placenta Praevia & Abruption Nursing Guide

Definition — Antepartum Haemorrhage (APH) Bleeding from the genital tract of ≥24 weeks gestation and before the onset of labour. Any visible APH warrants immediate assessment. Do NOT perform a vaginal examination until placenta praevia has been excluded by ultrasound.

📋Causes of APH

Placenta praevia — low-lying placenta covering or adjacent to os
Placental abruption — premature separation of normally sited placenta
Vasa praevia — fetal vessels crossing internal os
Bloody show (cervical mucus plug) — not true APH
Cervical lesion (polyp, ectropion, carcinoma)
Trauma (domestic violence — always consider)
Undiagnosed / idiopathic (~50% of APH cases)

⚠NEVER Perform Vaginal Examination

Until placenta praevia has been excluded by ultrasound

Digital VE with praevia can provoke catastrophic haemorrhage
Speculum examination ONLY after USS clearance
USS (transabdominal ± transvaginal) must confirm placental location first
If no USS available — treat as praevia until proven otherwise

Initial ABCDE Assessment

ABCDE Primary Survey & Immediate Actions

Airway & Breathing

Assess airway patency
O₂ saturation — target ≥95%
High-flow O₂ if compromised
Respiratory rate, auscultate

Circulation

HR, BP, capillary refill
IV access × 2 (14–16G)
Blood: FBC, coagulation, G&S, crossmatch
UEC, LFTs, fibrinogen
Left lateral tilt (aortocaval relief)

Disability & Exposure

GCS / AVPU
Uterine tenderness, tone
Pad count — estimate blood loss
CTG for fetal wellbeing
Fetal parts palpable?

📅Blood Loss Estimation

Pad count — weigh saturated pads (1g ≈ 1mL blood)
Clot weight — estimate in addition to free blood
Minor APH: <50mL, haemodynamically stable
Major APH: 50–1000mL without clinical shock
Massive APH: >1000mL OR haemodynamic instability
Note: concealed abruption underestimates true loss

📊Fetal Assessment — CTG

Commence CTG immediately on all APH presentations
Bradycardia — sustained <100bpm = fetal emergency
Late decelerations — uteroplacental insufficiency
Reduced variability — assess in clinical context
Pathological CTG + APH = emergency delivery assessment
CTG normal does NOT exclude significant abruption

🔍Placental Localisation

Routine 20-week anomaly scan identifies low-lying placenta
Low-lying = placenta within 20mm of internal os
~90% of low-lying placentas at 20 weeks resolve by 36 weeks (due to lower uterine segment development)
Repeat USS at 32 weeks if low-lying at 20 weeks
Transvaginal USS is safe and more accurate than transabdominal for placental localisation
MRI useful for accreta spectrum assessment

🧪Anti-D Immunoglobulin

All Rh-negative women with APH require anti-D

Kleihauer-Betke test — quantifies feto-maternal haemorrhage (FMH) volume
Standard dose anti-D: 250IU (<20 weeks) / 500IU (≥20 weeks)
Large FMH on Kleihauer → additional anti-D doses needed
Administer within 72 hours of bleed
Document blood group on all APH presentations

Shock Index Reference

Shock Index (HR ÷ SBP)	Interpretation	Action
<0.9	Normal	Continue monitoring
0.9–1.0	Mild compromise	Increased vigilance, fluid challenge
1.0–1.7	Significant haemorrhage	Active resuscitation, team alert
>1.7	Critical — life-threatening	MTP activation, immediate senior obstetric & anaesthetic review

Placenta Praevia — Key Principle Painless, bright red vaginal bleeding with a soft uterus. The placenta lies in the lower uterine segment, partially or completely covering the internal os. NEVER perform digital vaginal examination.

Classification of Placenta Praevia

Grade	Description	Clinical Significance
Grade I	Placenta encroaches lower uterine segment but does not reach os	Minor — vaginal birth possible
Grade II	Placenta reaches internal os but does not cover it	Marginal — individualised management
Grade III	Placenta partially covers the internal os	Major praevia — Caesarean section required
Grade IV	Placenta completely covers the internal os	Major praevia — elective LSCS mandatory

Major Praevia = Grade III or IV Always plan delivery by elective lower segment Caesarean section (LSCS). Prepare for potential accreta spectrum.

