Emergent Management of Abruptio Placentae

Updated: Dec 29, 2015
  • Author: Slava V Gaufberg, MD; Chief Editor: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE  more...
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Overview

Overview

Abruptio placentae (ie, placental abruption) refers to separation of the normally located placenta after the 20th week of gestation and prior to birth. [1, 2, 3, 4]

The following factors are among those that increase the risk for placental abruption:

  • Maternal hypertension [5]
  • Maternal trauma
  • Association with domestic violence
  • Smoking habit [6]
  • Substance abuse [6]
  • Advanced maternal age
  • Premature ruptured membranes
  • Uterine fibromyomas
  • Amniocentesis

In a retrospective study (2003-2012) that reviewed 55,926 deliveries after 24 weeks' gestation, including 247 cases of PA (0.4%), French investigators reported that independent risk factors for placental abruption were preterm premature rupture of membranes, gestational hypertension, preeclampsia, and major multiparity. [7]  Only 9.7% of the affected women presented with the classic clinical triad of metrorrhagia, uterine hypertonia, and abdominopelvic pain. Moreover, maternofetal morbidity and perinatal mortality was high. [7]

Potential maternal complications include the following:

  • Hemorrhagic shock
  • Coagulopathy/disseminated intravascular coagulation (DIC) [8]
  • Uterine rupture
  • Renal failure
  • Ischemic necrosis of distal organs (eg, hepatic, adrenal, pituitary)

Potential fetal complications include the following:

  • Hypoxia
  • Anemia
  • Growth retardation
  • CNS anomalies
  • Fetal death

Also see Abruptio Placentae.

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History

Patients usually present with the following symptoms:

  • Vaginal bleeding - 80%
  • Abdominal or back pain and uterine tenderness - 70%
  • Fetal distress - 60%
  • Abnormal uterine contractions (eg, hypertonic, high frequency) - 35%
  • Idiopathic premature labor - 25%
  • Fetal death - 15%
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Physical

Placental abruption is mainly a clinical diagnosis based on findings of vaginal bleeding, abdominal pain, uterine tenderness, uterine contractions, and fetal distress.

Classification of placental abruption is based on extent of separation (ie, partial vs complete) and the location of separation (ie, marginal vs central). Clinical characteristics are divided into the following classes:

  • Class 0 - Asymptomatic
  • Class 1 - Mild (represents approximately 48% of all cases)
  • Class 2 - Moderate (represents approximately 27% of all cases)
  • Class 3 - Severe (represents approximately 24% of all cases)

Class 0

The diagnosis in these patients is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.

Class 1

Characteristics include the following:

  • No vaginal bleeding to mild vaginal bleeding
  • Slightly tender uterus
  • Normal maternal BP and heart rate
  • No coagulopathy
  • No fetal distress

Class 2

Characteristics include the following:

  • No vaginal bleeding to moderate vaginal bleeding
  • Moderate to severe uterine tenderness, with possible tetanic contractions
  • Maternal tachycardia, with orthostatic changes in BP and heart rate
  • Fetal distress
  • Hypofibrinogenemia (ie, 50-250 mg/dL)

Class 3

Characteristics include the following:

  • No vaginal bleeding to heavy vaginal bleeding
  • Very painful tetanic uterus
  • Maternal shock
  • Hypofibrinogenemia (ie, < 150 mg/dL)
  • Coagulopathy
  • Fetal death
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Differential Diagnosis

The following conditions should be considered in the differential diagnosis of abruptio placentae:

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Laboratory Studies in Abruptio Placentae

Laboratory studies used in the diagnosis of placental abruption include the following:

  • Hemoglobin
  • Hematocrit
  • Platelets
  • Prothrombin time/activated partial thromboplastin time
  • Fibrinogen
  • Fibrin/fibrinogen degradation products
  • D-dimer
  • Blood type
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Ultrasonography and MRI

Ultrasonography helps to determine the location of the placenta in order to exclude placenta previa.

Ultrasonography is not very useful in diagnosing placental abruption (and normal ultrasonographic findings do not exclude the condition). [9]

Retroplacental hematoma may be recognized in 2-25% of all abruptions. This recognition depends on the degree of hematoma and on the operator's skill level.

MRI is diagnostically effective and can accurately depict placental abruption. Consider using MRI in cases where ultrasonography findings in the presence of late pregnancy bleeding are negative, but positive diagnosis of abruption would change patient management. [10]

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Diagnostic Concerns

Some patients may not have the classic presentation of abruption, especially with posterior implantation.

Consider a diagnosis of placental abruption for every patient in premature labor. Carefully monitor patients to exclude or establish this diagnosis.

Absence of vaginal bleeding does not exclude placental abruption.

Disseminated intravascular coagulation (DIC)/coagulopathy may occur even if clotting factors initially are within reference ranges. Continue to monitor clotting factors.

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Prehospital Care

Provide emergency care at the advanced life support (ALS) level to all patients with suspected placental abruption. This care includes the following:

  • Continuous monitoring of vital signs
  • Continuous high-flow supplemental oxygen
  • One or 2 large-bore intravenous (IV) lines with normal saline (NS) or lactated Ringer (LR) solution
  • Monitoring of amount of vaginal bleeding
  • Monitoring of fetal heart
  • Treatment of hemorrhagic shock, if needed
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Emergency Department Care

Emergency department (ED) care depends on the stage of gestation and the severity of symptoms. The following steps should be performed:

  • Closely observe the patient
  • Administer supplemental oxygen
  • Continuous fetal monitoring
  • Administer IV fluids
  • Perform aggressive fluid resuscitation to maintain adequate perfusion, if needed
  • Monitor vital signs and urine output
  • Crossmatch 4 units of packed red blood cells; transfuse, if necessary
  • Perform amniotomy to decrease intrauterine pressure, extravasation of blood into the myometrium, and entry of thromboplastic substances into the circulation [11]
  • Immediately deliver the fetus by cesarean delivery if the mother or fetus becomes unstable
  • Treatment of coagulopathy or DIC may be necessary [8]

With regard to the last item, above, some degree of coagulopathy occurs in about 30% of severe cases of placental abruption. The best treatment for DIC as a complication of placental abruption is immediate delivery. [12]

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Consultations and Inpatient Care

Consult an obstetrician as soon as possible.

Inpatient care includes the following:

  • Labor, delivery, and postpartum care
  • Further management of the complications of abruptio placentae
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Deterrence and Prevention

Treat maternal hypertension. [5] Note that although hypertensive conditions increase the risk of placental abruption, they do not appear to increase the rate of recurrence of placental abruption in subsequent pregnancies. [13]

Prevent maternal trauma/domestic violence.

Prevent smoking and substance abuse.

Diagnose placental abruption at an early stage in high-risk groups (eg, maternal hypertension, maternal trauma, association with domestic violence, smoking habit, substance abuse, advanced maternal age, premature ruptured membranes, uterine fibromyomas, amniocentesis). [6]

Data from a Netherlands longitudinal linked national cohort study of all singleton pregnancies that ended (1999-2007) revealed an increased risk of recurrence of placental abruption in women who had placental abruption in their first pregnancy. [13]  The investigators suggested an elective induction from 37 weeks' gestation for women with such a history. [13]

For patient education information, see the Pregnancy Center and the Women's Health Center, as well as Bleeding During Pregnancy and Vaginal Bleeding.

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