Emergent Management of Abruptio Placentae 

  • Author: Slava V Gaufberg, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: May 19, 2011
 

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]

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

  • Maternal hypertension
  • Maternal trauma
  • Association with domestic violence
  • Smoking habit[3]
  • Substance abuse[3]
  • Advanced maternal age
  • Premature ruptured membranes
  • Uterine fibromyomas
  • Amniocentesis

Potential maternal complications include the following:

  • Hemorrhagic shock
  • Coagulopathy/disseminated intravascular coagulation (DIC)
  • 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

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Lab 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).[4]

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.[7]

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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.

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[5]
  • Immediately deliver the fetus by cesarean delivery if the mother or fetus becomes unstable
  • Treatment of coagulopathy or DIC may be necessary

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.[6]

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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.

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).[3]

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Patient Education

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

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Contributor Information and Disclosures
Author

Slava V Gaufberg, MD  Assistant Professor of Medicine, Harvard Medical School; Director of Transitional Residency Training Program, Cambridge Health Alliance

Slava V Gaufberg, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Roy Alson, MD, PhD, FACEP, FAAEM  Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Deputy Medical Advisor, North Carolina Office of EMS; Associate Medical Director, North Carolina Baptist AirCare

Roy Alson, MD, PhD, FACEP, FAAEM is a member of the following medical societies: Air Medical Physician Association, American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, North Carolina Medical Society, North Carolina Medical Society, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Ananth CV, Oyelese Y, Yeo L, Pradhan A, Vintzileos AM. Placental abruption in the United States, 1979 through 2001: temporal trends and potential determinants. Am J Obstet Gynecol. Jan 2005;192(1):191-8. [Medline].

  2. Plunkett J, Borecki I, Morgan T, Stamilio D, Muglia LJ. Population-based estimate of sibling risk for preterm birth, preterm premature rupture of membranes, placental abruption and pre-eclampsia. BMC Genet. Jul 8 2008;9:44. [Medline]. [Full Text].

  3. Tikkanen M, Nuutila M, Hiilesmaa V, Paavonen J, Ylikorkala O. Clinical presentation and risk factors of placental abruption. Acta Obstet Gynecol Scand. 2006;85(6):700-5. [Medline].

  4. Green JR. Placental abnormalities: Placenta previa and abruptio placentae. In: Creasy RK, Resnik R, eds. Maternal Fetal Medicine. Philadelphia, Pa: WB Saunders; 1984:539.

  5. Signore C, Mills JL, Qian C, Yu K, Lam C, Epstein FH, et al. Circulating angiogenic factors and placental abruption. Obstet Gynecol. Aug 2006;108(2):338-44. [Medline].

  6. Steer PL, Finley BE, Blumenthal LA. Abruptio placentae and disseminated intravascular coagulation: use of thrombelastography and sonoclot analysis. Int J Obstet Anesth. Oct 1994;3(4):229-33. [Medline].

  7. Masselli G, Brunelli R, Di Tola M, Anceschi M, Gualdi G. MR imaging in the evaluation of placental abruption: correlation with sonographic findings. Radiology. Apr 2011;259(1):222-30. [Medline].

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