Obstetrics Book

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Placental Abruption

Aka: Placental Abruption, Abruptio Placenta
  1. Also see
    1. Late Pregnancy Bleeding
  2. Definition
    1. Premature placenta separation from uterine wall
    2. Accompanied by hemorrhage
  3. Types separation
    1. Marginal sinus separation or marginal sinus rupture
      1. Presumed separation resolves without other findings
    2. Concealed hemorrhage
    3. Partial abruption
    4. Complete abruption (concealed hemorrhage)
  4. Epidemiology
    1. Most common cause of serious bleeding in pregnancy
    2. Most common cause of maternal death due to bleeding
    3. Incidence Placental Abruption
      1. All Placental Abruptions: 1-2%
      2. Severe Placental Abruption (Grade 3): 0.2%
    4. Risk of recurrence in future pregnancy
      1. One prior Placental Abruption: 5-16%
      2. Two or more prior Placental Abruptions: 25%
  5. Risk Factors
    1. Pregnancy Induced Hypertension
    2. High parity
    3. Abdominal Trauma
      1. MVA (unrestrained, rapid deceleration)
    4. Previous Placental Abruption (10 fold increased risk)
    5. Twin Gestation (over distention of Uterus)
      1. Related to rapid decompression of distended Uterus
      2. Occurs after delivery of first twin
    6. Polyhydramnios
    7. Maternal Substance Abuse
      1. Cocaine abuse
      2. Methamphetamine abuse
    8. Maternal Tobacco abuse (2 fold increased risk)
    9. Increased msAFP
    10. Maternal Thrombophilia
  6. History
    1. Trauma (MVA, physical abuse)
      1. Usually all or nothing event
      2. Traumatic abruption will occur definitively
      3. Contrast with chronic course for other causes
    2. Pain between contractions
    3. Rupture of Membranes
    4. Abruption risk factors as above
  7. Symptoms
    1. Vaginal Bleeding (78%)
      1. See Late Pregnancy Bleeding
      2. Quantitate amount of bleeding
      3. Assess color of blood
      4. Bleeding is occult (concealed) in 20% of cases
      5. Consider Vasa Previa if bleeding occurs with SROM
    2. Abdominal Pain (66%)
      1. May be severe and constant
      2. Posterior placenta may present with back pain
  8. Signs
    1. Vital signs suggestive of cardiovascular compromise
      1. Tachycardia
      2. Orthostatic changes in Blood Pressure and pulse
    2. Evaluate for external signs of trauma
    3. Fetal evaluation
      1. Fetal Distress (Non-reassuring Fetal Heart Tracing)
        1. Continuous Fetal Heart Tracing
        2. Consider ceserean for persistent Fetal Distress
      2. Fundal height
      3. Fetal Lie
      4. Toco monitoring (Intrauterine Pressure Catheter)
        1. High resting tone
        2. Small, frequent superimposed contractions
    4. Uterus hypertonic or tense (Couvelaire Uterus)
      1. Fundus tender to palpation
      2. Related to concealed clot, bleeding into myometrium
  9. Differential Diagnosis
    1. Abdominal Pain
      1. Acute polyhydramnios
      2. Uterine Fibroid degeneration
      3. Chorioamnionitis
      4. Peritonitis
        1. Ruptured peptic ulcer
        2. Appendicitis
    2. Vaginal Bleeding
      1. See Late Pregnancy Bleeding
  10. Grading: Sher Severity Grading system
    1. Grade 1: (Herald bleed)
      1. Less than 100cc of uterine bleeding
      2. Uterus non-tender
      3. No Fetal Distress
    2. Grade 2
      1. Uterus tender
      2. Fetal Distress
      3. Concealed hemorrhage
      4. Progresses to Grade 3 without delivery
    3. Grade 3
      1. Fetal death
      2. Maternal shock
      3. Extensive concealed hemorrhage
      4. Coagulopathy
        1. Absent: 3A (66% of patients)
        2. Present: 3B (33% of patients)
  11. Imaging: Ultrasound immediately
    1. Placental Abruption is a clinical diagnosis
      1. Do not delay definitive management for ultrasound
      2. Ultrasound should be done if no delay
    2. Ultrasound
      1. Inconsistent findings
        1. Both both clots and placenta are hyperechoic
        2. Differentiating the two is difficult
      2. Findings suggestive of Placental Abruption
        1. Sonolucent area between placenta and Uterus
        2. Rounding of placental edge
        3. Placenta appears thick (variably present)
    3. References
      1. Glantz (2002) J Ultrasound Med 21:837-40
  12. Labs: Initial
    1. Complete Blood Count with platelets
    2. Blood type
    3. Kleihauer-Betke
    4. Urinalysis for Urine Protein
    5. Serum Creatinine