Clinical Features — Placenta Praevia

PAINLESS bright red (fresh) vaginal bleeding
Uterus soft and non-tender
Fetal parts palpable (normal fetal lie/presentation OR malpresentation due to praevia)
Abnormal fetal lie (transverse/oblique) common
Fetal compromise less common than abruption unless massive haemorrhage
Recurrent bleeds — sentinel bleed often precedes major haemorrhage
Haemodynamic instability with large bleed

Antepartum Management

Hospitalisation from 34 weeks for major praevia
Complete bed rest; no pelvic (sexual) rest
IV access × 2, group and crossmatch 4–6 units
Corticosteroids if <34 weeks (betamethasone 12mg IM × 2 doses, 24h apart)
MgSO₄ neuroprotection if <34 weeks and delivery anticipated
Tocolysis controversial — only if benefits outweigh risks (not for abruption)
Iron supplementation for chronic anaemia from repeated bleeds
Platelet target >80 × 10⁹/L for LSCS; crossmatch available in theatre

Delivery Planning

Major praevia (III/IV): Elective LSCS at 36–38 weeks gestation
Minor praevia (I/II): Vaginal birth possible if ≥20mm from os — senior decision
Delivery location: tertiary centre with blood bank, level 3 NICU, interventional radiology
Theatre immediately available for all praevia patients
Senior obstetrician to perform LSCS (risk of torrential haemorrhage)
Cell salvage consideration (autologous blood)
Paediatric team at delivery

Accreta Spectrum (PAS)

Accreta: villi adhere to myometrium (no decidua)
Increta: villi invade into myometrium
Percreta: villi penetrate through uterus (bladder/bowel)
Highest risk: praevia + previous Caesarean section
Risk increases with each prior CS — up to 67% with ≥3 prior CS + praevia
MRI ± USS with colour Doppler for diagnosis
Interventional radiology pre-operatively (balloon occlusion / UAE)
Planned hysterectomy may be required — consent includes fertility loss

Interventional Radiology in GCC Major GCC tertiary centres (SKMC Abu Dhabi, Cleveland Clinic Abu Dhabi, KFSH Riyadh) have active interventional radiology teams capable of internal iliac artery balloon occlusion and uterine artery embolisation for accreta spectrum haemorrhage. Ensure referral pathway is established antenatally.

Placental Abruption — Key Principle Premature separation of a normally sited placenta. Can be CONCEALED (no external bleeding but severe pain and shock) or REVEALED (visible dark bleeding). DIC risk is high. Fetal compromise is common.

Clinical Features — Abruption

PAINFUL — sudden onset severe abdominal pain
Dark red (old) blood — or concealed (no visible bleed)
Hypertonic, board-like uterus — tender on palpation
Fetal parts difficult to palpate (uterine rigidity)
Fetal compromise — CTG abnormalities common
Maternal shock disproportionate to visible blood loss (concealed)
Uterine tenderness localised or generalised
Passage of clots

Revealed vs Concealed

Feature	Revealed	Concealed
External bleeding	Present	Absent / minimal
Pain severity	Moderate	Severe
Shock index	Correlates with loss	Disproportionate
Uterine tenderness	Present	Marked
DIC risk	Moderate	High
Fetal compromise	Variable	High

Disseminated Intravascular Coagulation (DIC)

Pathophysiology

Retroplacental haematoma releases tissue thromboplastin
Activates extrinsic coagulation cascade
Consumptive coagulopathy — fibrinogen falls rapidly
Fibrinogen <2g/L is critically low in obstetrics (<4g/L = early warning)
Thrombocytopaenia develops
PT / APTT prolonged

