Review Question - QID 105202

This patient's presentation is consistent with placental abruption. Given the clinical deterioration of mother and fetus (hemodynamic instability and sinusoidal fetal heart rate pattern, respectively), emergent cesarean section is warranted.

Risk factors for development of placental abruption include history of prior abruption, pregnancy induced hypertension, eclampsia, abdominal trauma, tobacco use, cocaine use, PPROM, multifetal gestation, advanced maternal age, polyhydramnios, and intrauterine infection. Ultrasound is not sensitive in the detection of placental abruption. Findings on ultrasound suggestive of the diagnosis include retroplacental clot and concealed/expanding hemorrhage.

Sakornbut et al. discuss the differential diagnosis of third trimester bleeding. Placenta previa, vasa previa, and placental abruption are the most serious conditions that may present with vaginal bleeding late in pregnancy. Placental abruption can cause serious vaginal bleeding and occurs in 1% of pregnancies. Significant vaginal bleeding, regardless of etiology, is managed with monitoring of fetal and maternal condition, fluid resuscitation, blood product replacement as needed, and an appropriately timed delivery.

Oyelese and Ananth review placental abruption. The diagnosis of placental abruption is clinical, as testing with ultrasound and the Kleihauer-Betke test are not reliable. If the abruption involves greater than 50% of the placenta, fetal death is common. In situations where fetal demise has already occurred at the time of presentation and the mother is stable, vaginal delivery is the preferred management strategy.

Figure A shows a fetal heart tracing demonstrating a sinusoidal fetal heart rate pattern. Illustration A depicts the difference between visible and concealed bleeding in placental abruption. Illustration B shows an ultrasound of a retroplacental hemorrhage.

Incorrect Answers:
Answer 1: Expectant management is not appropriate when either mother or baby is in distress.
Answer 2: Amniotomy and immediate vaginal delivery would be appropriate if the mother was stable and fetal monitoring was reassuring.
Answer 4: Although this patient is at 34 weeks gestation, steroids would not be indicated in this case due to the need for emergent delivery given the poor condition of mother and fetus.
Answer 5: Embolization and ligation procedures are indicated in cases of postpartum hemorrhage; this is not the next best step in this instance.