Placental abruption: Difference between revisions
(Major expansion: concealed abruption, fibrinogen thresholds, DIC management, low US sensitivity, references)
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==Background==
==Background==
[[File:2910 The Placenta-02.jpg|thumb|Normal placental anatomy.]]
*Premature separation of a normally implanted placenta from the uterine wall
*Premature separation of placenta from uterus
*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>
*Usually occurs spontaneously but also associated with trauma (even minor trauma)
*Significant cause of third-trimester hemorrhage, fetal distress, and maternal morbidity
*Usually occurs at >15 weeks gestation
*Maternal mortality ~1%; fetal mortality 15-20%
*Must be considered in patients who presenting with painful vaginal bleeding near term
*Abruption may be concealed (hemorrhage trapped behind placenta) with minimal vaginal bleeding
*Abruption may be complete, partial, or concealed
**Amount of external bleeding may not correlate with severity


===Risk Factors===
==Risk Factors==
*[[Hypertension]]- Most common
*Hypertension / [[Preeclampsia]]
*[[Trauma]]
*Prior abruption (10-15% recurrence)
*Trauma (including [[Motor vehicle collision|MVC]] — most common cause of traumatic abruption)
*[[Cocaine]] use
*Smoking
*Smoking
*Advanced maternal age <ref>Rosen's</ref>
*Advanced maternal age
*Multiparity
*Premature rupture of membranes
*[[Preeclampsia]]
*Short umbilical cord
*Prior placental abruption
*Thrombophilia
*[[Cocaine]] abuse
*History of C-section or other uterine symptoms


==Clinical Features==
==Clinical Features==
*Painful [[vaginal bleeding]] (may be absent if retro-placental)
*'''Painful''' vaginal bleeding (contrast with painless bleeding of [[Placenta previa|previa]])
**Characteristically dark and the amount is often insignificant
*'''Rigid, tender uterus''' ("board-like" in severe cases)
**Up to 20% have no vaginal bleeding or pain
*Uterine contractions or hypertonicity
*Severe uterine/[[pelvic pain]]
*Fetal distress (decelerations, bradycardia) or fetal demise
*Uterine contractions
*'''Concealed abruption''': hemodynamic instability with minimal external bleeding
*[[Hypotension]]
*Signs of [[Hemorrhagic shock|hemorrhagic shock]]: tachycardia, hypotension
*[[Nausea and vomiting]]
*May trigger [[DIC]] (present in ~10-20% of severe cases)
*[[Back pain]]
*[[Premature labor]]
*Fetal distress
*Increasing fundal height


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
*Type & Cross
*'''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>
*CBC
*'''Labs'''
*Platelets
**CBC (may show anemia; serial Hgb)
*PT/INR
**Type and screen / crossmatch
*PTT
**Coagulation studies: PT, PTT, fibrinogen ('''fibrinogen <200 mg/dL is concerning; <100 suggests severe DIC''')
*Fibrinogen
**D-dimer
** Strongly correlates with severity of hemorrhage (≤ 200 mg/dL has 100% PPV for severe bleed)
**[[Kleihauer-Betke test]] (quantify fetomaternal hemorrhage, especially if Rh-negative)
*[[D-dimer]]
**BMP (renal function)
*Fibrin Degraded Products
*'''Fetal monitoring''' — continuous cardiotocography
*[[Pelvic US]]
*'''Ultrasound''' — useful to rule out [[Placenta previa]] but cannot reliably exclude abruption
**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==
==Management==
*[[Fluid resuscitation]]
===Unstable / Severe Abruption===
*[[Transfuse blood]] products (as needed)
*Aggressive IV fluid resuscitation, [[Massive transfusion protocol|massive transfusion protocol]]
*Emergent OB/GYN consult
*'''Emergent cesarean delivery''' if fetal distress or maternal instability
**If unavailable consider C-section in ED
*Treat [[DIC]] with blood products (FFP, cryoprecipitate, platelets)
*Consider minimum 6 hours observation even if abruption not identified, if mechanism is concerning
*Target fibrinogen >150-200 mg/dL
*OB/GYN emergent consultation


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


===Neonatal===
==Disposition==
*Neurodevelopmental abnormalities
*'''All patients with suspected abruption require admission'''
*Death: 67 to 75% rate of fetal mortality
*Emergent OB/GYN consultation
*ICU if hemodynamically unstable or DIC


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


==References==
==References==

Revision as of 18:34, 21 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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