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Snapshot
  • 30-year-old G1P0 woman at 36 weeks of gestation presents to the emergency room with sudden onset of moderate back pain and strong uterine cramping that began 2 hours ago. Thirty minutes prior to the onset of back pain, she noted bright red vaginal bleeding. She has had no prenatal care. On physical exam she is afebrile; her blood pressure is 130/80 mmHg, pulse is 109/min, and respirations are 18/min. Abdominal palpation reveals a gravid, hypertonic uterus and palpable uterine contractions. You observe blood in the vaginal vault. Results of transabdominal ultrasound demonstrate retroplacental hemorrhage.
Introduction
  • Overview 
    • partial or complete placental detachment prior to delivery of the fetus
    • diagnosis typically only applies to pregnancies > 20 weeks of gestation
      • placenta abruptio and placenta previa are the 2 most common causes of third trimester bleeding
  • Epidemiology
    • incidence
      • ~1% of all pregnancies
        • 2/3 of cases are "severe" based on maternal, fetal, and neonatal morbidity
    • demographics
      • more common in African-American women
    • risk factors  
      • prior placental abruption
      • trauma (e.g., motor vehicle accident)
      • maternal smoking
      • cocaine use
      • hypertensive disorders
        • eclampsia
        • preeclampsia
        • chronic hypertension
      • premature rupture of membranes
      • uterine structural abnormalities
        • bicornate uterus
        • uterine synechiae
        • leiomyoma
      • abnormalities of maternal serum biochemical markers
        • increased alpha fetoprotein
        • increased hCG
        • very low or very high levels of inhibin A
      • hyperhomocystinemia
  • Pathophysiology
    • rupture of maternal vessels in the decidua basalis
      • bleeding into the decidual-placental interface causes placental separation from the uterine wall
  • Prognosis
    • mother
      • increased morbidity and mortality
        • prompt intervention decreases the incidence of maternal mortality
      • increased long-term risk of premature cardiovascular disease
      • 2x risk of death after coronary artery revascularization in the future
        • may reflect underlying maternal vascular abnormalities that manifest as abruption during pregnancy
    • fetus
      • increased morbidity and mortality
        • especially when preterm
Presentation
  • Symptoms
    • abrupt third trimester bleeding 
    • abdominal and/or back pain 
    • uterine contractions
  • Physical exam
    • vital signs consistent with bleeding if severe
      • hypotension
      • tachycardia
    • gravid hypertonic uterus
    • uterine tenderness
    • blood/clots may be observed in the vaginal vault
    • fetal distress
      • nonreassuring fetal heart rate pattern
Imaging
  • Ultrasound 
    • indications
      • diagnosis of retroplacental hematoma
        • classic for placental abruption
        • usually present if abruption is more severe
        • may be absent in milder cases of abruption
      • used to rule out placenta previa
Studies
  • Serum fibrinogen
    • has the best correlation with severity of bleeding, presence of DIC, and need for blood products
    • ≤ 200 mg/dL predicts severe postpartum hemorrhage
  • Pathologic placental evaluation
    • supports the clinical diagnosis
Differential
  • Placenta previa 
    • key distinguishing feature
      • presents as painless vaginal bleeding
  • Uterine rupture 
    • also associated with trauma
    • may also have sudden onset symptoms
      • vaginal bleeding
      • abdominal pain
      • fetal heart rate abnormalities
      • maternal hypotension and tachycardia
    • key distinguishing features
      • loss of uterine tone/contractions
      • occurs after onset of labor
      • other risk factors
        • previous C-section
  • Normal or pre-term labor
    • key distinguishing feature
      • has more gradual onset of signs/symptoms
Treatment
  • Medical
    • expectant management with continuous fetal monitoring
      • indications
        • when both the mother and fetus are stable and the fetus is < 34 weeks gestation
    • fluid replacement
      • indications
        • all patients with signs of bleeding
      • modalities
        • placement of 1-2 large-bore intravenous lines
        • administer lactated ringers (LR) to maintain urine output > 30 mL/hr
    • serum studies
      • indications
        • all patients with suspected plantental abruption
      • modalities
        • complete blood count (CBC)
        • blood type and screen
          • with crossmatch if transfusion is likely
        • coagulation studies
        • liver chemistries
          • in patients with suspected preeclampsia or HELLP syndrome
    • RhoGAM 
      • indications 
        • all Rh(D)-negative mothers with vaginal bleeding if father is Rh(D)-positive or unknown 
      • modalities 
        • single intramuscular or intravenous dose 
    • vaginal delivery
      • indications
        • fetus is ≥ 36 weeks gestation
        • no other indications for cesarean delivery
      • if the patient is not in active labor
        • amniotomy and oxytocin administration
      • administer standard delivery medications
        • group B streptococcus prophylaxis according to guidelines
        • magnesium sulfate for neuroprotection if < 32 weeks of gestation
  • Surgical
    • immediate delivery with cesarean delivery
      • indications
        • non-reassuring fetal status 
        • hemodynamic instability in the mother
        • if fetus is 34-36 weeks gestation
          • due to risk of progressive placental separation and maternal/fetal compromise
Complications
  • Disseminated intravascular coagulation (DIC)
    • when placental separation > 50%
  • Hemorrhagic shock
  • Maternal death
  • Recurrence risk in future pregnancies
    • 3-15% have a recurrence
  • Fetal anemia
  • Fetal death
    • when placental separation >50%
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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