Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

bleeding with unknown placental position

1st line – resuscitation and stabilisation

Back
INITIAL
|
bleeding with unknown placental position
1st line – 

resuscitation and stabilisation

A digital vaginal examination should not be performed. This may turn severe bleeding into torrential bleeding.[1][15][44] Bleeding can increase from mild to severe very rapidly, and it is therefore best to overestimate the degree of bleeding. Severe bleeding is usually obvious, but occasionally blood can pool in the vagina.

Standard resuscitation guidelines should be followed.

Administration of an antifibrinolytic (such as tranexamic acid) should be considered as soon as possible as they have been shown to have a survival benefit.[60]

Transfusion of red blood cells, fresh frozen plasma and platelets should be considered, depending on the Hb level, platelet count, and level of coagulopathy.

Continuous electronic fetal heart monitoring should be arranged as long as significant bleeding continues; fetal compromise (abnormal fetal heart tracing) is usually an indication of severe bleeding.[5][44]

Proceed to an immediate caesarean section if bleeding does not subside or if there is evidence of significant fetal compromise.[1][2]

Consider – urgent ultrasound

Back
INITIAL
|
bleeding with unknown placental position
Consider – 

urgent ultrasound

Additional treatment recommended for SOME patients in selected patient group

Some women will present with bleeding in pregnancy and no prior ultrasound. If so, urgent ultrasound to define the underlying cause of the bleeding should be obtained (if the woman is in a haemodynamically stable enough condition to allow this).[37]

Plus – emergency caesarean section

Back
INITIAL
|
bleeding with unknown placental position
|
not stabilised by resuscitation
Plus – 

emergency caesarean section

Treatment recommended for ALL patients in selected patient group

If bleeding is not controlled, an immediate caesarean section should be performed.[1][2]

Prophylactic intra-operative antibiotics are indicated routinely in caesarean sections.[2][15][39][44][59]

Consider – anti-D immunoglobulin

Back
INITIAL
|
bleeding with unknown placental position
|
not stabilised by resuscitation
Consider – 

anti-D immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

The indication for anti-D immunoglobulin should be assessed.[55]

In practice, the dose should be given: at 28 weeks' gestation when the fetal blood type is unknown or known to be Rh positive; and within 72 hours of delivery to a postpartum non-sensitised Rh-negative woman delivering an Rh-positive infant.[46]

In the UK, the National Institute for Health and Care Excellence and the British Society for Haematology advise that anti-D immunoglobulin may be administered as a single dose at 28 weeks' gestation, or as two doses at 28 weeks' and 34 weeks' gestation.[56][57]

Primary options

anti-D immunoglobulin: 300 micrograms intramuscularly

ACUTE

bleeding with known placenta praevia

1st line – resuscitation and stabilisation

Back
ACUTE
|
bleeding with known placenta praevia
1st line – 

resuscitation and stabilisation

A digital vaginal examination should not be performed. This may turn severe bleeding into torrential bleeding.[1][15][44] Bleeding can increase from mild to severe very rapidly, and it is therefore best to overestimate the degree of bleeding. Severe bleeding is usually obvious, but occasionally blood can pool in the vagina.

Standard resuscitation guidelines should be followed.

Administration of an antifibrinolytic (such as tranexamic acid) should be considered as soon as possible as they have been shown to have a survival benefit.[60]

Transfusion of red blood cells, fresh frozen plasma and platelets should be considered, depending on the Hb level, platelet count, and level of coagulopathy.

Continuous electronic fetal heart monitoring should be arranged as long as significant bleeding continues; fetal compromise (abnormal fetal heart tracing) is usually an indication of severe bleeding.[5][44]

Proceed to an immediate caesarean section if bleeding does not subside or if there is evidence of significant fetal compromise.[1][2]

Plus – emergency caesarean section

Back
ACUTE
|
bleeding with known placenta praevia
|
not stabilised by resuscitation
Plus – 

emergency caesarean section

Treatment recommended for ALL patients in selected patient group

Proceed to an immediate caesarean section if bleeding is not controlled.[1][2]

Prophylactic intra-operative antibiotics are indicated routinely in caesarean sections.[2][15][39][44][59]

