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Placental Abruption, Emergency Medicine

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Placental Abruption, Emergency Medicine

Basics

Description

Consider with obstetrician recommendation: ‚

  • 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 pregnancies30% of bleeding episodes in the 2nd half of pregnancy15% of all fetal deathsNeonatal death in 10 " “30% of cases6% of all maternal mortality
  • Synonym(s): Abruptio placentae, accidental hemorrhage (in UK)
  • ¢ 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

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 placentaManifestation of ischemic placental disease
  • Acute abruption can occur due to:TraumaRapid uterine decompressionPlacenta implantation over a uterine anomaly or fibroid
  • Multiple known risk factors:Previous abruption (10 " “20% recurrence risk)Maternal hypertension (>140/90) and preeclampsiaIncreased parity and maternal ageMultiple gestationFibroids or other uterine/placental abnormalitiesTobacco useCocaine abuseTraumaPremature rupture of membranes, particularly if associated with chorioamnionitis or oligohydramniosRapid uterine decompression:Polyhydramnios with membrane ruptureRapid delivery of 1st twinElevated 2nd trimester maternal serumα-fetoproteinThrombophiliasMaternal race:More common among African American and Caucasian womenIncidence increasing more rapidly among African American women
  • Development of disseminated intravascular coagulation (DIC)
  • Maternal " “fetal compromise
  • Inflammatory changes in the placenta
  • Manifestation of ischemic placental disease
  • Trauma
  • Rapid uterine decompression
  • Placenta implantation over a uterine anomaly or fibroid
  • 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 ruptureRapid delivery of 1st twin
  • Elevated 2nd trimester maternal serumα-fetoprotein
  • Thrombophilias
  • Maternal race:More common among African American and Caucasian womenIncidence increasing more rapidly among African American women
  • Polyhydramnios with membrane rupture
  • Rapid delivery of 1st twin
  • More common among African American and Caucasian women
  • Incidence increasing more rapidly among African American women

Diagnosis

Signs and Symptoms

  • 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
  • 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
  • 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

  • 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)
  • 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
  • All indicated radiographs should be performed as needed

Medication

  • Rh-immunoglobulin in Rh-negative women:300 Ž ¼g IM in women at ≥12 wk gestationHigher doses if indicated by results of Kleihauer " “Betke test
  • Blood products as indicated
  • 300 Ž ¼g IM in women at ≥12 wk gestation
  • Higher doses if indicated by results of Kleihauer " “Betke test
  • Magnesium sulfate if tocolysis is indicated
  • Steroids for fetal lung maturation if gestational age between 24 and 34 wk

Follow-Up

Disposition

  • 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
  • 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

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
  • 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