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Updated: Jan 27 2020

Abruptio Placentae


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  • Snapshot
    • A 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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