Consider – anti-D immunoglobulin

Back
ACUTE
|
bleeding with known placenta praevia
|
not stabilised by resuscitation
Consider – 

anti-D immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

The indication for anti-D immunoglobulin should be assessed.[55]

In practice, the dose should be given: at 28 weeks' gestation when the fetal blood type is unknown or known to be Rh positive; and within 72 hours of delivery to a postpartum non-sensitised Rh-negative woman delivering an Rh-positive infant.[46]

In the UK, the National Institute for Health and Care Excellence and the British Society for Haematology advise that anti-D immunoglobulin may be administered as a single dose at 28 weeks' gestation, or as two doses at 28 weeks' and 34 weeks' gestation.[56][57]

Primary options

anti-D immunoglobulin: 300 micrograms intramuscularly

Plus – urgent consultation and transfer

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: not in labour
Plus – 

urgent consultation and transfer

Treatment recommended for ALL patients in selected patient group

Urgent consultation with appropriately trained personnel should be obtained for further management. The woman should be refered and/or transfered to a suitable obstetric and neonatal unit if they are stable and bleeding subsides.

Plus – magnesium sulfate if less than 34 weeks

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: not in labour
Plus – 

magnesium sulfate if less than 34 weeks

Treatment recommended for ALL patients in selected patient group

If delivery is planned or expected before 34 weeks' gestation, intravenous magnesium sulfate is recommended for neuroprotection of the baby.[62][63]​ Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria, treatment regimens, and concurrent tocolysis.[63]​ There is no evidence that magnesium sulfate has any value as a tocolytic agent, and its use should only be for neuroprotection in appropriate groups of women.[64]

The US Food and Drug Administration (FDA) recommends against using magnesium sulfate injection for more than 5 to 7 days to stop preterm labour in pregnant women (an off-label use), as it may lead to low calcium levels and bone problems in the fetus or baby. The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) also recommends against any use of magnesium sulfate in pregnancy for more than 5 to 7 days. If prolonged or repeated use occurs during pregnancy (e.g., multiple courses or use for >24 hours), consider monitoring of neonates for abnormal calcium and magnesium levels and skeletal adverse effects.[70][71]

Primary options

magnesium sulfate: consult specialist for guidance on dose

More

Plus – corticosteroid if less than 34 weeks

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: not in labour
Plus – 

corticosteroid if less than 34 weeks

Treatment recommended for ALL patients in selected patient group

Corticosteroids may be considered from 24 to 34 weeks' gestation, to accelerate lung maturation in the premature infant prior to and up to 24 hours before anticipated delivery.[65][66][67] The Society of Obstetricians and Gynaecologists of Canada recommends corticosteroid administration only if the risk of delivery within 7 days is determined to be very high.[1]

Consider a repeat dose of corticosteroids if the mother remains at risk for preterm birth 7 or more days after the initial course of corticosteroids.[66][67][68][72] Repeat doses of antenatal corticosteroids seem to reduce the need for neonatal respiratory support, however compared with a single dose there may be no difference in serious morbidity or mortality outcomes for the baby. There is also an increased risk of low birthweight with repeat corticosteroids which is dose dependent.[67] 

Primary options

betamethasone sodium phosphate: 12 mg intramuscularly every 24 hours for 2 doses

OR

dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses

Consider – anti-D immunoglobulin

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: not in labour
Consider – 

anti-D immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

The indication for anti-D immunoglobulin should be assessed.[55]

In practice, the dose should be given: at 28 weeks' gestation when the fetal blood type is unknown or known to be Rh positive; and within 72 hours of delivery to a postpartum non-sensitised Rh-negative woman delivering an Rh-positive infant.[46]

In the UK, the National Institute for Health and Care Excellence and the British Society for Haematology advise that anti-D immunoglobulin may be administered as a single dose at 28 weeks' gestation, or as two doses at 28 weeks' and 34 weeks' gestation.[56][57]

Primary options

anti-D immunoglobulin: 300 micrograms intramuscularly

Plus – tocolytic

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: preterm labour
Plus – 

tocolytic

Treatment recommended for ALL patients in selected patient group

If there is evidence of preterm labour, consider tocolytics. The use of tocolytics in placenta praevia with bleeding is controversial. The major purpose of tocolytic therapy is to prolong pregnancy to allow the administration of corticosteroids.[68][73]​ The secondary use is to allow time for transfer to a secondary or tertiary referral centre (if indicated and if the woman’s condition is stable).

