Introduction: Antepartum haemorrhage is defined as bleeding from 24 weeks of pregnancy. Most important cause is preavia and abruption placenta causing obstetric haemorrhage which remains one of the major causes of maternal mortality in Malaysia despite efforts and protocols have been made to reduce and prevent it.  Concealed bleeding may mislead clinicians causing delayed diagnosis leading to maternal shock, DIVC and intrauterine death. Couvelaire uterus is an intraoperative finding following placenta abruption due to blood seeping through the myometrium. This may further worsen uterine atony which may not be responding to uterotonics hence requiring surgical intervention (i.e. B-lynch suture, hysterectomy).

Case Illustration: Ms S, 19 years old Primigravida presented at 36 weeks of gestation with a history of contraction pain and cervical opening of 3 cm. No history of bleeding per vagina, trauma, fall or drug abuse. She was however anaemic requiring blood transfusion at 33 weeks due to symptomatic hypochromic microcytic anemia. On arrival her blood pressure was 110/70 mmhg, pulse rate 80 and contracting 1 in 10 minutes. The uterus was relaxed in between contraction while uterus corresponding to date. Admission CTG was reactive. 4 hours later, during routine fetal heart monitoring by daptone noted fetal heart rate is 60 bpm. Abdomen was hard and tense on palpation, she was in severe pain. Artificial rupture of membrane revealed fresh blood at 3 cm dilated. She was pushed for crash caesarean for abruption placenta. Time from decision to delivery was 35 minutes, baby A/S 7 and 9 weighing 2.5 kilogram. There was >500 mls of retroplacenta clots with couvelair uterus. She bled continuously as DIVC has sets in where INR is >6. Blood products and fluids resuscitation aggressively given including IV tranxenamic acid and uterotonics. B-lynch suture was placed while correcting her DIVC. Estimated blood loss was 6 litres. Once her INR reached 1 her abdominal drain still draining 1.5L of hemoserous blood for another 10 hours before it subsequently reduced. Urine output remains good with no acute organ damage.

Discussion: Abruptio placenta is associated with maternal and perinatal morbidity and mortality. Clinicians managing these women should be aware of these potential consequences. Predisposing risk factors includes preeclampsia, polyhydramios, advanced maternal age, trauma, smoking, and drug misuse during pregnancy. Other than being severely anaemic no other risk factors identified.   Fortunately despite massive bleeding and deranged coagulation, baby outcome is well.