Updated: 5/18/2021

Abruptio Placentae

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  • 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
  • ETIOLOGY
    • 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
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(M2.OB.17.4867) A 35-year-old G3P2 woman currently 39 weeks pregnant presents to the emergency department with painful vaginal bleeding shortly after a motor vehicle accident in which she was a passenger. She had her seat belt on and reports that the airbag deployed immediately upon her car's impact against a tree. She admits that she actively smokes cigarettes. Her prenatal workup is unremarkable. Her previous pregnancies were remarkable for one episode of chorioamnionitis that resolved with antibiotics. Her temperature is 98.6°F (37°C), blood pressure is 90/60 mmHg, pulse is 130/min, and respirations are 20/min. The fetal pulse is 110/min. Her uterus is tender and firm. The remainder of her physical exam is unremarkable. What is the most likely diagnosis?

QID: 109555
1

Preeclampsia

0%

(0/7)

2

Preterm labor

0%

(0/7)

3

Vasa previa

0%

(0/7)

4

Placental abruption

100%

(7/7)

5

Eclampsia

0%

(0/7)

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(M2.OB.17.4868) A 35-year-old woman at 36 weeks gestation presents to the emergency department with voluminous bloody discharge from her vagina. The patient states that she was at home when her symptoms suddenly started. She states that she is currently experiencing abdominal pain and feels dehydrated. The patient has a past medical history of substance abuse, obesity, and hypertension. Her social history is significant for being a victim of domestic abuse. Her current medications include folic acid, ibuprofen, and sodium docusate. Her temperature is 99.5°F (37.5°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air. External fetal monitoring is seen in Figure A. The patient is started on IV fluids and 100% oxygen. She continues to complain of abdominal pain. Which of the following best describes this patient's presentation?

QID: 109558
FIGURES:
1

Separation of the placenta from the decidua

90%

(56/62)

2

Partial covering of the external cervical os by the placenta

3%

(2/62)

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Placental invasion of the decidua basalis

0%

(0/62)

4

Partial tear of fetal vessels

3%

(2/62)

5

Normal progression of labor

3%

(2/62)

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(M2.OB.15.4675) A 32-year-old G2P1 female at 30 weeks gestation presents to the emergency department with complaints of vaginal bleeding and severe abdominal pain. She states that she began feeling poorly yesterday with a stomach-ache, nausea, and vomiting. She first noted a small amount of spotting this morning that progressed to much larger amounts of vaginal bleeding with worsened abdominal pain a few hours later, prompting her to come to the emergency department. Her previous pregnancy was without complications, and the fetus was delivered at 40 weeks by Cesarean section. Fetal heart monitoring shows fetal distress with late decelerations. Which of the following is a risk factor for this patient's presenting condition?

QID: 107221
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Hyperlipidemia

3%

(1/29)

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Hypertension

69%

(20/29)

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Patient age

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Prior Cesarean section

24%

(7/29)

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Singleton pregnancy

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(M2.OB.14.8) A 31-year-old G1P0 woman with a history of hypertension presents to the emergency department because she believes that she is in labor. She is in her 38th week of pregnancy and her course has thus far been uncomplicated. This morning, she began feeling painful contractions and noted vaginal bleeding after she fell off her bike while riding to work. She is experiencing lower abdominal and pelvic pain between contractions as well. Her temperature is 97.6°F (36.4°C), blood pressure is 177/99 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 98% on room air. Physical exam is notable for a gravid and hypertonic uterus and moderate blood in the vaginal vault. Ultrasound reveals no abnormalities. Which of the following is the most likely diagnosis?

QID: 105178
1

Abruptio placentae

72%

(68/94)

2

Normal labor

5%

(5/94)

3

Placenta previa

5%

(5/94)

4

Uterine rupture

0%

(0/94)

5

Vasa previa

16%

(15/94)

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