The American College of Obstetricians and Gynecologists advises against the use of tocolysis in the late preterm period (34 weeks to 36 weeks plus 6 days) for the purpose of allowing corticosteroids to be administered.[66]

Oral terbutaline is not approved and should not be used for acute or maintenance tocolysis.

Terbutaline sulfate injection should not be used for prolonged tocolysis (beyond 48 to 72 hours) due to potential serious maternal cardiac adverse effects and death.

The European Medicines Agency (EMA) recommends that the use of injectable beta agonists should be restricted to a maximum of 48 hours between the 22nd and 37th week of pregnancy. Beta agonists should only be used under specialist supervision, with continuous monitoring of the mother and unborn baby, because of the risk of adverse cardiovascular effects in both the mother and baby. The EMA no longer recommends oral or rectal formulations for obstetric indications.[74]

One systematic review found that there was evidence to support the use of calcium-channel blockers, mainly nifedipine, for tocolysis. The blockers were shown to have benefits over betamimetics in relation to prolongation of pregnancy, serious neonatal morbidity, and maternal adverse effects. However, there was no difference noted in perinatal mortality, data on longer-term outcomes were limited, and the optimal dose has yet to be determined.[75]

Consultation with appropriately trained personnel should be obtained for further management.

Decisions about initiation, drug, and dose should be made only after consultation.

If the attempt to arrest labour is not successful, a caesarean section should be performed.

Primary options

terbutaline: 0.25 mg subcutaneously every 20 minutes to 3 hours

OR

indometacin: 50-100 mg orally as a loading dose, followed by 25-50 mg every 6 hours for 48 hours

Secondary options

nifedipine: consult specialist for guidance on dose

Plus – magnesium sulfate if less than 34 weeks

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: preterm labour
Plus – 

magnesium sulfate if less than 34 weeks

Treatment recommended for ALL patients in selected patient group

If delivery is planned or expected before 34 weeks' gestation, intravenous magnesium sulfate is recommended for neuroprotection of the baby.[62][63]​ Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria, treatment regimens, and concurrent tocolysis.[63] There is no evidence that magnesium sulfate has any value as a tocolytic agent, and its use should only be for neuroprotection in appropriate groups of women.[64]

The US FDA recommends against using magnesium sulfate injection for more than 5 to 7 days to stop preterm labour in pregnant women (an off-label use), as it may lead to low calcium levels and bone problems in the fetus or baby. The UK-based MHRA also recommends against any use of magnesium sulfate in pregnancy for more than 5 to 7 days. If prolonged or repeated use occurs during pregnancy (e.g., multiple courses or use for >24 hours), consider monitoring of neonates for abnormal calcium and magnesium levels and skeletal adverse effects.[70][71]

Primary options

magnesium sulfate: consult specialist for guidance on dose

More

Plus – corticosteroid if less than 34 weeks

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: preterm labour
Plus – 

corticosteroid if less than 34 weeks

Treatment recommended for ALL patients in selected patient group

Corticosteroids may be considered from 24 to 34 weeks' gestation, to accelerate lung maturation in the premature infant prior to and up to 24 hours before anticipated delivery.[65][66][67] The Society of Obstetricians and Gynaecologists of Canada recommends corticosteroid administration only if the risk of delivery within 7 days is determined to be very high.[1]

Consider a repeat dose of corticosteroids if the mother remains at risk for preterm birth 7 or more days after the initial course of corticosteroids.[66][67][68][72] Repeat doses of antenatal corticosteroids seem to reduce the need for neonatal respiratory support, however compared with a single dose there may be no difference in serious morbidity or mortality outcomes for the baby. There is also an increased risk of low birthweight with repeat corticosteroids which is dose dependent.[67]

Primary options

betamethasone sodium phosphate: 12 mg intramuscularly every 24 hours for 2 doses

OR

dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses

Consider – caesarean section

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: preterm labour
Consider – 

caesarean section

Additional treatment recommended for SOME patients in selected patient group

If the attempt to arrest labour is not successful, a caesarean section should be performed.

