Placental Abruption

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Chapter 217 Placental Abruption

INTRODUCTION

Description: Placental abruption is premature separation of an otherwise normally implanted placenta before delivery of the fetus.

Prevalence: One in 185 to 290 deliveries; sufficient to result in fetal death, 1 in 1600 deliveries (approximately 10% of third-trimester fetal demise).

Predominant Age: Reproductive.

Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Pregnancy-induced hypertension (most common), trauma to the abdomen, decompression of an overdistended uterus (loss of amniotic fluid, delivery of a twin), cocaine use.

Risk Factors: Pregnancy-induced hypertension (most common). Prior abruption: 15% chance if one prior episode, 20% to 25% for two or more prior events. Others: smoking >1 pack/day (2-fold increased risk), multiparity, alcohol abuse, cocaine use, polyhydramnios, maternal hypertension, premature rupture of the membranes, external trauma, uterine leiomyomata, increased age or parity, and multiple gestation.

DIAGNOSTIC APPROACH

Differential Diagnosis

• Uterine rupture

• Placenta or vasa previa

• Bloody show

• Chorioamnionitis

• Other sources of abdominal pain

Associated Conditions: Hypertension, pre-eclampsia, eclampsia, intrauterine fetal demise, postpartum hemorrhage, consumptive coagulopathy, tumultuous labor, premature delivery, and fetal bradycardia.

Workup and Evaluation

Laboratory: Complete blood count, assessment of clotting function (bleeding time, prothrombin time, partial thromboplastin time, fibrinogen, D-dimer assay).

Imaging: Ultrasound may show signs of a retroplacental clot or collection of blood, but absence does not rule out abruption.

Special Tests: Kleihauer-Betke test for fetal–maternal transfusion, clot tube to assess possibility of coagulopathy, Apt test to identify fetal blood loss (vasa previa).

Diagnostic Procedures: History, physical examination, and laboratory evaluation. Fetal heart rate and uterine activity monitoring.

Pathologic Findings

Bleeding into the decidua basalia with hematoma formation, leading to progressive separation of the placenta and pressure necrosis. Acute anemia, evidence of clotting activation and consumption, histologically normal placenta.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Prompt evaluation, fluid support, cross-match blood or blood products, Rh typing (if not known).

Specific Measures: Fetal and uterine activity monitoring, monitoring of maternal condition (pulse, blood pressure, pulse oxygenation), expedited delivery.

Diet: Nothing by mouth until the diagnosis is established and the patient’s condition is stabilized.

Activity: Bed rest until the diagnosis is established and the patient’s condition is stabilized.

Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP038 (Bleeding During Pregnancy). (Often there is insufficient time for any more than the most basic information and counseling.)

Drug(s) of Choice

None. (Oxygen and intravenous fluid, Rh immune globulin if indicated.)

Contraindications: Tocolytics should not be used until a diagnosis is established.

FOLLOW-UP

Patient Monitoring: Close attention to vaginal bleeding, fetal well-being, and maternal circulatory status.

Prevention/Avoidance: Eliminate modifiable risk fac-tors. The risk of recurrence is estimated to be 9% to 15%.

Possible Complications: Consumptive coagulopathy, maternal mortality 0.5% to 1% and fetal mortality 20% to 70% based on the size of the separation, the cause, and gestational age; 10% to 15% neurologic sequelae in fetal survivors. Acute renal failure can occur with severe forms of abruption and hypovolemia.

Expected Outcome: Small abruption may be managed conservatively; larger separations may jeopardize mother and fetus and frequently require immediate delivery.

MISCELLANEOUS

ICD-9-CM Code: 641.2.

Ananth CV, Savitz DA, Williams MA. Placental abruption and its association with hypertension and prolonged rupture of membranes: a methodologic review and meta-analysis. Obstet Gynecol. 1996;88:309.

Ananth CV, Smulian JC, Vintzileos AM. Incidence of placental abruption in relation to cigarette smoking and hypertensive disorders during pregnancy: a meta-analysis of observational studies. Obstet Gynecol. 1999;93:622.

Joshi VM, Otiv SR, Majumder R, et al. Internal iliac artery ligation for arresting postpartum haemorrhage. BJOG. 2007;114:356. Epub 2007 Jan 22

Reddy UM, Wapner RJ, Rebar RW, Tasca RJ. Infertility, assisted reproductive technology, and adverse pregnancy outcomes: executive summary of a National Institute of Child Health and Human Development workshop. Obstet Gynecol. 2007;109:967.

Sibai BM, Lindheimer M, Hauth J, et al. Risk factors for preeclampsia, abruptio placentae, and adverse neonatal outcomes among women with chronic hypertension. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1998;339:667.

American College of Obstetricians and Gynecologists. Obstetric aspects of trauma management. ACOG Educational Bulletin 251. Washington, DC: ACOG, 1998.

Chamberlain G. ABC of antenatal care. Antepartum haemorrhage. BMJ. 1991;302:1526.

Chamberlain G, Steer P. ABC of labour care. Obstetric emergencies. BMJ. 1999;318:1342.

Fretts RC. Etiology and prevention of stillbirth. Am J Obstet Gynecol. 2005;193:1923.

Nash P, Driscoll P. ABC of major trauma. Trauma in pregnancy. BMJ. 1990;301:974.

Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006;108:1005.

Slutsker L. Risks associated with cocaine use during pregnancy. Obstet Gynecol. 1992;79:778.

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