History
Symptoms may include vaginal bleeding, contractions, abdominal tenderness, and decreased fetal movement. Eliciting any history of trauma, such as assault, abuse, or motor vehicle accident, is important.
A quick review of the patient's prenatal course, such as a known history of placenta previa, may help lead to the correct diagnosis. [16] The patient should also be asked if she has had a placental abruption in a previous pregnancy.
Questioning the patient about cocaine abuse, hypertension, trauma, or tobacco abuse is also crucial.
Frequency of symptoms in placental abruption is as follows:
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Vaginal bleeding - 80%
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Abdominal or back pain and uterine tenderness - 70%
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Fetal distress - 60%
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Abnormal uterine contractions (eg, hypertonic, high frequency) - 35%
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Idiopathic premature labor - 25%
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Fetal death - 15%
Vaginal bleeding
Vaginal bleeding is present in 80% of patients diagnosed with placental abruptions.
Bleeding may be significant enough to jeopardize fetal and maternal health in a relatively short period.
Remember that 20% of abruptions are associated with a concealed hemorrhage, and the absence of vaginal bleeding does not exclude a diagnosis of abruptio placentae.
Contractions/uterine tenderness
Contractions and uterine hypertonus are part of the classic triad observed with placental abruption.
Uterine activity is a sensitive marker of abruption and, in the absence of vaginal bleeding, should suggest the possibility of an abruption, especially after some form of trauma or in a patient with multiple risk factors.
Decreased fetal movement
This may be the presenting complaint.
Decreased fetal movement may be due to fetal jeopardy or death.
Physical Examination
The physical examination of a patient who is bleeding must be targeted at determining the origin of the hemorrhage. Simultaneously, the patient must be stabilized quickly. With placental abruption, a relatively stable patient may rapidly progress to a state of hypovolemic shock.
Do not perform a digital examination on a pregnant patient with vaginal bleeding without first ascertaining the location of the placenta. Before a pelvic examination can be safely performed, an ultrasonographic examination should be performed to exclude placenta previa. [17] If placenta previa is present, a pelvic examination, either with a speculum or with bimanual examination, may initiate profuse bleeding.
Vaginal bleeding
Bleeding may be profuse and come in "waves" as the patient's uterus contracts.
A fluid the color of port wine may be observed when the membranes are ruptured.
Contractions/uterine tenderness
Uterine contractions are a common finding with placental abruption.
Contractions progress as the abruption expands, and uterine hypertonus may be noted.
Contractions are painful and palpable.
Uterine hyperstimulation may occur with little or no break in uterine activity between contractions
Shock
Patients may present with hypovolemic shock, with or without vaginal bleeding, because a concealed hemorrhage may be present.
As with any hypovolemic condition, blood pressure drops as the pulse increases, urine output falls, and the patient progresses from an alert to an obtunded state as the condition worsens.
Absence of fetal heart sounds
This occurs when the abruption progresses to the point of fetal death.
Signs of possible fetal jeopardy
Signs of possible fetal jeopardy include the following:
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Prolonged fetal bradycardia
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Repetitive, late decelerations
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Decreased short-term variability
Fundal height
This may increase rapidly because of an expanding intrauterine hematoma.
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Placental abruption seen after delivery.
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Fetal tracing with placental abruption. Decreased short-term variability, increased baseline uterine tone, uterine hyperstimulation, and worsening variable decelerations.