Management of DIC

ROTEM / TEG point-of-care testing guides component therapy
Cryoprecipitate (fibrinogen source) — target fibrinogen >2g/L
FFP (1:1 ratio with RBCs in MTP)
Platelet transfusion — target >75 × 10⁹/L
Tranexamic acid 1g IV (antifibrinolytic)
Calcium gluconate 10mL 10% with each 4 units FFP (chelation prevention)
Haematology team involvement essential

Kleihauer-Betke Test

Detects fetal red cells in maternal circulation
Quantifies feto-maternal haemorrhage (FMH) volume
Used to calculate additional anti-D dose in Rh-negative women
Positive result with abruption — significant FMH possible
Flow cytometry increasingly used as alternative
Perform on all significant APH in Rh-negative women

Couvelaire Uterus

Extravasation of blood into uterine myometrium
Uterus appears purple/bruised at Caesarean section
Impairs uterine contractility → increases PPH risk
May prevent response to uterotonics
Hysterectomy may be required to control haemorrhage
ICU admission post-operatively

Abruption Management by Severity

Severity	Features	Management
Minor / Stable	Small bleed, stable vitals, normal CTG, no coagulopathy	Continuous CTG monitoring, IV access, bloods, senior review, consider steroids if <34/40
Moderate	Moderate bleed, maternal tachycardia, suspicious CTG, early coagulopathy	Active resuscitation, crossmatch 4–6U, haematology alert, delivery assessment
Severe / Major	Massive haemorrhage, shock, fetal compromise, DIC, concealed	MTP activation, emergency delivery (LSCS vs instrumental depending on stage), HDU/ICU

Abruption in Pre-eclampsia Up to 25% of severe pre-eclampsia cases are complicated by placental abruption. Concurrent hypertension worsens outcomes — vasospasm reduces uteroplacental flow. MgSO₄ should continue for seizure prophylaxis while managing the abruption. Anti-hypertensives must be maintained. These patients have significantly worse maternal and fetal outcomes.

Vasa Praevia — Definition Fetal blood vessels, unsupported by placenta or umbilical cord, run across or near the internal cervical os. Rupture of these vessels at membrane rupture causes rapid FETAL exsanguination. Fetal mortality 60–75% if undiagnosed.

Risk Factors

Velamentous cord insertion (cord inserts into membranes not placental disc)
Bilobed or succenturiate placenta (accessory lobe with bridging vessels)
IVF / ART — significantly higher risk of velamentous insertion
Multiple pregnancy
Low-lying placenta in second trimester
Placenta praevia in previous pregnancy

Clinical Features

Painless bright fresh bleeding at membrane rupture
Sudden fetal bradycardia — sinusoidal CTG pattern
Fetal tachycardia (compensatory) before bradycardia
Blood loss is FETAL — small volume causes fetal shock
Normal maternal haemodynamics (maternal blood not lost)
Fetal mortality 60–75% if undiagnosed and vessels rupture
Survival approaches 97% with antenatal diagnosis and planned delivery

Diagnosis

Colour Doppler ultrasound at 16–20 weeks anomaly scan
Transvaginal USS with Doppler — vessels overlying os
Screen all high-risk women (IVF, velamentous insertion, succenturiate lobe)
MRI can confirm in difficult cases
Apt test (blood diluted in water — fetal Hb resistant to alkali denaturation) — rarely used, rapid but imprecise
Confirm placental cord insertion at anomaly scan in all pregnancies

Antenatal Management (Diagnosed)

Diagnosis at 28–32 weeks → planned hospitalisation
Corticosteroids for fetal lung maturity (34 weeks if not given earlier)
Planned elective LSCS at 34–36 weeks — BEFORE spontaneous labour / membrane rupture
Avoid amniotomy, membrane sweep, or sexual intercourse
Education — warn of emergency symptoms (bleeding + bradycardia = call emergency)
Tertiary centre delivery with immediate surgical capability
Neonatal team present at delivery

Emergency Management — Suspected Vasa Praevia Rupture

Call emergency team immediately — obstetrician, anaesthetist, neonatologist

Rush patient to theatre — every minute counts (fetal exsanguination rate is rapid)