Prophylactic intra-operative antibiotics are indicated routinely in caesarean sections.[2][15][39][44][59]

The decision as to the timing of the caesarean section should be left to the consultant.

Consider – anti-D immunoglobulin

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: preterm labour
Consider – 

anti-D immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

The indication for anti-D immunoglobulin should be assessed.[55]

In practice, the dose should be given: at 28 weeks' gestation when the fetal blood type is unknown or known to be Rh positive; and within 72 hours of delivery to a postpartum non-sensitised Rh-negative woman delivering an Rh-positive infant.[46]

In the UK, the National Institute for Health and Care Excellence and the British Society for Haematology advise that anti-D immunoglobulin may be administered as a single dose at 28 weeks' gestation, or as two doses at 28 weeks' and 34 weeks' gestation.[56][57]

Primary options

anti-D immunoglobulin: 300 micrograms intramuscularly

Plus – caesarean section

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: at term or in labour
Plus – 

caesarean section

Treatment recommended for ALL patients in selected patient group

If in labour, an urgent caesarean section is indicated as significant bleeding may occur.

Prophylactic intra-operative antibiotics are indicated routinely in caesarean sections.[2][15][39][44][59]

Consider – anti-D immunoglobulin

Back
ACUTE
|
bleeding with known placenta praevia
|
stabilised: at term or in labour
Consider – 

anti-D immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

The indication for anti-D immunoglobulin should be assessed.[55]

In practice, the dose should be given within 72 hours of delivery to a postpartum non-sensitised Rh-negative woman delivering an Rh-positive infant.[46]

In the UK, the National Institute for Health and Care Excellence and the British Society for Haematology advise that anti-D immunoglobulin may be administered as a single dose at 28 weeks' gestation, or as two doses at 28 weeks' and 34 weeks' gestation.[56][57]

Primary options

anti-D immunoglobulin: 300 micrograms intramuscularly

placenta praevia with no bleeding

1st line – monitoring and pelvic rest

Back
ACUTE
|
placenta praevia with no bleeding
|
preterm: not in labour
1st line – 

monitoring and pelvic rest

Women should be given advice about pelvic rest (e.g., no penetrative sexual intercourse or use of tampons) and advised to go to hospital in case of significant bleeding.[1][15]

Many low-lying placentas migrate during pregnancy and resolve spontaneously. If PP or a low-lying placenta are detected at the routine anatomical scan (typically 18 to 22 weeks' gestation) and there is no significant bleeding, a repeat ultrasound should be obtained at approximately 32 weeks.[1][2][38] If the placenta is now in normal position, no further investigations are indicated. If a low-lying placenta or a PP is detected, however, it is very unlikely to resolve spontaneously, and a further ultrasound should be arranged for 36 weeks to aid delivery planning.[1][2]

If there is risk of placenta accreta spectrum (e.g., previous uterine scarring) then an ultrasound with colour flow Doppler imaging should be obtained.[2][3]

The decision on the method and timing of imaging should be left to the consultant. Depending on local expertise and resources, appropriate referral may be made to a centre where suitable obstetric and neonatal expertise is available.

Plus – magnesium sulfate if less than 34 weeks

Back
ACUTE
|
placenta praevia with no bleeding
|
preterm: not in labour
Plus – 

magnesium sulfate if less than 34 weeks

Treatment recommended for ALL patients in selected patient group

If delivery is planned or expected before 34 weeks' gestation, intravenous magnesium sulfate is recommended for neuroprotection of the baby.[62][63]​ Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria, treatment regimens, and concurrent tocolysis.[63]​ There is no evidence that magnesium sulfate has any value as a tocolytic agent, and its use should only be for neuroprotection in appropriate groups of women.[64]

The US FDA recommends against using magnesium sulfate injection for more than 5 to 7 days to stop preterm labour in pregnant women (an off-label use), as it may lead to low calcium levels and bone problems in the fetus or baby. The UK-based MHRA also recommends against any use of magnesium sulfate in pregnancy for more than 5 to 7 days. If prolonged or repeated use occurs during pregnancy (e.g., multiple courses or use for >24 hours), consider monitoring of neonates for abnormal calcium and magnesium levels and skeletal adverse effects.[70][71]

