Placental abruption

Background

Normal placental anatomy.

• 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- Most common
• Trauma
• Smoking
• Advanced maternal age
• Multiparity
• Preeclampsia
• 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
  • 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

Differential Diagnosis

Abdominal Pain in Pregnancy

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

<20 Weeks

• Ectopic pregnancy
• First trimester abortion
  • Complete abortion
  • Threatened abortion
  • Inevitable abortion
  • Incomplete abortion
  • Missed abortion
  • Septic abortion
• Round ligament stretching
• Incarcerated uterus
• Malposition of the uterus

>20 Weeks

• Labor/Preterm labor
• Placental abruption
• Placenta previa
• Vasa previa
• Uterine rupture
• Vaginal trauma
• HELLP syndrome
• Cholestasis of pregnancy
• Chorioamnionitis
• Incarcerated uterus
• Acute fatty liver of pregnancy
• Malposition of the uterus
• Placenta accreta
• Placenta increta
• Placenta percreta

Any time

• Hemorrhagic ovarian cyst
• Fibroid degeneration or torsion
• Ovarian torsion
• Constipation

Evaluation

• Type & Cross
• CBC
• Platelets
• PT/INR
• PTT
• Fibrinogen
  • Strongly correlates with severity of hemorrhage (≤ 200 mg/dL has 100% PPV for severe bleed)
• 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

• 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