Emergency LSCS under general anaesthesia if fetal bradycardia present

Alert neonatal team — neonate will likely require immediate resuscitation

Prepare O-negative blood for neonate — exchange transfusion may be required

Maternal IV access and bloods — maternal haemodynamics usually stable

Neonatal team to manage fetal haemorrhagic shock: volume resuscitation, blood transfusion

Immediate Emergency Steps (First 5 Minutes)

Call for help: Obstetric registrar/consultant + Anaesthetist + Midwife coordinator + Haematology + Neonatal team (if viable fetus)

Position: Left lateral tilt 15° (reduces aortocaval compression, improves cardiac output)

Airway & Breathing: High-flow O₂ 15L/min via non-rebreather mask; target SpO₂ ≥95%

IV Access × 2: 14–16G large-bore cannulae; draw bloods simultaneously (FBC, coag, fibrinogen, G+S, crossmatch, UEC, LFT, glucose, ABG)

Fluid resuscitation: Crystalloid 500mL bolus × 2 while awaiting blood; do NOT over-dilute coagulation factors

Urinary catheter: Monitor urine output hourly — target ≥0.5mL/kg/hr (reflects organ perfusion)

CTG: Continuous fetal monitoring — pathological CTG = emergency delivery

Massive Transfusion Protocol (MTP)

Activate MTP when ≥4U pRBCs in 4 hours OR haemodynamic instability despite resuscitation
1:1:1 ratio: pRBCs : FFP : Platelets (empirical until ROTEM available)
Tranexamic acid (TXA) 1g IV over 10 minutes — within 3 hours of bleeding onset; repeat 1g if ongoing at 30 minutes
Calcium gluconate 10mL 10% IV with every 4 units of FFP (citrate chelation)
Fibrinogen concentrate 2–4g IV if fibrinogen <2g/L
Aim: Hb ≥80g/L, Platelets ≥75×10⁹/L, Fibrinogen ≥2g/L, INR <1.5

Point-of-Care Coagulation Testing

ROTEM (Rotational Thromboelastometry) or TEG (Thromboelastography)
Guides targeted component therapy — avoids empirical over-transfusion
EXTEM/FIBTEM: fibrinogen function assessment
APTEM: detects hyperfibrinolysis (responds to TXA)
Results available within 10–15 minutes
Available in most GCC tertiary obstetric centres
Repeat every 30–60 minutes during active haemorrhage

Perimortem Caesarean Section

Maternal cardiac arrest in pregnancy — standard CPR ineffective after 20 weeks (aortocaval compression)
Perimortem CS must be initiated within 4 minutes of maternal cardiac arrest
Delivery by 5 minutes optimises maternal AND fetal outcome
Do NOT delay for theatre — perform at bedside in resuscitation room
CPR continues throughout and after delivery
Most common cause of perimortem CS = APH / haemorrhagic shock

Post-Operative / HDU Care

Minimum HDU care × 24h post major APH
DIC monitoring: coagulation profile 4-hourly × 24h
Fluid balance — strict hourly documentation
Urine output ≥0.5mL/kg/hr — alert if less than this for ≥2 hours
Serial Hb (6h and 12h post-surgery)
Wound inspection × 4h post-delivery
VTE prophylaxis when safe (post-DIC resolution)
Psychological debrief — traumatic birth experience support
Neonatal unit liaison for maternal-infant bonding support

Praevia vs Abruption — Key Comparison

Feature

Placenta Praevia

Placental Abruption

Pain

PAINLESS

PAINFUL (severe)

Blood colour

Bright red (fresh)

Dark red / concealed

Uterine tone

Soft, non-tender

Hard, hypertonic, tender

Fetal parts

Palpable

Difficult to palpate

Fetal compromise

Less common

Common / early

DIC risk

Low (unless accreta)

HIGH — early feature

VE safety

NEVER without USS

Avoid until assessed

Delivery route

LSCS (major praevia)

Emergency LSCS if fetal compromise

GCC-Specific Context for APH Management The Gulf Cooperation Council region has unique demographic, cultural, and healthcare system factors that directly affect APH incidence, presentation, and management. GCC nurses must understand this context.