Primary options

magnesium sulfate: consult specialist for guidance on dose

More

Plus – corticosteroid if less than 34 weeks

Back
ACUTE
|
placenta praevia with no bleeding
|
preterm: not in labour
Plus – 

corticosteroid if less than 34 weeks

Treatment recommended for ALL patients in selected patient group

Corticosteroids may be considered from 24 to 34 weeks' gestation, to accelerate lung maturation in the premature infant prior to and up to 24 hours before anticipated delivery.[65][66][67] The Society of Obstetricians and Gynaecologists of Canada recommends corticosteroid administration only if the risk of delivery within 7 days is determined to be very high.[1]

Consider a repeat dose of corticosteroids if the mother remains at risk for preterm birth 7 or more days after the initial course of corticosteroids.[66][67][68][72] Repeat doses of antenatal corticosteroids seem to reduce the need for neonatal respiratory support, however compared with a single dose there may be no difference in serious morbidity or mortality outcomes for the baby. There is also an increased risk of low birthweight with repeat corticosteroids which is dose dependent.[67]

Primary options

betamethasone sodium phosphate: 12 mg intramuscularly every 24 hours for 2 doses

OR

dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses

Consider – anti-D immunoglobulin

Back
ACUTE
|
placenta praevia with no bleeding
|
preterm: not in labour
Consider – 

anti-D immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

The indication for anti-D immunoglobulin should be assessed.[55]

In practice, the dose should be given: at 28 weeks' gestation when the fetal blood type is unknown or known to be Rh positive; and within 72 hours of delivery to a postpartum non-sensitised Rh-negative woman delivering an Rh-positive infant.[46]

In the UK, the National Institute for Health and Care Excellence and the British Society for Haematology advise that anti-D immunoglobulin may be administered as a single dose at 28 weeks' gestation, or as two doses at 28 weeks' and 34 weeks' gestation.[56][57]

Primary options

anti-D immunoglobulin: 300 micrograms intramuscularly

1st line – tocolytic

Back
ACUTE
|
placenta praevia with no bleeding
|
with preterm labour
1st line – 

tocolytic

If there is evidence of preterm labour, consider tocolytics. The use of tocolytics in placenta praevia with bleeding is controversial. The major purpose of tocolytic therapy is to prolong pregnancy to allow the administration of corticosteroids.[68][73]​ The secondary use is to allow time for transfer to a secondary or tertiary referral centre (if indicated and if the woman’s condition is stable).

The American College of Obstetricians and Gynecologists advises against the use of tocolysis in the late preterm period (34 weeks to 36 weeks plus 6 days) for the purpose of allowing corticosteroids to be administered.[66]

Oral terbutaline is not approved and should not be used for acute or maintenance tocolysis.

Terbutaline sulfate injection should not be used for prolonged tocolysis (beyond 48 to 72 hours).

The European Medicines Agency (EMA) recommends that the use of injectable beta agonists should be restricted to a maximum of 48 hours between the 22nd and 37th week of pregnancy. Beta agonists should only be used under specialist supervision, with continuous monitoring of the mother and unborn baby, because of the risk of adverse cardiovascular effects in both the mother and baby. The EMA no longer recommends oral or rectal formulations for obstetric indications.[74]

One systematic review found that there was evidence to support the use of calcium-channel blockers, mainly nifedipine, for tocolysis. The blockers were shown to have benefits over betamimetics in relation to prolongation of pregnancy, serious neonatal morbidity, and maternal adverse effects. However, there was no difference noted in perinatal mortality, data on longer-term outcomes were limited, and the optimal dose has yet to be determined.[75]

Consultation with appropriately trained personnel should be obtained for further management.

Decisions about initiation, drug, and dose should be made only after consultation.

If the attempt to arrest labour is not successful, a caesarean section should be performed.

