Basics
Description
- Hemorrhage at the decidual " “placental interface leading to complete or partial separation of the normally
implanted placenta before delivery of the fetus - Incidence/prevalence:
- ¢ ˆ ¼1% of all pregnancies
- 30% of bleeding episodes in the 2nd half of pregnancy
- 15% of all fetal deaths
- Neonatal death in 10 " “30% of cases
- 6% of all maternal mortality
- Synonym(s): Abruptio placentae, accidental hemorrhage (in UK)
Etiology
- Primary cause unknown
- Vascular injury with dissection of blood into the decidua basalis or mechanical shearing between the placenta and uterus leading to bleeding and clot formation
- More severe cases lead to:
- Development of disseminated intravascular coagulation (DIC)
- Maternal " “fetal compromise
- Research suggests that the majority of abruptions are due to chronic processes:
- Inflammatory changes in the placenta
- Manifestation of ischemic placental disease
- Acute abruption can occur due to:
- Trauma
- Rapid uterine decompression
- Placenta implantation over a uterine anomaly or fibroid
- Multiple known risk factors:
- Previous abruption (10 " “20% recurrence risk)
- Maternal hypertension (>140/90) and preeclampsia
- Increased parity and maternal age
- Multiple gestation
- Fibroids or other uterine/placental abnormalities
- Tobacco use
- Cocaine abuse
- Trauma
- Premature rupture of membranes, particularly if associated with chorioamnionitis or oligohydramnios
- Rapid uterine decompression:
- Polyhydramnios with membrane rupture
- Rapid delivery of 1st twin
- Elevated 2nd trimester maternal serumα-fetoprotein
- Thrombophilias
- Maternal race:
- More common among African American and Caucasian women
- Incidence increasing more rapidly among African American women
Diagnosis
Signs and Symptoms
History
- 20+ wk of pregnancy
- Vaginal bleeding (>80%, usually painful)
- Abdominal or back pain (>50%)
- Uterine cramps, tenderness, frequent contractions, or tetany
- Nausea, vomiting
- Otherwise unexplained preterm labor
- History of recent trauma should be elicited
- Recent drug use, particularly cocaine or other sympathomimetics
- Prior abruption or other risk factors
- Estimated gestational age
- Prenatal care history
Physical Exam
- Signs of hypotensive shock may be present
- Uterine tenderness frequently present
- Vaginal bleeding (absent in 20 " “25%)
- Petechiae, bleeding, and other signs of DIC
- Decreased fetal heart tones and movement
- Fetal bradycardia or nonreassuring fetal heart rate tracings
- Sterile vaginal exam must be performed with caution to avoid tissue injury, especially if placenta previa suspected:
- Assess for presence of amniotic fluid (nitrazine paper turns blue; ferning of fluid on glass slide)
- Evaluate for vaginal or cervical lacerations
Essential Workup
- Large-bore IV access
- Blood type, Rh, and cross-match
- Rapid hemoglobin determination
- Determine fetal heart tones by Doppler
- Fetal monitoring to detect signs of early fetal distress
- Uterine tocographic monitoring
Diagnosis Tests & Interpretation
Diagnosis is primarily clinical, supportive tests include ‚
Lab
- Blood type and Rh
- CBC
- PT/PTT
- Fibrinogen levels (normally 450 in latter half of pregnancy) and fibrin split products
- Fibrinogen <200 mg/dL and platelets <100,000/ Ž ¼L highly suggestive of abruption
- Kleihauer " “Betke if mother Rh-negative (significant fetal-to-maternal hemorrhage more likely in traumatic abruption)
Imaging
- US demonstrates evidence of abruption in only 50% of cases (false-negative common)
- MRI sensitive but impractical
- If abdomen/pelvis CT scan done as part of maternal trauma evaluation, evidence of abruption may be visible (must ask the radiologist to evaluate specifically)
Differential Diagnosis
- Placenta previa
- Bleeding during labor
- Vaginal or cervical lacerations
- Uterine rupture
- Preterm labor
- Ovarian torsion
- Pyelonephritis
- Cholelithiasis/cholecystitis
- Appendicitis
- Other blunt intra-abdominal or pelvic injuries
Treatment
Pre-Hospital
- Patients with abruption may be in shock and need full resuscitative measures
- Transport in the left lateral recumbent position
Initial Stabilization/Therapy
- Airway, breathing, circulation (ABCs), oxygen
- Cardiac monitor
