Difference between revisions of "Placental abruption"

(Treatment)
(Risk Factors)
 
(48 intermediate revisions by 13 users not shown)
Line 1: Line 1:
 
==Background==
 
==Background==
# premature separation of placenta from uterus
+
*Premature separation of placenta from uterus
# amount of external bleeding may not correlate with severity of abruption since bleeding may be concealed.
+
*Usually occurs spontaneously but also associated with trauma (even minor trauma)
# fetal death by hypoxia. can also cause fetal blood loss, maternal Rh sens, amniotic fluid embolism, DIC.
+
*Usually occurs at >15 weeks gestation
# 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.
+
*Must be considered in patients who presenting with painful vaginal bleeding near term
# 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
+
*Abruption may be complete, partial, or concealed
# GRADE 1/ MILD- spotting with limited ut irritabillity- no organizedcontractions. Mat BP normal, fibrinogen normal at 450 mg/%, normalfetal heart rate.
+
**Amount of external bleeding may not correlate with severity
  
==Risk Factors==
+
===Risk Factors===
# mat hypertension
+
*[[Hypertension]]- Most common
# eclampsia, preeclampsia
+
*[[Trauma]]
# h/o prev abruption
+
*Smoking
# ut distension from multiple gestations, hydramnios, tumors
+
*Advanced maternal age <ref>Rosen's</ref>
# vascular dz- collagen vasc, DM, CRF
+
*Multiparity
# smoking
+
*[[Preeclampsia]]
# coccaine- increases BP
+
*Prior placental abruption
# microangiopathic hemolytic anemia
+
*Thrombophilia
# premature rupture of membranes
+
*[[Cocaine]] abuse
# uterine blunt trauma- mva, domestic violence
+
*History of C-section or other uterine symptoms
# short umbilical cord
 
# advanced mat age,
 
# male fetal gender
 
# short umbilical cord
 
  
==Diagnosis==
+
==Clinical Features==
===Symptoms===
+
*Painful [[vaginal bleeding]] (may be absent if retro-placental)
abd pain, ut contractions, vag bleeding.  possibly also mat hypoTN,tachycardia, ARDS, ATN, DIC- (bruising, hematuria)
+
**Characteristically dark and the amount is often insignificant
 +
**Up to 20% have no vaginal bleeding or pain
 +
*Severe uterine/[[pelvic pain]]
 +
*Uterine contractions
 +
*[[Hypotension]]
 +
*[[Nausea and vomiting]]
 +
*[[Back pain]]
 +
*[[Premature labor]]
 +
*Fetal distress
 +
*Increasing fundal height
  
===Labs===
+
==Differential Diagnosis==
# Thrombomodulin (marker for endothelial cell damage) is elevated
+
{{Abdominal Pain Pregnancy DDX}}
# 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===
+
==Evaluation==
# will still fail to detect 50% of cases
+
*Type & Cross
# can measure gest age if mom unsure- if near term do crash c seciton.
+
{{DIC Orders}}
# will see if hematoma is subchorionic, retroplacental or preplacental- will not change management other that to rule out placenta previa
+
*[[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
  
==Treatment==
+
==Management==
# stable/ grade 1- admit for observation and elective delivery
+
*[[Fluid resuscitation]]
# 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.
+
*[[Transfuse blood]] products (as needed)
# xfuse saline, blood, ffp, platelets as needed.
+
*Emergent OB/GYN consult
# emergent c section if near term. if preterm, use tocolytics- mag sulfate and terbutaline to prevent ut contractions and prevent labor
+
**If unavailable consider C-section in ED
 +
*Consider minimum 6 hours observation even if abruption not identified, if mechanism is concerning
  
[[Category:OB/GYN]]
+
==Complications==
 +
===Maternal===
 +
*[[Hemorrhagic shock]]
 +
*[[DIC]]
 +
*[[Uterine rupture]]
 +
*Multi-organ failure
 +
 
 +
===Neonatal===
 +
*Neurodevelopmental abnormalities
 +
*Death: 67 to 75% rate of fetal mortality
 +
 
 +
==See Also==
 +
*[[Vaginal Bleeding (Main)]]
 +
*[[Trauma in pregnancy]]
 +
 
 +
==References==
 +
<references/>
 +
 
 +
[[Category:OBGYN]]

Latest revision as of 12:31, 22 February 2020

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

Clinical Features

Differential Diagnosis

Abdominal Pain in Pregnancy

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

<20 Weeks

>20 Weeks

Any time

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