Placental Abruption

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