Clinical Diagnosis & Immediate Next Step

• 37-week primigravida with painless, intermittent per vaginal bleeding
• No abdominal tenderness (contrasting with placental abruption, which causes painful bleeding with a tender, tense uterus)
• Haemodynamic compromise: BP 90/60 mmHg (hypotension) + pulse 110 bpm (tachycardia) — indicating significant blood loss and hypovolaemic shock

⚠️ The Most Critical Rule: DO NOT perform a digital or speculum vaginal examination

1. Two large-bore IV lines — establish access immediately
2. Fluid resuscitation — crystalloids to restore haemodynamic stability
3. Urgent bedside ultrasonography — confirm placenta praevia, determine type (complete/partial/low-lying), fetal position, and fetal well-being
4. Blood investigations: CBC, coagulation profile (PT, aPTT, fibrinogen, platelet count), type and cross-match
5. Continuous fetal heart rate monitoring
6. Obstetric consultation — immediate
7. Given gestational age of 37 weeks (term): emergency caesarean section is indicated once resuscitation is underway — vaginal delivery is absolutely contraindicated in placenta praevia

If Rh-negative and not yet sensitised: administer 300 µg Rh immunoglobulin within 72 hours.

Complete Placenta Praevia Illustration

Antepartum Haemorrhage (APH): Full Management Algorithm

Step 1 — Initial Assessment & Differentiation of Cause

Step 2 — Initial Resuscitation (All APH)

1. Airway, Breathing, Circulation — ABC assessment
2. 2 large-bore IV cannulae (16G or larger)
3. Fluid resuscitation: warm crystalloids (normal saline / Ringer's lactate)
4. Blood transfusion: packed red cells; fresh frozen plasma if fibrinogen <300 mg/dL or coagulopathy present; platelets if <50,000/µL
5. Position: left lateral tilt (to relieve aortocaval compression)
6. Oxygen by face mask
7. Labs: Full blood count, coagulation screen (PT, aPTT, fibrinogen, D-dimer), urea/electrolytes, LFTs, type and cross-match (hold ≥4 units PRBC)
8. Continuous fetal monitoring (CTG)
9. Foley catheter — monitor urine output
10. DO NOT perform digital vaginal examination until placenta praevia is excluded

Step 3 — Diagnostic Imaging

• Transabdominal ultrasound (first-line): localise placenta, assess fetal well-being, estimate blood loss
• Transvaginal ultrasound (TVU): safe and more accurate for defining the relationship between placental edge and internal cervical os; preferred when transabdominal view is suboptimal — TVU will not precipitate haemorrhage when performed carefully
• Empty the bladder before scanning: a full bladder can falsely elongate the lower uterine segment, leading to overdiagnosis of praevia

Step 4 — Subsequent Management by Cause

A. Placenta Praevia

• Vaginal delivery is absolutely contraindicated in confirmed placenta praevia
• Warn of risk of uterine atony and placenta accreta spectrum at time of LSCS
• Neuraxial anaesthesia is preferred if haemodynamically stable (less blood loss than GA)

B. Placental Abruption

• Key: Monitor fibrinogen closely — <150 mg/dL with fetal demise signals severe DIC
• Replace coagulation factors (FFP, cryoprecipitate, platelets) aggressively
• If fetal demise occurs, cautious vaginal delivery is acceptable if mother is haemodynamically stable

C. Vasa Praevia

• Rare but catastrophic: umbilical vessels cross the cervical os; fetal exsanguination occurs rapidly with membrane rupture
• Treatment: immediate operative delivery

Step 5 — Definitive Delivery Decision (Summary)

APH Confirmed
      │
      ├─ Haemodynamically UNSTABLE  ──→  Emergency CS (regardless of gestation)
      │
      └─ Haemodynamically STABLE
              │
              ├─ Gestation < 34 weeks ──→  Expectant management + corticosteroids
              │                             (unless bleeding worsens)
              │
              ├─ Gestation 34–37 weeks ──→  Individualise (severity, praevia vs. abruption)
              │
              └─ Gestation ≥ 37 weeks  ──→  Deliver
                      │
                      ├─ Placenta praevia  ──→  CAESAREAN SECTION
                      └─ Abruption (stable) ──→  Vaginal delivery may be considered

Key Points for the Presented Case