Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Sep 28 2022

Abruptio Placentae

  • Snapshot
    • A 30-year-old G1P0 woman at 36 weeks of gestation presents to the emergency room with sudden onset of moderate back pain and strong uterine cramping that began 2 hours ago. Thirty minutes prior to the onset of back pain she noted bright red vaginal bleeding. She has had no prenatal care. On physical exam she is afebrile; her blood pressure is 130/80 mmHg, pulse is 109/min, and respirations are 18/min. Abdominal palpation reveals a gravid, hypertonic uterus and palpable uterine contractions. You observe blood in the vaginal vault. Results of transabdominal ultrasound demonstrate retroplacental hemorrhage.
  • Introduction
    • Overview
      • partial or complete placental detachment prior to delivery of the fetus
      • diagnosis typically only applies to pregnancies > 20 weeks of gestation
        • placenta abruptio and placenta previa are the 2 most common causes of third trimester bleeding
  • Epidemiology
    • Incidence
      • ~1% of all pregnancies
        • 2/3 of cases are "severe" based on maternal, fetal, and neonatal morbidity
    • Demographics
      • more common in African-American women
    • Risk factors
      • prior placental abruption
      • trauma (e.g., motor vehicle accident)
      • maternal smoking
      • cocaine use
      • hypertensive disorders
        • eclampsia
        • preeclampsia
        • chronic hypertension
      • premature rupture of membranes
      • uterine structural abnormalities
        • bicornate uterus
        • uterine synechiae
        • leiomyoma
      • abnormalities of maternal serum biochemical markers
        • increased alpha fetoprotein
        • increased hCG
        • very low or very high levels of inhibin A
      • hyperhomocystinemia
    • Pathophysiology
      • rupture of maternal vessels in the decidua basalis
        • bleeding into the decidual-placental interface causes placental separation from the uterine wall
  • Presentation
    • Symptoms
      • abrupt third trimester vaginal bleeding
      • abdominal and/or back pain
      • uterine contractions
    • Physical exam
      • vital signs consistent with bleeding if severe
        • hypotension
        • tachycardia
      • gravid hypertonic uterus
      • uterine tenderness
      • blood/clots may be observed in the vaginal vault
      • fetal distress
        • nonreassuring fetal heart rate pattern
  • Imaging
    • Ultrasound
      • indications
        • diagnosis of retroplacental hematoma
          • classic for placental abruption
            • usually present if abruption is more severe
            • may be absent in milder cases of abruption
        • used to rule out placenta previa
  • Studies
    • Serum fibrinogen
      • has the best correlation with severity of bleeding, presence of DIC, and need for blood products
      • ≤ 200 mg/dL predicts severe postpartum hemorrhage
    • Pathologic placental evaluation
      • supports the clinical diagnosis
  • Differential
    • Placenta previa
      • key distinguishing feature
        • presents as painless vaginal bleeding
    • Uterine rupture
      • also associated with trauma
      • may also have sudden onset symptoms
        • vaginal bleeding
        • abdominal pain
        • fetal heart rate abnormalities
        • maternal hypotension and tachycardia
      • key distinguishing features
        • loss of uterine tone/contractions
        • occurs after onset of labor
        • other risk factors
          • previous cesarean section
    • Normal or pre-term labor
      • key distinguishing feature
        • has more gradual onset of signs/symptoms
  • Treatment
    • Medical
      • expectant management with continuous fetal monitoring
        • indications
          • when both the mother and fetus are stable and the fetus is < 34 weeks gestation
      • fluid replacement 
        • indications
          • all patients with signs of bleeding
        • modalities
          • placement of 1-2 large-bore intravenous lines
          • administer lactated ringers (LR) to maintain urine output > 30 mL/hr
      • serum studies
        • indications
          • all patients with suspected plantental abruption
        • modalities
          • complete blood count (CBC)
          • blood type and screen
            • with crossmatch if transfusion is likely
          • coagulation studies
          • liver chemistries
            • in patients with suspected preeclampsia or HELLP syndrome
      • RhoGAM
        • indications
          • all Rh(D)-negative mothers with vaginal bleeding if father is Rh(D)-positive or unknown
        • modalities
          • single intramuscular or intravenous dose
      • vaginal delivery
        • indications
          • fetus is ≥ 36 weeks gestation
          • no other indications for cesarean delivery
        • if the patient is not in active labor
          • amniotomy and oxytocin administration
        • administer standard delivery medications
          • group B streptococcus prophylaxis according to guidelines
          • magnesium sulfate for neuroprotection if < 32 weeks of gestation
    • Surgical
      • immediate delivery with cesarean delivery
        • indications
          • non-reassuring fetal status
          • hemodynamic instability in the mother
          • if fetus is 34-36 weeks gestation
            • due to risk of progressive placental separation and maternal/fetal compromise
  • Complications
    • Disseminated intravascular coagulation (DIC)
      • decreased fibrinogen levels
      • more likely when placental separation >50%
    • Hemorrhagic shock
    • Maternal death
    • Recurrence risk in future pregnancies
      • 3-15% have a recurrence
    • Fetal anemia
    • Fetal death
      • when placental separation >50%
  • Prognosis
    • Mother
      • increased morbidity and mortality
        • prompt intervention decreases the incidence of maternal mortality
      • increased long-term risk of premature cardiovascular disease
      • 2x risk of death after coronary artery revascularization in the future
        • may reflect underlying maternal vascular abnormalities that manifest as abruption during pregnancy
    • Fetus
      • increased morbidity and mortality
        • especially when preterm
1 of 0
1 of 6
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options