Placental abruption: Difference between revisions
(Major expansion: concealed abruption, fibrinogen thresholds, DIC management, low US sensitivity, references) |
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==Clinical Features== | ==Clinical Features== | ||
* | *Painful vaginal bleeding (contrast with painless bleeding of [[Placenta previa|previa]]) | ||
* | *Rigid, tender uterus ("board-like" in severe cases) | ||
*Uterine contractions or hypertonicity | *Uterine contractions or hypertonicity | ||
*Fetal distress (decelerations, bradycardia) or fetal demise | *Fetal distress (decelerations, bradycardia) or fetal demise | ||
* | *Concealed abruption: hemodynamic instability with minimal external bleeding | ||
*Signs of [[Hemorrhagic shock|hemorrhagic shock]]: tachycardia, hypotension | *Signs of [[Hemorrhagic shock|hemorrhagic shock]]: tachycardia, hypotension | ||
*May trigger [[DIC]] (present in ~10-20% of severe cases) | *May trigger [[DIC]] (present in ~10-20% of severe cases) | ||
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==Evaluation== | ==Evaluation== | ||
* | *Clinical diagnosis primarily — ultrasound has low sensitivity (~25-50%) for abruption<ref name="glantz">Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment of placental abruption. ''J Ultrasound Med''. 2002;21(8):837-840. PMID 12164566.</ref> | ||
* | *Labs | ||
**CBC (may show anemia; serial Hgb) | **CBC (may show anemia; serial Hgb) | ||
**Type and screen / crossmatch | **Type and screen / crossmatch | ||
**Coagulation studies: PT, PTT, fibrinogen ( | **Coagulation studies: PT, PTT, fibrinogen (fibrinogen <200 mg/dL is concerning; <100 suggests severe DIC) | ||
**D-dimer | **D-dimer | ||
**[[Kleihauer-Betke test]] (quantify fetomaternal hemorrhage, especially if Rh-negative) | **[[Kleihauer-Betke test]] (quantify fetomaternal hemorrhage, especially if Rh-negative) | ||
**BMP (renal function) | **BMP (renal function) | ||
* | *Fetal monitoring — continuous cardiotocography | ||
* | *Ultrasound — useful to rule out [[Placenta previa]] but cannot reliably exclude abruption | ||
==Management== | ==Management== | ||
===Unstable / Severe Abruption=== | ===Unstable / Severe Abruption=== | ||
*Aggressive IV fluid resuscitation, [[Massive transfusion protocol|massive transfusion protocol]] | *Aggressive IV fluid resuscitation, [[Massive transfusion protocol|massive transfusion protocol]] | ||
* | *Emergent cesarean delivery if fetal distress or maternal instability | ||
*Treat [[DIC]] with blood products (FFP, cryoprecipitate, platelets) | *Treat [[DIC]] with blood products (FFP, cryoprecipitate, platelets) | ||
*Target fibrinogen >150-200 mg/dL | *Target fibrinogen >150-200 mg/dL | ||
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==Disposition== | ==Disposition== | ||
* | *All patients with suspected abruption require admission | ||
*Emergent OB/GYN consultation | *Emergent OB/GYN consultation | ||
*ICU if hemodynamically unstable or DIC | *ICU if hemodynamically unstable or DIC | ||
Latest revision as of 09:35, 22 March 2026
Background
- Premature separation of a normally implanted placenta from the uterine wall
- Occurs in 0.4-1% of pregnancies[1]
- Significant cause of third-trimester hemorrhage, fetal distress, and maternal morbidity
- Maternal mortality ~1%; fetal mortality 15-20%
- Abruption may be concealed (hemorrhage trapped behind placenta) with minimal vaginal bleeding
Risk Factors
- Hypertension / Preeclampsia
- Prior abruption (10-15% recurrence)
- Trauma (including MVC — most common cause of traumatic abruption)
- Cocaine use
- Smoking
- Advanced maternal age
- Premature rupture of membranes
- Short umbilical cord
Clinical Features
- Painful vaginal bleeding (contrast with painless bleeding of previa)
- Rigid, tender uterus ("board-like" in severe cases)
- Uterine contractions or hypertonicity
- Fetal distress (decelerations, bradycardia) or fetal demise
- Concealed abruption: hemodynamic instability with minimal external bleeding
- Signs of hemorrhagic shock: tachycardia, hypotension
- May trigger DIC (present in ~10-20% of severe cases)
Differential Diagnosis
Abdominal Pain in Pregnancy
The same abdominal pain differential as non-pregnant patients, plus:
<20 Weeks
- Ectopic pregnancy
- First trimester abortion
- Complete abortion
- Threatened abortion
- Inevitable abortion
- Incomplete abortion
- Missed abortion
- Septic abortion
- Round ligament stretching
- Incarcerated uterus
- Malposition of the uterus
>20 Weeks
- Labor/Preterm labor
- Placental abruption
- Placenta previa
- Vasa previa
- Uterine rupture
- Vaginal trauma
- HELLP syndrome
- Cholestasis of pregnancy
- Chorioamnionitis
- Incarcerated uterus
- Acute fatty liver of pregnancy
- Malposition of the uterus
- Placenta accreta
- Placenta increta
- Placenta percreta
Any time
- Hemorrhagic ovarian cyst
- Fibroid degeneration or torsion
- Ovarian torsion
- Constipation
Evaluation
- Clinical diagnosis primarily — ultrasound has low sensitivity (~25-50%) for abruption[2]
- Labs
- CBC (may show anemia; serial Hgb)
- Type and screen / crossmatch
- Coagulation studies: PT, PTT, fibrinogen (fibrinogen <200 mg/dL is concerning; <100 suggests severe DIC)
- D-dimer
- Kleihauer-Betke test (quantify fetomaternal hemorrhage, especially if Rh-negative)
- BMP (renal function)
- Fetal monitoring — continuous cardiotocography
- Ultrasound — useful to rule out Placenta previa but cannot reliably exclude abruption
Management
Unstable / Severe Abruption
- Aggressive IV fluid resuscitation, massive transfusion protocol
- Emergent cesarean delivery if fetal distress or maternal instability
- Treat DIC with blood products (FFP, cryoprecipitate, platelets)
- Target fibrinogen >150-200 mg/dL
- OB/GYN emergent consultation
Stable / Mild Abruption
- Admit to labor and delivery
- Continuous fetal monitoring
- Serial labs (Hgb, fibrinogen, coagulation studies)
- If preterm: antenatal corticosteroids (Betamethasone) for fetal lung maturity
- RhoGAM if Rh-negative
- Expectant management may be appropriate if fetus is preterm and both mother and fetus are stable
Disposition
- All patients with suspected abruption require admission
- Emergent OB/GYN consultation
- ICU if hemodynamically unstable or DIC
See Also
References
- ↑ Tikkanen M. Placental abruption: epidemiology, risk factors and consequences. Acta Obstet Gynecol Scand. 2011;90(2):140-149. PMID 21241259.
- ↑ Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment of placental abruption. J Ultrasound Med. 2002;21(8):837-840. PMID 12164566.