Placental abruption: Difference between revisions

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==Background==
==Background==
 
*Premature separation of a normally implanted placenta from the uterine wall
 
*Occurs in 0.4-1% of pregnancies<ref name="tikkanen">Tikkanen M. Placental abruption: epidemiology, risk factors and consequences. ''Acta Obstet Gynecol Scand''. 2011;90(2):140-149. PMID 21241259.</ref>
- premature separation of placenta from uterus
*Significant cause of third-trimester hemorrhage, fetal distress, and maternal morbidity
 
*Maternal mortality ~1%; fetal mortality 15-20%
- amount of external bleeding may not correlate with severity of
*Abruption may be concealed (hemorrhage trapped behind placenta) with minimal vaginal bleeding
 
abruption since bleeding may be concealed.
 
- fetal death by hypoxia. can also cause fetal blood loss, maternal Rh
 
sens, amniotic fluid embolism, DIC.
 
-GRADE 3/ COMPLETE- mod to severe bleeding with painful tetanic
 
uterine contractions.  maternal hypotension and tachycardia.  DIC with
 
fibrinogen levels less than 150 mg/%, representing a blood loss of 2L.
 
Maternal coagulopathy with thrombocytopenia, clooting factor,
 
fibrinogen depletion. fetal death common.
 
- GRADE 2/ PARTIAL- ex ut bleeding mild to mod, uterine irritability
 
with tetanic comtractions at times, maternal orthostatic hypotension,
 
fibrinogen levels 150- 250 mg/%, fetal distress with compromised fetal
 
heart rate patterns
 
- GRADE 1/ MILD- spotting with limited ut irritabillity- no organized
 
contractions. Mat BP normal, fibrinogen normal at 450 mg/%, normal
 
fetal heart rate.
 


==Risk Factors==
==Risk Factors==
*Hypertension / [[Preeclampsia]]
*Prior abruption (10-15% recurrence)
*Trauma (including [[Motor vehicle collision|MVC]] — most common cause of traumatic abruption)
*[[Cocaine]] use
*Smoking
*Advanced maternal age
*Premature rupture of membranes
*Short umbilical cord


==Clinical Features==
*Painful vaginal bleeding (contrast with painless bleeding of [[Placenta previa|previa]])
*Rigid, tender uterus ("board-like" in severe cases)
*Uterine contractions or hypertonicity
*Fetal distress (decelerations, bradycardia) or fetal demise
*Concealed abruption: hemodynamic instability with minimal external bleeding
*Signs of [[Hemorrhagic shock|hemorrhagic shock]]: tachycardia, hypotension
*May trigger [[DIC]] (present in ~10-20% of severe cases)


- mat hypertension
==Differential Diagnosis==
 
{{Abdominal Pain Pregnancy DDX}}
- eclampsia, preeclampsia
 
- h/o prev abruption
 
- ut distension from multiple gestations, hydramnios, tumors
 
- vascular dz- collagen vasc, DM, CRF
 
- smoking
 
- coccaine- increases BP
 
- microangiopathic hemolytic anemia
 
- premature rupture of membranes
 
- uterine blunt trauma- mva, domestic violence
 
- short umbilical cord
 
- advanced mat age,
 
- male fetal gender
 
-short umbilical cord
 
 
==Diagnosis==
 
 
SYMPTOMS
 
- abd pain, ut contractions, vag bleeding.  possibly also mat hypoTN,
 
tachycardia, ARDS, ATN, DIC- (bruising, hematuria)
 
 
LABS
 
- Thrombomodulin (marker for endothelial cell damage) is elevated
 
- DIC- triggered by massive hem.  stumulates production of tissue
 
thromboplastin causing extensive microvascular clotting; these small
 
clots stumulate the fibrinolytic cascade which leads to  cosumpiton of
 
platelets, fibrinogen and other clotting factors.
 
- normal fibrinogen is 450, at 300 see spont bleeding at puncture
 
sites, at 150- mother has already lost 2L
 
- DIC panel- fibrinogen, platelets, pt/ptt, raised D- dimer- from
 
fibrin degredation
 
 
UTZ
 
- will still fail to detect 50% of cases
 
- can measure gest age if mom unsure- if near term do crash c seciton.
 
- will see if hematoma is subchorionic, retroplacental or
 
preplacental- will not change management other that to rule out
 
placenta previa
 
 
==Treatment==
 
 
- stable/ grade 1- admit for observation and elective delivery
 
- if pt with large concealed hem, are at risk for ut rupture. tx c
 
decompression of  of ut cavity by amniotomy- only do if all other
 
resuscitative measures are failing.
 
- xfuse saline, blood, ffp, platelets as needed.


