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 login to view 1 more bullet demographics more common in African-American women risk factors prior placental abruption trauma (e.g., motor vehicle accident) maternal smoking cocaine use hypertensive disorders login to view 3 more bullets premature rupture of membranes uterine structural abnormalities login to view 3 more bullets abnormalities of maternal serum biochemical markers login to view 3 more bullets 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 login to view 1 more bullet increased long-term risk of premature cardiovascular disease 2x risk of death after coronary artery revascularization in the future login to view 1 more bullet fetus increased morbidity and mortality login to view 1 more bullet 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 login to view 3 more bullets 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 login to view 1 more bullet Normal or pre-term labor key distinguishing feature has more gradual onset of signs/symptoms Treatment Medical expectant management with continuous fetal monitoring indications login to view 1 more bullet fluid replacement indications login to view 1 more bullet modalities login to view 2 more bullets serum studies indications login to view 1 more bullet modalities login to view 6 more bullets RhoGAM indications login to view 1 more bullet modalities login to view 1 more bullet vaginal delivery indications login to view 2 more bullets if the patient is not in active labor login to view 1 more bullet administer standard delivery medications login to view 2 more bullets Surgical immediate delivery with cesarean delivery indications login to view 4 more bullets 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%