Primary options

terbutaline: 0.25 mg subcutaneously every 20 minutes to 3 hours

OR

indometacin: 50-100 mg orally as a loading dose, followed by 25-50 mg every 6 hours for 48 hours

Secondary options

nifedipine: consult specialist for guidance on dose

Plus – magnesium sulfate if less than 34 weeks

Back
ACUTE
|
placenta praevia with no bleeding
|
with preterm labour
Plus – 

magnesium sulfate if less than 34 weeks

Treatment recommended for ALL patients in selected patient group

If delivery is planned or expected before 34 weeks' gestation, intravenous magnesium sulfate is recommended for neuroprotection of the baby.[62][63]​ Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria, treatment regimens, and concurrent tocolysis.[63]​There is no evidence that magnesium sulfate has any value as a tocolytic agent, and its use should only be for neuroprotection in appropriate groups of women.[64]

The US FDA recommends against using magnesium sulfate injection for more than 5 to 7 days to stop preterm labour in pregnant women (an off-label use), as it may lead to low calcium levels and bone problems in the fetus or baby. The UK-based MHRA also recommends against any use of magnesium sulfate in pregnancy for more than 5 to 7 days. If prolonged or repeated use occurs during pregnancy (e.g., multiple courses or use for >24 hours), consider monitoring of neonates for abnormal calcium and magnesium levels and skeletal adverse effects.[70][71]

Primary options

magnesium sulfate: consult specialist for guidance on dose

More

Plus – corticosteroid if less than 34 weeks

Back
ACUTE
|
placenta praevia with no bleeding
|
with preterm labour
Plus – 

corticosteroid if less than 34 weeks

Treatment recommended for ALL patients in selected patient group

Corticosteroids may be considered from 24 to 34 weeks' gestation, to accelerate lung maturation in the premature infant prior to and up to 24 hours before anticipated delivery.[65][66][67] The Society of Obstetricians and Gynaecologists of Canada recommends corticosteroid administration only if the risk of delivery within 7 days is determined to be very high.[1]

Consider a repeat dose of corticosteroids if the mother remains at risk for preterm birth 7 or more days after the initial course of corticosteroids.[66][67][68][72] Repeat doses of antenatal corticosteroids seem to reduce the need for neonatal respiratory support, however compared with a single dose there may be no difference in serious morbidity or mortality outcomes for the baby. There is also an increased risk of low birthweight with repeat corticosteroids which is dose dependent.[67]

Primary options

betamethasone sodium phosphate: 12 mg intramuscularly every 24 hours for 2 doses

OR

dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses

Consider – caesarean section

Back
ACUTE
|
placenta praevia with no bleeding
|
with preterm labour
Consider – 

caesarean section

Additional treatment recommended for SOME patients in selected patient group

If the attempt to arrest labour is not successful, a caesarean section should be performed.

Prophylactic intra-operative antibiotics are indicated routinely in caesarean sections.[2][15][39][44][59]

The decision as to the timing of the caesarean section should be left to the consultant.

Consider – anti-D immunoglobulin

Back
ACUTE
|
placenta praevia with no bleeding
|
with preterm labour
Consider – 

anti-D immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

The indication for anti-D immunoglobulin should be assessed.[55]

In practice, the dose should be given: at 28 weeks' gestation when the fetal blood type is unknown or known to be Rh positive; and within 72 hours of delivery to a postpartum non-sensitised Rh-negative woman delivering an Rh-positive infant.[46]

In the UK, the National Institute for Health and Care Excellence and the British Society for Haematology advise that anti-D immunoglobulin may be administered as a single dose at 28 weeks' gestation, or as two doses at 28 weeks' and 34 weeks' gestation.[56][57]

Primary options

anti-D immunoglobulin: 300 micrograms intramuscularly

1st line – caesarean section

Back
ACUTE
|
placenta praevia with no bleeding
|
full term
1st line – 

caesarean section

In general, PP after 36 weeks is an indication for caesarean section as the route of delivery.[1]

The decision as to the timing of the caesarean section is based on the gestational age (which may be uncertain) and the presence of risk factors, including the degree of bleeding, the start of labour (and the associated degree of cervical dilation), the danger of blood transfusion (which varies locally), and the presence of adequate neonatal care.[1][2] In the presence of risk factors, caesarean section is recommended at 36 weeks to 36 weeks plus 6 days.[1][2][5] In the absence of risk factors, caesarean section is recommended at 37 weeks to 37 weeks plus 6 days.[1][2][5]

If in labour, an urgent caesarean section is indicated as significant bleeding may occur.

