Placental Abruption

Placental abruption is premature placental separation before delivery and occurs in approximately 0.6% to 1.2% of pregnancies. Presentation ranges from recurrent light bleeding in chronic abruption to concealed hemorrhage, uterine hypertonus, fetal hypoxia, maternal shock, and DIC. PubMedPubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and Management

Suspect abruption with new vaginal bleeding plus abdominal or back pain, uterine tenderness or hypertonus, frequent contractions/tachysystole, decreased fetal movement, nonreassuring fetal heart rate (FHR) findings, or trauma. Absence of vaginal bleeding does not exclude abruption because bleeding may be concealed. PubMed+2PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental Abruption - StatPearls - NCBI BookshelfPubMedPlacental abruption

Risk is increased by prior abruption, chronic hypertension, preeclampsia, cigarette smoking, cocaine or other illicit drug exposure, PPROM, chorioamnionitis, fetal growth restriction, multifetal gestation, polyhydramnios or sudden uterine decompression, and abdominal trauma. Chronic hypertension confers a 3- to 4-fold higher risk and preeclampsia a 4- to 6-fold higher risk in the cited review. PubMedPubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and Management

Diagnosis integrates presentation, examination, fetal assessment, exclusion of placenta previa and other causes of antepartum bleeding, and postpartum placental findings when available. Do not delay resuscitation or indicated delivery to obtain imaging. PubMed+2PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental Abruption - StatPearls - NCBI BookshelfPubMedPlacental abruption

Perform sterile speculum examination to evaluate bleeding and cervical source. If placental location is unknown, defer digital cervical examination until ultrasound has excluded placenta previa. PubMedPubMedPlacental Abruption - StatPearls - NCBI Bookshelf

Ultrasound is useful to determine placental location and may identify retroplacental, marginal, subchorionic, preplacental, or intraplacental collections. However, acute hemorrhage can be isoechoic to placenta. In one cited study, ultrasound sensitivity was 57.0% and negative predictive value 14.0%; another review reports high specificity but poor sensitivity. Thus, a negative scan must not provide reassurance when the clinical syndrome suggests abruption. PubMed+1PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental abruption

Place the patient in a monitored obstetric setting, establish at least two large-bore IV lines, begin crystalloid resuscitation as needed, obtain blood samples and crossmatched blood, and activate obstetric anesthesia, neonatal, blood-bank, and operating-room resources early when hemorrhage or fetal compromise is suspected. PubMed+1PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental abruption

The amount of external bleeding should not determine urgency. Maternal status, fetal status, ongoing bleeding, uterine tone, and laboratory trajectory should drive escalation. Severe hemorrhage, maternal cardiovascular instability, or both mandate immediate delivery regardless of gestational age or neonatal resources. PubMed+1PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental abruption

At near-term and term gestations, acute abruption is generally managed with maternal stabilization followed by delivery. Intrauterine maneuvers may have limited benefit in acute severe abruption and must not delay delivery for persistent category III FHR patterns or maternal deterioration. PubMedPubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and Management

Abruption is described as the most common cause of DIC in pregnancy. The classic pattern is thrombocytopenia, prolonged PT/aPTT, and hypofibrinogenemia, although fibrinogen may initially be normal or only mildly reduced because it is an acute-phase reactant in pregnancy. Early hypofibrinogenemia is particularly concerning in major obstetric hemorrhage. PubMedPubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and Management

Give packed red blood cells according to active blood loss, hemodynamics, expected ongoing hemorrhage, and time to delivery rather than a static hemoglobin threshold in active bleeding. Fresh frozen plasma is appropriate for multiple acquired factor deficiencies, including DIC or massive transfusion. Cryoprecipitate provides concentrated fibrinogen for acquired hypofibrinogenemia. PubMedPubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and Management

In the cited near-term and term review, cryoprecipitate was recommended to maintain fibrinogen above 50 to 100 mg/dL and platelets above 50,000/mL in active bleeding. A more recent anesthesia review emphasizes that fibrinogen below 2 g/L is inadequate for effective coagulation and predicts severe hemorrhage; institutional obstetric hemorrhage protocols should govern target selection and product dosing. PubMed+1PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental abruption

For acute abruption, severe hemorrhage or maternal instability requires immediate delivery. A viable fetus with severe FHR compromise generally requires emergent cesarean delivery unless vaginal delivery is imminent. With reassuring fetal status and maternal stability, delivery route can be individualized; vaginal birth may be appropriate when labor is progressing and can be safely completed. PubMed+1PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental abruption

If fetal death has occurred, vaginal delivery is preferred in most cases because cesarean delivery increases surgical hemorrhage risk in a setting predisposed to DIC and may add future uterine scar morbidity. Cesarean delivery may still be required for maternal indications, contraindication to vaginal delivery, or individualized concern for uterine rupture. PubMed+1PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental abruption

Chronic abruption has limited evidence for optimal timing. Following inpatient observation, selected stable preterm patients may be managed outpatient if they can comply with surveillance. The cited review recommends once- or twice-weekly antenatal surveillance from diagnosis, serial growth assessment, and Dopplers when fetal growth restriction or fetal anemia is suspected. Delivery during 36 to 37 weeks is presented as expert opinion, with earlier delivery for ongoing bleeding, FHR abnormalities, oligohydramnios, or growth restriction. PubMedPubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and Management

Neuraxial anesthesia may be feasible in a normovolemic, cardiovascularly stable patient without clinically significant coagulopathy, but abruption can produce rapidly evolving coagulopathy. Coagulation assessment and correction are necessary before neuraxial catheter removal. General anesthesia is indicated with major hemorrhage or instability. PubMedPubMedPlacental abruption

After delivery, monitor closely for recurrent hemorrhage, uterine atony, persistent coagulopathy, renal injury, and complications of major transfusion. Patients with major hemorrhage or DIC may require higher-acuity postpartum monitoring or intensive care. PubMed+1PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental abruption

Placental pathology can support retrospective diagnosis but cannot direct initial management. Placental examination may show an adherent retroplacental clot or decidual hemorrhage with placental indentation; acute and chronic cases can have nonspecific findings. PubMedPubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and Management

A history of abruption confers up to a 10-fold increased recurrence risk in a subsequent pregnancy; risk is reported as 25-fold higher after two prior affected pregnancies. In another cited review, recurrence is reported as 4% to 12%. Counseling should therefore include early prenatal risk assessment and attention to modifiable contributors, especially smoking, cocaine or other illicit drug use, and hypertension control. PubMed+1PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental Abruption - StatPearls - NCBI Bookshelf

Maternal short-term risks include hemorrhagic shock, DIC, transfusion, hysterectomy, renal failure, ICU admission, and death. Perinatal risks include fetal hypoxia, stillbirth, preterm birth, and fetal growth restriction. PubMed+1PubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and ManagementPubMedPlacental Abruption - StatPearls - NCBI Bookshelf

A systematic review and meta-analysis cited in the near-term/term review found a 2.65-fold higher risk of combined cardiovascular and stroke mortality after abruption. This association supports communication of abruption history to longitudinal primary care and cardiovascular clinicians, while recognizing that causal pathways and optimal preventive interventions are not established by the cited literature. PubMedPubMedPlacental Abruption at Near-Term and Term Gestations: Pathophysiology, Epidemiology, Diagnosis, and Management