eMedicine Specialties > Obstetrics and Gynecology > Obstetrical Complications

Abruptio Placentae: Differential Diagnoses & Workup

Author: Shad H Deering, MD, Clinical Assistant Professor, Department of Obstetrics and Gynecology, University of Washington; Medical Director, Andersen Simulation Center, Madigan Army Medical Center
Contributor Information and Disclosures

Updated: Dec 22, 2008

Differential Diagnoses

Placenta Previa
Preterm Labor

Other Problems to Be Considered

Labor with bloody show
Vasa previa
Vaginal trauma
Malignancy (rare)

Workup

Laboratory Studies

  • No laboratory studies have been shown to definitively help with the differential diagnosis of abruptio placentae; however, multiple laboratory studies may be helpful in the management of this problem.
  • CBC count
    • A CBC count can help determine the patient's current hemodynamic status, but findings are not reliable for estimating acute blood loss.
    • In an acute hemorrhage, the fall in hematocrit value lags several hours behind the bleeding and may be falsely decreased by the administration of crystalloid fluids during resuscitation.
  • Fibrinogen
    • Pregnancy is associated with hyperfibrinogenemia; therefore, modestly depressed fibrinogen levels may represent significant coagulopathy. A fibrinogen level of less than 200 mg/dL suggests that the patient has a severe abruption.
    • The goal should be to keep the fibrinogen level above 100 mg/dL, which can be accomplished via transfusion of fresh frozen plasma or cryoprecipitate, as necessary.
  • Prothrombin time/activated partial thromboplastin time
    • Some form of DIC is present in up to 20% of patients with severe abruptions.
    • Because many of these patients may require cesarean delivery, knowing a patient's coagulation status is imperative.
  • Blood urea nitrogen/creatinine
    • The hypovolemic condition brought on by a significant abruption also affects renal function.
    • The condition usually self-corrects without significant residual dysfunction if fluid resuscitation is timely and adequate.
  • Kleihauer-Betke test
    • Findings help detect fetal red blood cells in the maternal circulation.
    • If the abruption is significant, inadvertent transfusion of fetal blood into the maternal circulation may occur. In women who are Rh-negative, this fetal-to-maternal transfusion may lead to isoimmunization of the mother to Rh factor. Kleihauer-Betke test findings help determine the volume of fetal blood transfused into the maternal circulation.
    • All patients who are D-negative should receive Rho (D) immune globulin (RhoGAM) after significant trauma. Kleihauer-Betke test findings may help determine the appropriate dosage of Rho (D) immune globulin in cases of significant fetal-maternal hemorrhage.
  • Blood type: The patient should have her blood typed and at least 2 units of packed red blood cells crossmatched in the event she requires a transfusion.
  • Rh type: The blood Rh type is important to determine because patients who are Rh-negative require Rh immune globulin in order to prevent isoimmunization, which could affect future pregnancies.
  • Thrombophilia workup
    • While this is not of immediate concern or helpful in stabilizing the acute event, patients with an early or severe abruption may be tested for genetic thrombophilias given their possible association with this complication.
    • Laboratory studies should evaluate for the following:
      • Factor V Leiden mutation
      • Prothrombin gene (A20210) mutation
      • Antithrombin III deficiency
      • Protein C and protein S deficiencies
      • Fasting homocysteine level
      • Anticardiolipin antibodies
      • Activated protein C resistance

Imaging Studies

  • Ultrasonography
    • Ultrasonography is a readily available and important imaging modality for assessing bleeding in pregnancy.
    • The quality and sensitivity of ultrasonography in detecting placental abruptions has improved significantly; however, it is not a sensitive modality for this purpose—findings are positive in only 25% of cases confirmed at delivery and the negative predictive value is low at around 50%.
    • In addition, there does not appear to be any clinical difference in presentation between women who have an abruption seen on ultrasound and those who do not.
    • Ultrasonographic studies help to quickly diagnose placenta previa as the etiology of bleeding, if present.
    • Placental abruption shows as a retroplacental clot on an ultrasound image, but not all abruptions are ultrasonographically detectable.
    • In the acute phase, a hemorrhage is generally hyperechoic, or even isoechoic, compared with the placenta; a hemorrhage does not become hypoechoic for nearly a week.
    • Ultrasonography can help exclude other causes of third-trimester bleeding. Possible findings consistent with an abruption include (1) retroplacental clot (ie, hyperechoic to isoechoic in the acute phase, changing to hypoechoic within a wk), (2) concealed hemorrhage, or (3) expanding hemorrhage.

Other Tests

  • Nonstress test
    • External fetal monitors often reveal fetal distress, as evidenced by late decelerations, fetal bradycardia, or decreased beat-to-beat variability.
    • An increase in the uterine resting tone may also be noticed, along with frequent contractions that may progress to uterine hyperstimulation.
  • Biophysical profile
    • A biophysical profile (BPP) can be used to help evaluate patients with chronic abruptions who are being managed conservatively.
    • A BPP score less than 6 (maximum of 10) may be an early sign of fetal compromise.
    • A modified BPP (nonstress test with amniotic fluid index) is sometimes used for monitoring in this situation.

Procedures

Any procedures that may be required (ie, continuous monitoring of the fetal heart rate tracing, vaginal delivery, cesarean section) will be dictated by both the gestational age and the overall status of the fetus. This is discussed in more detail below.

Histologic Findings

After delivery of the placenta, a retroplacental clot may be noted. Another possible finding involves extravasation of blood into the myometrium, which produces a purple discoloration of the uterine serosa. This phenomenon is known as a Couvelaire uterus.

More on Abruptio Placentae

Overview: Abruptio Placentae
Differential Diagnoses & Workup: Abruptio Placentae
Treatment & Medication: Abruptio Placentae
Follow-up: Abruptio Placentae
Multimedia: Abruptio Placentae
References
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References

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Further Reading

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Keywords

abruptio placentae, placental abruption, fetal death, maternal mortality, fetal mortality, pregnancy, parturition, pregnancy complication, cesarean delivery, cesarean section, caesarean delivery, caesarean section, c-section, C-section, c section, C section, prematurity, premature infant, Couvelaire uterus

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Contributor Information and Disclosures

Author

Shad H Deering, MD, Clinical Assistant Professor, Department of Obstetrics and Gynecology, University of Washington; Medical Director, Andersen Simulation Center, Madigan Army Medical Center
Shad H Deering, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Medical Editor

Bruce A Meyer, MD, MBA, Vice President for Medical Affairs, Associate Dean for Health System Affairs and Director of the Faculty Practice Plan, Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School
Bruce A Meyer, MD, MBA is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Physician Executives, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Medical Group Management Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Antonio V Sison, MD, Medical Director, Ob/Gyn Group, Robert Wood Johnson University Hospital at Hamilton
Antonio V Sison, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Association of Professors of Gynecology and Obstetrics
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Carl V Smith, MD, The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, University of Nebraska Medical Center
Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Arkansas Medical Society, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

 
 
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