- Placement of large-bore IVs
- IV crystalloid resuscitation
Ed Treatment/Procedures
- Maternal cardiac and tocographic monitoring
- Continuous fetal monitoring
- Transfuse PRBCs, fresh frozen plasma (FFP), cryoprecipitate, and platelets as indicated (may require massive transfusion protocol)
- Immediate OB/GYN consultation
- Foley catheter for close monitoring of urine output
- Tocolysis is generally contraindicated
- If abruption is suspected in the setting of trauma, maternal stabilization is of primary importance:
- All indicated radiographs should be performed as needed
Medication
First Line
- Rh-immunoglobulin in Rh-negative women:
- 300 Ž ¼g IM in women at ≥12 wk gestation
- Higher doses if indicated by results of Kleihauer " “Betke test
- Blood products as indicated
Second Line
Consider with obstetrician recommendation: ‚
- Magnesium sulfate if tocolysis is indicated
- Steroids for fetal lung maturation if gestational age between 24 and 34 wk
Follow-Up
Disposition
Admission Criteria
- Patients with placental abruption must be admitted for maternal and fetal monitoring
- Admit to ICU if DIC, amniotic fluid embolism, or significant hemorrhage (known or suspected)
- Victims of multiple trauma with abruption should be admitted and managed in accordance with trauma protocols
- Transportation to higher trauma or obstetric level of care is appropriate if the patient is stable for transfer or appropriate care unavailable at existing facility
Discharge Criteria
- Trauma patients with no evidence of abruption or other significant injury may be discharged after 4 " “6 hr of normal maternal and fetal monitoring
- Discharge instructions include pelvic rest, no intercourse, no heavy lifting, no prolonged standing
- Discharge decision should be made in consultation with OB/GYN and include close follow-up
Issues for Referral
All cases of confirmed or suspected abruption require immediate obstetric consultation ‚
Pearls and Pitfalls
- Primarily a clinical diagnosis: No single test reliably confirms or rules out placental abruption
- Hypotension typically occurs late in the course of hypovolemic shock in pregnancy
- Anticipate a consumptive coagulopathy and consider the need for blood products early in presentation
- Abruption may be associated with severe preeclampsia, causing a hypovolemic patient to be normotensive:
- Maintain a high index of suspicion for preeclampsia in patients with severe abruption and no obvious cause
Additional Reading
- Ananth ‚ CV, Kinzler ‚ WL. Placental abruption: Clinical features and diagnosis. In: UpToDate. Rose ‚ BD, ed. Waltham, MA: UpToDate; 2012.
- Ananth ‚ CV, Oyelese ‚ Y, Yeo ‚ L, et al. Placental abruption in the United States, 1979 through 2001: Temporal trends and potential determinants. Am J Obstet Gynecol. 2005;192:191 " “198.
- Elasser ‚ DA, Ananth ‚ CV, Prasad ‚ V, et al. Diagnosis of placental abruption: Relationship between clinical and histopathological findings. Eur J Obstet Gynecol Repro Biol. 2010;148:125 " “130.
- Kopelman ‚ TR, Berardoni ‚ NE, Manriquez ‚ M, et al. The ability of computed tomography to diagnose placental abruption in the trauma patient. J Trauma Acute Care Surg. 2013;74:236 " “241.
- Oyelese ‚ Y, Ananth ‚ CV. Placental abruption: Management. In: UpToDate. Rose ‚ BD, ed. Waltham, MA: UpToDate; 2012.
See Also (Topic, Algorithm, Electronic Media Element)
- Placenta Previa
- Trauma in Pregnancy
- Vaginal Bleeding in Pregnancy
- DIC
Codes
ICD9
- 641.20 Premature separation of placenta, unspecified as to episode of care or not applicable
- 641.21 Premature separation of placenta, delivered, with or without mention of antepartum condition
- 641.23 Premature separation of placenta, antepartum condition or complication
- 641.2 Premature separation of placenta
ICD10
- O45.90 Premature separation of placenta, unsp, unsp trimester
- O45.91 Premature separation of placenta, unsp, first trimester
- O45.92 Premature separation of placenta, unsp, second trimester
- O45.93 Premature separation of placenta, unsp, third trimester
- O45.9 Premature separation of placenta, unspecified
SNOMED
- 415105001 placental abruption (disorder)
- 198911005 Placental abruption - not delivered
- 198910006 Placental abruption - delivered