II. Definition

  1. Premature placenta separation from uterine wall
  2. Accompanied by uterine Hemorrhage

III. Epidemiology

  1. Most common cause of serious bleeding in pregnancy
  2. Most common cause of maternal death due to bleeding
  3. Accounts for 30% of Late Pregnancy Bleeding (in the second half of pregnancy)
  4. Incidence Placental Abruption
    1. All Placental Abruptions: 1-2%
    2. Severe Placental Abruption (Grade 3): 0.2%
  5. Risk of recurrence in future pregnancy
    1. One prior Placental Abruption: 5-16%
    2. Two or more prior Placental Abruptions: 25%

IV. Pathophysiology

  1. Maternal vessels rupture in the Decidua basalis where they meet the placental villi (which anchor placenta to Uterus)
  2. Blood collects between the placenta and the Uterus
  3. Results in placental separation and ultimately uteroplacental insufficiency

V. 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)

VI. Risk Factors

  1. Pregnancy Induced Hypertension or Preeclampsia (most common)
  2. High parity
  3. Abdominal Trauma
    1. Accounts for a relatively small percentage of the overall number of abruptions
    2. 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
  11. Advanced maternal age

VII. 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

VIII. 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, occult, hidden behind placenta) 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 Low Back Pain

IX. 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

XI. 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)

XII. Imaging: Pelvic Ultrasound immediately

  1. Ultrasound Test Sensitivity is only 50% for Placental Abruption
  2. Placental Abruption is a clinical diagnosis
    1. Do not delay definitive management for Ultrasound
    2. Ultrasound should be done if no delay
  3. 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)
  4. References
    1. Glantz (2002) J Ultrasound Med 21:837-40 [PubMed]

XIII. 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

XIV. 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

XV. Complications

  1. Maternal complications
    1. Prolonged hypovolemic shock
    2. Renal Cortical necrosis
    3. Coagulopathy
      1. Consumptive Coagulopathy
      2. Disseminated Intravascular Coagulation (DIC)
        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

XVI. 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

XVII. 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
      3. Packed Red Blood Cell transfusion
    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

XVIII. References

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Ontology: Abruptio Placentae (C0000832)

Definition (NCI) Placental separation from the uterus with bleeding (concealed or vaginal) before fetal birth, with or without maternal/fetal compromise.(NICHD)
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 156102007, 360561001, 267198008, 35898002, 198909001, 198913008, 198908009, 415105001, 405736009
English Premature separation of placenta, unspecified as to episode of care, ABRUPTIO PLACENTAE, Accidental haemorrhage, Accidental hemorrhage, Placental abruption NOS, Placental abruption unspecif., Placental abruption unspecified, Premature separation of placenta, unspecified, placenta abruption, placenta abruption (diagnosis), Prem separ placen-unspec, 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 separation of placenta, unsp, unsp trimester, Premature separation of placenta, unspecified as to episode of care or not applicable, Accidental hemorrhage (finding), Placental abruption unspecified (disorder), Premature placental detachment, Placental abruption NOS (disorder), Premature separation of placenta (disorder), Premature placental separation, antepartum hemorrhage accidental, Accidental antepartum hemorrhage (diagnosis), Accidental antepartum hemorrhage, Accidental antepartum haemorrhage, Accidental antepartum hemorrhage (disorder), Abruptio Placentae, abruptio placentae, Couvelaire syndrome, ablatio placentae, placenta; abruptio, placenta; detachment, placentae; ablatio, pregnancy; placenta, separation, premature, pregnancy; separation, placental, premature, premature; separation placenta, 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), 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, Abruptio Placentae, Descolamento prematuro da placenta, Descolamento Prematuro da Placenta
Spanish Separación prematura de la placenta, sin especificación del episodio de asistencia, Desprendimiento prematuro de placenta, Abrupción placentaria, ABRUPTIO PLACENTAE, Desprendimiento Placentario, hemorragia accidental (hallazgo), desprendimiento prematuro de placenta, no especificado, desprendimiento prematuro de placenta, SAI (trastorno), desprendimiento prematuro de placenta, desprendimiento prematuro de placenta, no especificado (trastorno), hemorragia accidental, desprendimiento prematuro de placenta normoinserta (trastorno), abruptio placentae, desprendimiento prematuro de placenta normoinserta, desprendimiento prematuro de placenta, SAI, hemorragia prenatal accidental, Abruptio Placentae, Separación prematura de la placenta, hemorragia preparto accidental (trastorno), hemorragia preparto accidental, desprendimiento placentario (trastorno), desprendimiento placentario, Desprendimiento Prematuro de la Placenta
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, předčasné odlučování lůžka
Finnish Istukan ennenaikainen irtoaminen
Russian PREZHDEVREMENNAIA OTSLOIKA PLATSENTY, PONRP, ПОНРП, PREZHDEVREMENNAIA OTSLOIKA NORMAL'NO RASPOLOZHENNOI PLATSENTY, ПРЕЖДЕВРЕМЕННАЯ ОТСЛОЙКА НОРМАЛЬНО РАСПОЛОЖЕННОЙ ПЛАЦЕНТЫ, 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
Norwegian Morkakeløsning, Abruptio placentae, For tidlig morkakeløsning, Placentaløsning