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eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Abruptio Placentae

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

Updated: Dec 12, 2008

Introduction

Background

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

Pathophysiology

Bleeding into the decidua basalis leads to separation of the placenta. Hematoma formation further separates the placenta from the uterine wall, causing compression of these structures and compromise of blood supply to the fetus. Retroplacental blood may penetrate through the thickness of the uterine wall into the peritoneal cavity, a phenomenon known as Couvelaire uterus. The myometrium in this area becomes weakened and may rupture with increased intrauterine pressure during contractions. A myometrium rupture immediately leads to a life-threatening obstetrical emergency.

Severity of fetal distress correlates with the degree of placental separation. In near-complete or complete abruption, fetal death is inevitable unless an immediate cesarian delivery is performed.

Frequency

International

Abruptio placentae occurs in about 1% of all pregnancies throughout the world.

Mortality/Morbidity

Maternal and fetal death may occur because of hemorrhage and coagulopathy. The fetal perinatal mortality rate is approximately 15%.

Clinical

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%

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 location of separation (ie, marginal vs central). Clinical characteristics include the following:

  • Class 0: asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.
  • Class 1: mild and represents approximately 48% of all cases. 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: moderate and represents approximately 27% of all cases. 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: severe and represents approximately 24% of all cases. 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

Causes

  • Maternal hypertension - Most common cause of abruption, occurring in approximately 44% of all cases
  • Maternal trauma (eg, motor vehicle collision [MVC], assaults, falls) - Causes 1.5-9.4% of all cases
  • Cigarette smoking
  • Alcohol consumption
  • Cocaine use
  • Short umbilical cord
  • Sudden decompression of the uterus (eg, premature rupture of membranes, delivery of first twin)
  • Retroplacental fibromyoma
  • Retroplacental bleeding from needle puncture (ie, postamniocentesis)
  • Advanced maternal age
  • Idiopathic (probable abnormalities of uterine blood vessels and decidua)

Differential Diagnoses

Abdominal Trauma, Blunt
Pregnancy, Ectopic
Appendicitis, Acute
Pregnancy, Preeclampsia
Disseminated Intravascular Coagulation
Pregnancy, Trauma
Ovarian Cysts
Shock, Hemorrhagic
Ovarian Torsion
Shock, Hypovolemic
Placenta Previa
Vaginitis
Pregnancy, Delivery

Workup

Laboratory Studies

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

Imaging Studies

  • Ultrasonography helps determine the location of the placenta to exclude placenta previa. Ultrasonography is not very useful in diagnosing placental abruption.
    • Retroplacental hematoma may be recognized in 2-25% of all abruptions.
    • Recognition of retroplacental hematoma depends on the degree of hematoma and on the operator's skill level.

Treatment

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 IV lines with normal saline (NS) or lactated Ringer (LR) solution
  • Monitoring amount of vaginal bleeding
  • Monitoring of fetal heart
  • Treatment of hemorrhagic shock, if needed

Emergency Department Care

ED care depends on stage of gestation and severity of symptoms.

  • 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.
  • Immediately deliver the fetus by cesarean delivery if the mother or fetus becomes unstable.
  • Treatment of coagulopathy or disseminated intravascular coagulation (DIC) may be necessary. 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.

Consultations

Consult an obstetrician as soon as possible.

Follow-up

Further Inpatient Care

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

Deterrence/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).

Complications

  • Maternal complications
    • Hemorrhagic shock
    • Coagulopathy/DIC
    • Uterine rupture
    • Renal failure
    • Ischemic necrosis of distal organs (eg, hepatic, adrenal, pituitary)
  • Fetal complications
    • Hypoxia
    • Anemia
    • Growth retardation
    • CNS anomalies
    • Fetal death

Patient Education

  • For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Women's Health Center. Also, see eMedicine's patient education articles Pregnancy, Bleeding and Vaginal Bleeding.

Miscellaneous

Medicolegal Pitfalls

  • 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.
  • Normal ultrasound findings do not exclude placental abruption.

References

  1. Ananth CV, Oyelese Y, Yeo L, et al. 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. Broers T, King WD, Arbuckle TE, Liu S. The occurrence of abruptio placentae in Canada: 1990 to 1997. Chronic Dis Can. 2004;25(2):16-20. [Medline].

  3. Dahmus MA, Sibai BM. Blunt abdominal trauma: are there any predictive factors for abruptio placentae or maternal-fetal distress?. Am J Obstet Gynecol. Oct 1993;169(4):1054-9. [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. Lowe TW, Cunningham FG. Placental abruption. Clin Obstet Gynecol. Sep 1990;33(3):406-13. [Medline].

  6. Morgan MA, Berkowitz KM, Thomas SJ, et al. Abruptio placentae: perinatal outcome in normotensive and hypertensive patients. Am J Obstet Gynecol. Jun 1994;170(6):1595-9. [Medline].

  7. Nolan TE, Smith RP, Devoe LD. A rapid test for abruptio placentae: evaluation of a D-dimer latex agglutination slide test. Am J Obstet Gynecol. Aug 1993;169(2 Pt 1):265-8; discussion 268-9. [Medline].

  8. Plunkett J, Borecki I, Morgan T, et al. 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].

  9. Pritchard JA, Mason R, Corley M, Pritchard S. Genesis of severe placental abruption. Am J Obstet Gynecol. Sep 1 1970;108(1):22-7. [Medline].

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

  11. Steer PL, Finley BE, Blumenthal LA. Abruptio placentae and disseminated intravascular coagulation: use of thrombelastography and sonoclot analysis. Int J Obstet Anesth. 1994;3(4):229-233. [Medline].

  12. Steinborn A, Seidl C, Sayehli C, et al. Anti-fetal immune response mechanisms may be involved in the pathogenesis of placental abruption. Clin Immunol. Jan 2004;110(1):45-54. [Medline].

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

  14. Toivonen S, Heinonen S, Anttila M, et al. Obstetric prognosis after placental abruption. Fetal Diagn Ther. Jul-Aug 2004;19(4):336-41. [Medline].

Keywords

abruptio placentae, placental abruption, cesarean delivery, cesarean birth, cesarean section, c-section, Couvelaire uterus, separation of the placenta, vaginal bleeding, abdominal pain, back pain, uterine tenderness, fetal distress, abnormal uterine contractions, idiopathic premature labor, fetal death

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.

Medical Editor

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: American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, North Carolina Medical Society, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, 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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; 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.

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