    6. Fibrinogen <150 mg/dl suggests coagulopathy
    7. Also consider
      1. Factor V Leiden
      2. Prothrombin gene mutation
      3. Urine Drug Screen
  13. Labs: Other
    1. Initial labs as above
    2. Thrombomodulin
      1. New marker for Placental Abruption
    3. Coagulation studies
      1. ProTime (PT)
      2. Partial Thromboplastin Time (PTT)
      3. Fibrin split products (Fibrin Degradation Products)
      4. Fibrinogen as above
      5. Clot Test (4-8 minutes is normal clotting time)
        1. Coagulopathy if tube does not clot in 8 minutes
    4. Blood Type and Cross for 4 units
    5. Kleihauer-Betke Test (if Maternal blood Rh Negative)
      1. Indicated if positive sheep rosette test
      2. Not used to diagnose Placental Abruption
      3. Determines RhoGAM dose
  14. Complications
    1. Maternal complications
      1. Prolonged hypovolemic shock
      2. Renal Cortical necrosis
      3. Coagulopathy
        1. Consumptive Coagulopathy
        2. Disseminated Intravascular Coagulation
          1. Results from thromboplastin release
      4. Amniotic Fluid Embolism
      5. Maternal Death
      6. Uteroplacental apoplexy (Couvelaire Uterus)
        1. Bleeding into myometrium results in hypotonic wall
        2. Risk of Postpartum Hemorrhage
    2. Fetal complications
      1. Intrauterine Growth Retardation
      2. Preterm Labor
      3. Intrauterine Fetal Demise
        1. Risk is related to degrees of separation
        2. Fetal death in up to 30% of cases
  15. Management: Stable patient (Grade I)
    1. General
      1. Obstetrics Consultation
      2. RhoGAM if Maternal blood Rh Negative
    2. Criteria
      1. Reassuring Fetal Heart Tracing
      2. No coagulopathy
      3. Normotensive without Preeclampsia
      4. Nontender Uterus
      5. Negative ultrasound with normal AFI
    3. Preterm gestation
      1. Consider Tocolysis with Magnesium Sulfate
        1. Contraindicated in all but mild abruption <34 weeks
        2. Controversial and risky
      2. Steroids to promote lung maturity
      3. Consider Amniocentesis for lung maturity studies
      4. External Fetal Monitoring
      5. Observe during short term hospitalization
    4. Term gestation or mature lung studies
      1. Active management labor towards rapid fetal delivery
      2. Early Rupture of Membranes (AROM)
      3. Internal Fetal Monitoring (fetal scalp electrode)
      4. Tocometry
      5. Intrauterine Pressure Catheter
      6. Cautious use of Pitocin
    5. Risks
      1. Preterm birth
      2. Intrauterine Growth Retardation
  16. Management: Emergent
    1. Precautions
      1. Rapid management is critical
      2. Fetal death occurs in up to 30% within 2 hours
      3. Do not delay management for ultrasound confirmation
        1. Ultrasound is unreliable for diagnosis
        2. Placental Abruption is a clinical diagnosis
    2. Indications
      1. Brisk bleeding
      2. Unstable vital signs
      3. Fetal Distress
      4. Grade II or III Placental Abruption
    3. Immediate interventions
      1. Oxygen
      2. Trendelenburg position
      3. Obtain immediate Intravenous Access
        1. Two large bore IV (16-18 gauge)
        2. Initiate Isotonic crystalloid bolus
          1. Normal saline
          2. Lactated Ringers
      4. Call for immediate Obstetric and neonatal support
      5. Delivery within 20 minutes if Fetal Distress
        1. Cesarean Section unless imminent Vaginal Delivery
      6. RhoGAM if Maternal blood Rh Negative
    4. Monitoring
      1. Orthostatic Blood Pressure and pulse
      2. Monitor Intake and output
        1. Keep Urine Output over 30cc per hour
      3. Monitor Hemoglobin or Hematocrit q1-2 hours prn
        1. Keep Hemoglobin >10 g/dl or Hematocrit >30%
        2. Packed Red Blood Cell transfusion as needed
      4. Monitor coagulation studies (see labs above)
        1. Fresh Frozen Plasma transfusion as needed
        2. Platelet Transfusion as needed
  17. References
    1. Ananth (1999) JAMA 282:1646-51
    2. Sakornbut (2007) Am Fam Physician 75:1199-206

Abruptio Placentae (C0000832)

Definition (NCI) The separation of the placenta from the maternal uterine attachment when it occurs after the twentieth week of the pregnancy.
Definition (MSH) Premature separation of the normally implanted PLACENTA from the UTERUS. Signs of varying degree of severity include UTERINE BLEEDING, uterine MUSCLE HYPERTONIA, and FETAL DISTRESS or FETAL DEATH.
