Placental Abruption (Abruptio Placentae)

Last updated 20.09.12

Definition

-  Separation of placenta from myometrial wall after 20/40 gestation of pregnancy prior to birth

-  Revealed: vaginal bleeding

-  Concealed: not clinically apparent externally

-  Couvelaire uterus: blood extravasated into myometriun

 

Diagram

 

Features

-  Obstetric emergency

-  Bleeding into decidua basalis causes separation

-  Haemtoma compresses compromising blood to foetus

-  Incidence of 1% pregnancies

-  Partial vs complete

 

Risk Factors

-  Maternal HTN 44%

-  Maternal trauma 2-10%

-  MVA, fall, domestic violence

-  Drugs: cigarettes, EtOH, cocaine

-  Short umbilical cord

-  Sudden compression of uterus: rupture of membrance, delivery of 1st twin..

-  Retroplacental fibromyoma

-  Retroplacental bleeding

-  Amniocentesis

-  Advanced maternal age

-  Previous abruption

-  Idiopathic (? abnormal vasculature)

 

Associated S/S

-  Presentation

-  Vaginal bleeding during pregnancy 80%

-  APH

-  Intrapartum haemorrage

-  Volume of loss difficult to assess due to concealed bleeding

-  Abdominal/back/uterine pain 70%

-  Foetal distress 60%

-  Abnormal hypertonic or high freq uterine contractions 35%

-  Idiopathic premature delivery 25%

-  Foetal death 15%

-  Couvelaire uterus: blood in wall of uterus

-  Increased risk of uterine atony & PPH

-  Uterine rupture during contractions

-  Haemorrhage

-  Maternal death

-  Foetal distress or death (15%)

-  Coagulopathy (DIC): maternal death

-  IUGR

-  Foetal hypoxia

 

Classification

-  Class 0

-  Asymptomatic

-  Postnatal Dx by clot on placenta

-  Class 1 = mild

-  48% cases

-  Nil to mild vaginal bleeding during pregnancy

-  Tender uterus

-  Normal maternal BP & HR

-  No coagulopathy or foetal distress

-  Class 2 = moderate

-  27% cases

-  Nil to moderate vaginal bleeding during pregnancy

-  Moderate to severe uterine tenderness

-  +/- tetanic contractions

-  Maternal tachycardia + orthostatic BP & HR changes

-  Hypofibrinogenaemia

-  Foetal distress

-  Class 3 = severe

-  24% cases

-  Nil to heavy vaginal bleeding during pregnancy

-  Painful tetanic uterus

-  Maternal shock

-  Hypofibrinogenaemia

-  Coagulopathy

-  Fetal death

 

Ix

-  Vitals

-  HR, BP: hypotension, shock

-  Beware compensation w rapid decompensation in otherwise healthy women

-  Speculum

-  Determine source, volume & current state of bleeding (active or resolved)

-  DDx local causes, need to take time & inspect vulva, vagina & cervix

-  +/- VE

-  Cautious & considered use unless placental location known

-  Determine suitable method of delivery: LUSCS vs vaginal

-  CTG

-  Fetal wellbeing

-  Reduced variability, tachycardia, recurrent late decels, sinusoidal trace

-  Uterine hyperstimulation/irritability

-  FBE

-  Hb: anaemia

-  Plt: thrombocytopaenia

-  Group & Hold

-  Rhesus status for Anti-D

-  Blood transfusion

-  Coags: Fibrinogen, fibrin, D-dimer, INR, APTT: DIC

-  Kleihauer

-  Dx fetomaternal haemorrhage

-  Poor correlation w presence of abruption

-  Determine dose required of Anti-D

-  +/- ABG

-  In severe cases: acidosis

-  TV US: second or third trimester

-  Exclude placenta previa & vasa praevia

-  Retroplacental haemoatoma or placental separation Dx in 2%+ (up to 25%)

-  Operator dependant

 

US

 

Mx

-  +/- BLS & ALS

-  +/- Help

-  Consultant Obstetrician

-  Anaesthetist, Haematologist

-  MET call

-  Admission to hospital 48hrs+

-  Post trauma minimum 4/24 CTG

-  Be wary of compensation in otherwise health women

-  Rapid decompensation

-  Cannulation: x2 large bore

-  IV fluids +/- Blood transfusion

-  Analgesia

-  Anti-D

-  All rhesus negative mothers

-  +/- IDC: fluid balance

-  +/- O2

-  +/- Expediated delivery

-  No method available to prevent ongoing bleeding other than delivery

-  Consider steroids if <34/40, MgSO4 if <30/40

-  Regardless of gestation if

-  CTG unresponsive to O2, position or volume replacement

-  Life threatening maternal haemorrhage

-  If <32/40 consider conservative Mx if maternal & foetal stability

-  If >32/40 & foetus alive

-  Vaginal delivery reasonable if mother stable & delivery imminent

-   May still require emergency LUSCS

-   Even in context of significant bleed may attempt if CTG normal

-  If 32-37/40

-  Minor abruption consider conservative Mx

-  Emergency LUSCS or vaginal delivery (if imminent) if substantial blood loss, DIC, foetal compromise or significant uterine tenderness

-  If >37/40

-  Consider delivery even if minimal bleed to reduce risk of further catastrophic bleed

-  LUSCS vs vaginal w IOL (w Consultant advice)

-  Mx of DIC as necessary

-  Conservative Mx

-  Bleeding ceased for 48hrs

-  Minimal abruption & uterine tenderness

-  Foetal wellbeing assured

-  Regular CTG & serial US

-  Prepresent immediately if PV bleed

-  F/U post delivery

-  Placental pathology: thrombosis, perivillous fibrin deposition, infarction, decidual abnormalities

-  Screen mother for congenital & acquired thrombophillias

-  Avoid smoking & cocaine use in subsequent pregnancies

 

 

 

References

 

UpToDate: Management and outcome of pregnancies complicated by placental abruption, Oyelese et al, 06/01/2011

UpToDate: Clinical Features & Diagnosis of Abruption, Anath et al, 16/05/11

3 Centres Collaboration: Antepartum Haemorrhage (APH), Including Placenta Praevia, Abruption and Vasa Praevia, 21/12/11, 3centres.com.au/guidelines/antepartum-haemorrhage-aph-including-placenta-praevia-and-abruption/