30–50%

CS rate in some GCC hospitals (vs 20–25% global recommendation)

4–7

Average lifetime births per woman in some GCC populations (grand multiparity)

↑67%

Accreta risk with praevia + ≥3 prior Caesarean sections

Placenta Accreta Spectrum Rising in GCC

High CS rates (30–50% in many GCC hospitals) create scarred uteri at younger maternal ages
Multiple CSections in the same patient at younger age — earlier and more severe accreta
Grand multiparity common in GCC → increased uterine surgeries → accreta spectrum risk multiplied
Praevia + scarred uterus = highest accreta risk combination
Accreta spectrum may be diagnosed incidentally at anomaly scan in GCC tertiary centres
Dedicated placenta accreta clinics established in SKMC, KFSH, Cleveland Clinic Abu Dhabi

Antenatal Care Access Variation

Private clinic antenatal care prevalent — high-quality surveillance in major cities
Expatriate workers — variable antenatal care quality; late presentation possible
Remote/rural GCC areas — limited access to specialist obstetric care
Some patients present for first time in active haemorrhage with no USS on record
Language barriers (South Asian, Filipino, African expatriate workers)
Ensure translated patient information available in Arabic, Urdu, Tagalog, Hindi

Cultural & Religious Considerations

Female-only care preference: Many GCC women prefer female obstetricians and nurses for intimate examinations — organise when possible; document when unavailable in emergency
Fertility significance: Hysterectomy carries profound cultural weight — Arabic language informed consent essential; involve family spokesperson per patient wishes
Mahram presence: Male guardian (husband/father) may wish to be involved in major decisions — respect while ensuring patient autonomy
Ramadan fasting: Dehydration during Ramadan can trigger small APH bleeds; educate patients that medical exemptions apply
Consanguineous marriage: Higher rates of rare blood group antibodies in some populations — early blood group and antibody screen essential

Blood Products & Specialist Resources

Blood banks well-stocked in GCC tertiary centres — 24/7 crossmatch capability
O-negative blood available for emergency release without crossmatch
Cell salvage (intraoperative autotransfusion) available in major centres
ROTEM/TEG point-of-care coagulation testing widely available in GCC Level 1 hospitals
Interventional radiology (IR) teams for PAS management:

SKMC Abu Dhabi Cleveland Clinic ABD KFSH Riyadh KHMC Qatar KKUH Jeddah

Ramadan & Seasonal APH Considerations

Ramadan Risk Factors

Dehydration from prolonged fasting → uterine irritability → can trigger small bleeds or preterm labour
Hypoglycaemia may mask / mimic haemodynamic compromise
Delayed hospital attendance — patients may fear breaking fast for non-emergency
Educate: Islamic jurisprudence permits breaking fast for medical emergencies — reinforce this clearly
Increase hydration advice during non-fasting hours

Staff & System Considerations

Reduced staffing possible during Ramadan night shifts in GCC — ensure safe staffing ratios maintained
Blood product availability unchanged — blood bank staff on rotation
Emergency drills recommended before and during Ramadan
Summer heat (UAE/Saudi/Qatar) — dehydration risk year-round for outdoor workers' partners

Arabic-Language Consent — Hysterectomy

Hysterectomy for accreta/PPH requires formal Arabic-language written consent in GCC hospitals
Consent must cover: permanent loss of fertility, menstruation cessation, surgical risks (bladder/ureter injury, haemorrhage), anaesthetic risks
For emergency hysterectomy: documented verbal consent (husband/guardian if patient incapacitated) — legal requirements vary by country (UAE, KSA, Qatar, Kuwait, Bahrain, Oman)
Pre-plan consent discussion antenatally when accreta spectrum is diagnosed — avoids intraoperative crisis
Always involve hospital legal/social work team when consent is challenged
Patient's right to refuse documented clearly; senior obstetrician discussion

Antepartum Haemorrhage — Placenta Praevia & Abruption

MAJOR APH — ACTIVATE EMERGENCY RESPONSE

📋 Most Likely Diagnosis

▶ Immediate Management Steps