eMedicine Specialties > Obstetrics and Gynecology > Obstetrical Complications

Abruptio Placentae: Treatment & Medication

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

Treatment

Medical Care

Inpatient admission is required if abruptio placentae is considered likely.

  • Procedures
    • Begin continuous external fetal monitoring for both the fetal heart rate and contractions.
    • Obtain intravenous access using 2 large-bore intravenous lines.
    • Institute crystalloid fluid resuscitation for the patient.
    • Type and crossmatch blood.
    • Begin a transfusion if the patient is hemodynamically unstable after fluid resuscitation.
    • Correct coagulopathy, if present.
    • Administer Rh immune globulin if the patient is Rh-negative.
  • Vaginal delivery
    • This is the preferred method of delivery for a fetus that has died secondary to placental abruption.
    • The ability of the patient to undergo vaginal delivery depends on her remaining hemodynamically stable.
    • Delivery is usually rapid in these patients secondary to increased uterine tone and contractions.

Surgical Care

  • Cesarean delivery
    • Cesarean delivery is often necessary for both fetal and maternal stabilization.
    • While cesarean delivery facilitates rapid delivery and direct access to the uterus and its vasculature, it can be complicated by the patient's coagulation status. Because of this, a vertical skin incision, which has been associated with less blood loss, is often used when the patient appears to have DIC.
    • The type of uterine incision is dictated by the gestational age of the fetus, with a vertical or classic uterine incision often being necessary in the preterm patient.
    • If hemorrhage cannot be controlled after delivery, a cesarean hysterectomy may be required to save the patient's life.
    • Before proceeding to hysterectomy, other procedures, including correction of coagulopathy, ligation of the uterine artery, administration of uterotonics (if atony is present), packing of the uterus, and other techniques to control hemorrhage, may be attempted.
  • ICU: If the patient is hemodynamically unstable, either before or after delivery, invasive monitoring in an ICU may be required.

Consultations

  • Maternal-fetal medicine specialist
    • If a mild abruption is diagnosed or the diagnosis is questionable, a maternal-fetal medicine (MFM) specialist should be consulted.
    • In the case of a preterm fetus in which tocolysis is considered likely, consulting an MFM specialist may be prudent.
  • Pediatricians or neonatal intensive care specialists should be consulted if the fetus is considered viable, usually at 24 weeks' gestation, and delivery is anticipated.

Diet

The patient should be restricted to nothing by mouth (NPO) if emergent delivery is a possibility.

Activity

Preterm patients diagnosed with a chronic abruption may be started on a modified bedrest regimen and monitored closely for any signs of maternal or fetal distress that could necessitate delivery. Again, consultation with MFM specialists is advised for conservative management of abruptio placentae.

Medication

Tocolysis is considered controversial in the management of placental abruption and is considered only in patients (1) who are hemodynamically stable, (2) in whom no evidence of fetal jeopardy exists, and (3) in whom a preterm fetus may benefit from corticosteroids or delay of delivery.

Even in patients meeting these criteria, consultation with an MFM specialist is important. Tocolysis must be undertaken with caution because maternal or fetal distress can develop rapidly. In general, either magnesium sulfate or nifedipine (but not both) is used for tocolysis and beta-sympathomimetic agents are avoided, as the latter may cause significant undesirable cardiovascular effects, such as tachycardia, which may mask clinical signs of blood loss in these patients.

Tocolytics

May allow for effective administration of glucocorticoids to the preterm fetus to accelerate fetal lung maturation. In chronic abruption, may also help delay delivery to a gestational age when complications of prematurity are less severe.


Nifedipine (Adalat, Procardia)

A calcium channel blocker. The theory behind use as tocolytic is that by blocking influx of calcium into uterine muscle cells, it will decrease contractions, which are dependent on calcium.

Adult

Loading dose: 10 mg PO q20min for up to 4 doses
Maintenance dose: 10 mg PO q4-6 h

Pediatric

Not established

Coadministration with magnesium sulfate has potential to act in a synergistic manner with nifedipine and enhance the hypotensive effects; fentanyl and alcohol may increase hypotensive effects; calcium channel blocker may increase cyclosporine levels; H2 blockers (cimetidine), erythromycin, nafcillin, and azole antifungals may increase toxicity (avoid combination or monitor closely); carbamazepine may reduce bioavailability (avoid this combination); rifampin may decrease levels (monitor and adjust dose of calcium channel blocker)

Hypersensitivity to nifedipine; evidence of an acute myocardial infarction

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Potential side effects include hypotension, dizziness, nausea, pulmonary edema, reflex tachycardia; may cause lower extremity edema; allergic hepatitis have occurred but is rare


Magnesium sulfate

DOC for tocolysis in patients with placental abruption.

Adult

Initial dose: 4-6 g IV bolus over 20 min
Maintenance dose: 2-4 g/h IV, titrated prn to suppress contractions

Pediatric

Not established

Concurrent use with nifedipine may cause hypotension and neuromuscular blockade; may increase neuromuscular blockade noted with aminoglycosides and potentiate neuromuscular blockade produced by tubocurarine, vecuronium, and succinylcholine; may increase CNS effects and toxicity of CNS depressants and betamethasone and cardiotoxicity of ritodrine

Documented hypersensitivity; hypocalcemia; myasthenia gravis, renal failure

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adverse effects include flushing, blurry vision, headaches, and nausea; more serious adverse effects, observed only at toxic levels, include pulmonary edema, respiratory depression, cardiac arrest, maternal tetany, and profound hypotension; to reverse effects, calcium gluconate (1 g slow IV push) may be administered

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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