Concepts Pathologic Function (T046)
MSH D000037
ICD9 641.20, 641.2
ICD10 O45, O45.9, O45.90
SnomedCT 267198008, 156102007, 198913008, 198909001, 405736009, 198908009, 360561001, 415105001, 35898002
English Couvelaire placenta, Prematurely separated placenta, PLACENTA ABRUPTIO, Premature separation of placenta, unspecified as to episode of care, ABLATIO PLACENTAE, ABRUPTIO PLACENTAE, PLACENTA, PREMATURE SEPARATION, Placental separation, Abruptio Placenta, Accidental haemorrhage, Accidental hemorrhage, Placental abruption NOS, Placental abruption unspecif., Placental abruption unspecified, Premature separation of placenta, unspecified, Abruptio placentae syndrome, Couvelaire syndrome, Placenta abruptio, placenta abruption, placenta abruption (diagnosis), ABRUPTIO PLACENTA, Prem separ placen-unspec, Placental abruption unspecified (disorder), Placental abruption NOS (disorder), Abruptio placenta, Premature separation of placenta, unspecified, unspecified trimester, Premature separation of placenta [abruptio placentae], Abruptio placentae NOS, Abruptio Placentae [Disease/Finding], placental abruption, abruption placental, placentae abruptio, accidental haemorrhage, accidental hemorrhage, placental separation, premature separation of placenta, placenta abruptio, abruptio placenta, Premature placental detachment, Accidental antepartum hemorrhage, Accidental antepartum haemorrhage, Accidental antepartum hemorrhage (disorder), Abruptio Placentae, abruptio placentae, ablatio placentae, placenta; abruptio, placenta; detachment, placentae; ablatio, pregnancy; placenta, separation, premature, pregnancy; separation, placental, premature, premature; separation placenta, Accidental hemorrhage (finding), Placental abruption [Ambiguous], Premature Separation of Placenta, Premature separation of placenta, Abruptio placentae, Ablatio placentae, Premature detachment of normally implanted placenta, Premature detachment of placenta, Placental abruption, Placental abruption (disorder), Premature separation of placenta (disorder), Detachment of placenta, Premature separation of normally implanted placenta, Placental Abruptions, Placental Abruption, Abruption, Placental, Abruptions, Placental
Italian Distacco prematuro della placenta, Distacco di placenta, Distacco placentare prematuro, Distacco prematuro della placenta, episodio di cura non specificato, Distacco intempestivo della placenta
Dutch abruptio placentae, premature placentaloslating, vroegtijde placentaloslating, niet-gespecificeerd naar behandelperiode, placenta; ablatio, placenta; abruptio, placenta; loslating, prematuur; loslating placenta, zwangerschap; placenta, separatie, prematuur, zwangerschap; separatie placenta, prematuur, Premature loslating van placenta, niet gespecificeerd, voortijdige placentaloslating, Premature loslating van placenta [solutio placentae], Placentaloslating, Solutio placentae
French Séparation prématurée du placenta, épisode de soins non précisé, Décollement placentaire prématuré, DECOLLEMENT PREMATURE DU PLACENTA, Décollement prématuré du placenta, Hématome rétroplacentaire, Décollement placentaire, Hématome rétro-placentaire
German vorzeitige Plazentaabloesung, ohne Angabe der Behandlungsepisode, vorzeitige Abloesung der Plazenta, PLAZENTAABLOESUNG, Vorzeitige Plazentaloesung [Abruptio placentae], Vorzeitige Plazentaloesung, nicht naeher bezeichnet, vorzeitige Plazentaabloesung, Abruptio placentae, Plazentalösung, vorzeitige
Portuguese Descolamento prematuro da placenta, episódio de cuidados NE, RUPTURA PLACENTARIA, Descolamento prematuro da placenta, Descolamento Prematuro da Placenta, Abruptio Placentae
Spanish Separación prematura de la placenta, sin especificación del episodio de asistencia, Desprendimiento prematuro de placenta, Abrupción placentaria, hemorragia prenatal accidental, desprendimiento prematuro de placenta normoinserta, desprendimiento prematuro de placenta, abruptio placentae, desprendimiento prematuro de placenta normoinserta (trastorno), Ablatio placentae, Placental abruption [Ambiguous], Placental abruption, ABRUPTIO PLACENTAE, desprendimiento prematuro de placenta, SAI (trastorno), desprendimiento prematuro de placenta, SAI, desprendimiento prematuro de placenta, no especificado (trastorno), desprendimiento prematuro de placenta, no especificado, Separación prematura de la placenta, hemorragia accidental (hallazgo), hemorragia accidental, hemorragia preparto accidental (trastorno), hemorragia preparto accidental, desprendimiento placentario (trastorno), desprendimiento placentario, Desprendimiento Prematuro de la Placenta, Abruptio Placentae, Desprendimiento placentario
Japanese 胎盤早期剥離、治療経過詳細不明, タイバンソウキハクリ, タイバンソウキハクリチリョウケイカショウサイフメイ, 胎盤早期剥離, 正常位胎盤早期剥離, 胎盤早剥
Swedish Placentaavlossning
Czech abrupce placenty, předčasné odlučování placenty, Předčasné odlučování placenty, Předčasné odlučování placenty, bez určení vztahu k péči, Abrupce placenty
Finnish Istukan ennenaikainen irtoaminen
Russian PREZHDEVREMENNAIA OTSLOIKA PLATSENTY, ПРЕЖДЕВРЕМЕННАЯ ОТСЛОЙКА ПЛАЦЕНТЫ
Korean 상세불명의 태반 조기 분리, 태반의 조기 분리[태반 조기 박리]
Polish Odklejenie się łożyska, Przedwczesne odklejenie się łożyska
Hungarian Placenta korai leválása, Korai placentaleválás, Abruptio placentae, Korai placentaleválás, a terhesgondozás időszaka szerint nem meghatározott
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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