Placental abruption

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Background

  • Premature separation of placenta from uterus
  • Usually occurs spontaneously but also associated with trauma (even minor trauma)
  • Usually occurs at >15 weeks gestation
  • Must be considered in patients who presenting with painful vaginal bleeding near term
  • Abruption may be complete, partial, or concealed
    • Amount of external bleeding may not correlate with severity

Risk Factors

  • hypertension
  • Trauma
  • Smoking
  • Advanced maternal age [1]
  • Multiparity
  • Prior placental abruption
  • Thrombophilia
  • Cocaine abuse
  • History of C-section or other uterine symptoms

Clinical Features

  • 'Painful vaginal bleeding (may be absent if retro-placental)
    • Characteristically dark and the amount is often insignificant
    • But up to 20% have no vaginal bleeding or pain
  • Severe uterine pain
  • Uterine contractions
  • Hypotension
  • Nausea and vomiting
  • Back pain
  • Premature labor
  • Fetal distress
  • Increasing fundal height

Differential Diagnosis

Abdominal Pain in Pregnancy

<20 Weeks

>20 Weeks

Evaluation

  • Type & Cross
  • CBC
  • Platelets
  • PT/INR
  • PTT
  • Fibrinogen
  • D-dimer
  • Fibrin Degraded Products
  • Pelvic US
    • Specific, not Sensitive (as low as 24% sensitive)
    • Cannot be used alone to rule-out placental abruption if negative
    • Can rule-out placenta previa
  • If available, obtain fetal heart monitoring
  • Consider FAST exam if trauma

Management

  • Fluid resuscitation
  • Transfuse blood products (as needed)
  • Emergent OB/GYN consult
    • If unavailable consider C-section in ED
  • Consider minimum 6 hours observation even if abruption not identified, if mechanism is concerning

Complications

Maternal

Neonatal

  • Neurodevelopmental abnormalities
  • Death: 67 to 75% rate of fetal mortality

See Also

References

  1. Rosen's