- emergent c section if near term. if preterm, use tocolytics- mag
==Evaluation==
*Clinical diagnosis primarily — ultrasound has low sensitivity (~25-50%) for abruption<ref name="glantz">Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment of placental abruption. ''J Ultrasound Med''. 2002;21(8):837-840. PMID 12164566.</ref>
*Labs
**CBC (may show anemia; serial Hgb)
**Type and screen / crossmatch
**Coagulation studies: PT, PTT, fibrinogen (fibrinogen <200 mg/dL is concerning; <100 suggests severe DIC)
**D-dimer
**[[Kleihauer-Betke test]] (quantify fetomaternal hemorrhage, especially if Rh-negative)
**BMP (renal function)
*Fetal monitoring — continuous cardiotocography
*Ultrasound — useful to rule out [[Placenta previa]] but cannot reliably exclude abruption


sulfate and terbutaline to prevent ut contractions and prevent labor
==Management==
===Unstable / Severe Abruption===
*Aggressive IV fluid resuscitation, [[Massive transfusion protocol|massive transfusion protocol]]
*Emergent cesarean delivery if fetal distress or maternal instability
*Treat [[DIC]] with blood products (FFP, cryoprecipitate, platelets)
*Target fibrinogen >150-200 mg/dL
*OB/GYN emergent consultation


===Stable / Mild Abruption===
*Admit to labor and delivery
*Continuous fetal monitoring
*Serial labs (Hgb, fibrinogen, coagulation studies)
*If preterm: antenatal corticosteroids ([[Betamethasone]]) for fetal lung maturity
*[[RhoGAM]] if Rh-negative
*Expectant management may be appropriate if fetus is preterm and both mother and fetus are stable


==Disposition==
*All patients with suspected abruption require admission
*Emergent OB/GYN consultation
*ICU if hemodynamically unstable or DIC


==See Also==
*[[Placenta previa]]
*[[Vaginal Bleeding (Main)]]
*[[Postpartum hemorrhage]]
*[[DIC]]
*[[Preeclampsia]]


==References==
<references/>


[[Category:OB/GYN]]
[[Category:OBGYN]]

Latest revision as of 09:35, 22 March 2026

Background

  • Premature separation of a normally implanted placenta from the uterine wall
  • Occurs in 0.4-1% of pregnancies[1]
  • Significant cause of third-trimester hemorrhage, fetal distress, and maternal morbidity
  • Maternal mortality ~1%; fetal mortality 15-20%
  • Abruption may be concealed (hemorrhage trapped behind placenta) with minimal vaginal bleeding

Risk Factors

  • Hypertension / Preeclampsia
  • Prior abruption (10-15% recurrence)
  • Trauma (including MVC — most common cause of traumatic abruption)
  • Cocaine use
  • Smoking
  • Advanced maternal age
  • Premature rupture of membranes
  • Short umbilical cord

Clinical Features

  • Painful vaginal bleeding (contrast with painless bleeding of previa)
  • Rigid, tender uterus ("board-like" in severe cases)
  • Uterine contractions or hypertonicity
  • Fetal distress (decelerations, bradycardia) or fetal demise
  • Concealed abruption: hemodynamic instability with minimal external bleeding
  • Signs of hemorrhagic shock: tachycardia, hypotension
  • May trigger DIC (present in ~10-20% of severe cases)

Differential Diagnosis

Abdominal Pain in Pregnancy

The same abdominal pain differential as non-pregnant patients, plus:

<20 Weeks


>20 Weeks


Any time

Evaluation

  • Clinical diagnosis primarily — ultrasound has low sensitivity (~25-50%) for abruption[2]
  • Labs
    • CBC (may show anemia; serial Hgb)
    • Type and screen / crossmatch
    • Coagulation studies: PT, PTT, fibrinogen (fibrinogen <200 mg/dL is concerning; <100 suggests severe DIC)
    • D-dimer
    • Kleihauer-Betke test (quantify fetomaternal hemorrhage, especially if Rh-negative)
    • BMP (renal function)
  • Fetal monitoring — continuous cardiotocography
  • Ultrasound — useful to rule out Placenta previa but cannot reliably exclude abruption

Management

Unstable / Severe Abruption

  • Aggressive IV fluid resuscitation, massive transfusion protocol
  • Emergent cesarean delivery if fetal distress or maternal instability
  • Treat DIC with blood products (FFP, cryoprecipitate, platelets)
  • Target fibrinogen >150-200 mg/dL
  • OB/GYN emergent consultation

Stable / Mild Abruption

  • Admit to labor and delivery
  • Continuous fetal monitoring
  • Serial labs (Hgb, fibrinogen, coagulation studies)
  • If preterm: antenatal corticosteroids (Betamethasone) for fetal lung maturity
  • RhoGAM if Rh-negative
  • Expectant management may be appropriate if fetus is preterm and both mother and fetus are stable

Disposition

  • All patients with suspected abruption require admission
  • Emergent OB/GYN consultation
  • ICU if hemodynamically unstable or DIC

See Also

References

  1. ↑ Tikkanen M. Placental abruption: epidemiology, risk factors and consequences. Acta Obstet Gynecol Scand. 2011;90(2):140-149. PMID 21241259.
  2. ↑ Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment of placental abruption. J Ultrasound Med. 2002;21(8):837-840. PMID 12164566.
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