Prophylactic intra-operative antibiotics are indicated routinely in caesarean sections.[2][15][39][44][59]

Consider – anti-D immunoglobulin

Back
ACUTE
|
placenta praevia with no bleeding
|
full term
Consider – 

anti-D immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

The indication for anti-D immunoglobulin should be assessed.[55]

In practice, the dose should be given within 72 hours of delivery to a postpartum non-sensitised Rh-negative woman delivering an Rh-positive infant.[46]

In the UK, the National Institute for Health and Care Excellence and the British Society for Haematology advise that anti-D immunoglobulin may be administered as a single dose at 28 weeks' gestation, or as two doses at 28 weeks' and 34 weeks' gestation.[56][57]

Primary options

anti-D immunoglobulin: 300 micrograms intramuscularly within 72 hours of delivery

1st line – await spontaneous labour

Back
ACUTE
|
placenta praevia with no bleeding
|
low-lying placenta: full term
1st line – 

await spontaneous labour

The os-placental edge distance on ultrasound at 36 weeks' gestation is valuable in planning route of delivery.[1][2] When the placental edge is 11 to 20 mm from the internal cervical os, women can be offered a trial of labour with a high expectation of success.[1] Trial of labour can be considered in carefully selected women with an os-placental edge distance of ≤10 mm, providing it takes place in a facility with immediate access to an obstetrician, anaesthetist, neonatologist, and blood transfusion.[1]

The asymptomatic woman at term may be allowed to proceed with labour with careful monitoring and consultation in a 'double setup' situation (one that may be immediately converted to a caesarean section if bleeding becomes significant or the fetus becomes distressed).[2][15][39][44][59]

Consider – caesarean section

Back
ACUTE
|
placenta praevia with no bleeding
|
low-lying placenta: full term
Consider – 

caesarean section

Additional treatment recommended for SOME patients in selected patient group

If women with a placental edge 11 to >20 mm from the internal cervical os elect to have a caesarean delivery, optimal timing for the procedure is 39 weeks to 40 weeks plus 6 days.[1] In women with an os-placental edge distance of ≤10 mm, caesarean delivery should be timed for 37 weeks to 37 weeks plus 6 days in the presence of risk factors, or 38 weeks to 38 weeks plus 6 days in the absence of risk factors.[1]

Earlier, urgent delivery may be required in extenuating circumstances, including if antenatal haemorrhage results in maternal haemodynamic compromise or an abnormal fetal heart rate, or if there is significant antenatal haemorrhage at ≥34 weeks' gestation.[1]

Prophylactic intra-operative antibiotics are indicated routinely in caesarean sections.[2][15][39][44][59]

Consider – anti-D immunoglobulin

Back
ACUTE
|
placenta praevia with no bleeding
|
low-lying placenta: full term
Consider – 

anti-D immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

The indication for anti-D immunoglobulin should be assessed.[55]

In practice, the dose should be given within 72 hours of delivery to a postpartum non-sensitised Rh-negative woman delivering an Rh-positive infant.[46]

In the UK, the National Institute for Health and Care Excellence and the British Society for Haematology advise that anti-D immunoglobulin may be administered as a single dose at 28 weeks' gestation, or as two doses at 28 weeks' and 34 weeks' gestation.[56][57]

Primary options

anti-D immunoglobulin: 300 micrograms intramuscularly within 72 hours of delivery

with miscarriage or elective termination

1st line – expectant management, surgical abortion, or medical abortion

Back
ACUTE
|
with miscarriage or elective termination
1st line – 

expectant management, surgical abortion, or medical abortion

Miscarriage is not treated differently in the presence of PP.

Elective abortion (whether medical or surgical) in the first trimester does not differ in the presence of PP; in the second trimester, surgical abortion may be preferred over medical.

Consider – anti-D immunoglobulin

Back
ACUTE
|
with miscarriage or elective termination
Consider – 

anti-D immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

The indication for anti-D immunoglobulin should be assessed.[55]

In practice, the dose should be given within 72 hours of miscarriage/termination event.[46]

In the UK, the National Institute for Health and Care Excellence and the British Society for Haematology advise that anti-D immunoglobulin may be administered as a single dose at 28 weeks' gestation, or as two doses at 28 weeks' and 34 weeks' gestation.[56][57]

Primary options

anti-D immunoglobulin: 300 micrograms intramuscularly within 72 hours of miscarriage/termination event

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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