Review Question - QID 218740

This patient who presents with painful vaginal bleeding and a hypertonic uterus after trauma most likely has placental abruption. Patients with placental abruption secondary to trauma require immediate stabilization with left lateral decubitus positioning and intravenous fluids.

Placental abruption is partial or complete placental detachment before delivery of the fetus that can result from trauma. Signs and symptoms of placental abruption include painful vaginal bleeding in the third trimester, a gravid and hypertonic uterus, uterine tenderness, fetal distress, and vital signs consistent with severe bleeding. Diagnosis is clinical, though a transvaginal ultrasound can be used to help rule out other causes of vaginal bleeding. The initial management of placental abruption includes close maternal hemodynamic and fetal heart rate monitoring, left lateral decubitus positioning, securing intravenous access and administration of crystalloid, quantification of blood loss, transfusion of blood products as needed, and collecting basic laboratory studies (complete blood count, type and screen, coagulation studies). Subsequent management depends on the stability of the mother, fetal status, and gestational age. In unstable mothers or stable mothers with non-reassuring fetal status, emergent cesarean birth should be pursued. In a stable mother with fetal demise, vaginal birth is preferred. Stable mothers with reassuring fetal status should receive tocolytics and antenatal corticosteroids if indicated, followed by delivery.

Tikkanen reviewed the epidemiology, risk factors, and sequelae of placental abruption. The author found maternal sequelae of placental abruption include hemorrhage, need for blood transfusion, disseminated intravascular coagulopathy, and renal failure. The author recommends reducing the risk of placental abruption by encouraging smoking cessation and treatment of hypertensive disorders of pregnancy.

Incorrect Answers:
Answer 1: Administration of nifedipine, a tocolytic, can be considered in patients at less than 34 weeks of gestation in preterm labor and in whom both maternal and fetal status is reassuring. In this patient with abruption secondary to trauma, stabilizing the mother is important before further interventions for the fetus are undertaken.

Answer 2: Emergent cesarean section is indicated when the mother is unstable and vaginal birth is not imminent. However, patients should first receive stabilization with left lateral decubitus positioning and fluids before definitive treatment with cesarean section is considered.

Answer 3: Induction of labor can be considered in stable patients with placental abruption who are at or beyond 34 weeks of gestation. However, in this patient at 33 weeks of gestation, initial stabilization should be performed. If this patient continues to be stable, a course of antenatal corticosteroids should be administered before delivery.

Answer 5: A urine drug screen or a verbal screening should be performed in patients with suspected placental abruption and substance misuse. However, stabilization of the mother is more important than a urine drug screen for initial management.

Bullet Summary:
In patients who experience trauma that leads to placenta abruption, stabilization of the mother with left lateral decubitus positioning and intravenous fluids is the next most appropriate step in management.