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https://upload.medbullets.com/topic/111072/images/placental_abruption.jpg
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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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