[41] Placental Abruption Flashcards
What is placental abruption?
Where all or part of the placenta separates from the wall of the uterus prematurely
Why is placental abruption clinically important?
Because it is an important cause of antepartum haemorrhage
What causes placental abruption?
Thought to occur following a rupture of the maternal vessels within the basal layer of the endometrium
What is the result of the rupture of maternal vessels within the basal layer of the endometrium?
It causes blood to accumulate and splits the placental attachment from the basal layer
What is the result of the placental detachment from the basal layer?
It means the detached portion of the placenta is unable to function, leading to rapid fatal compromise
What are the 2 main types of placental abruption?
- Revealed
- Concealed
What is revealed placental abruption?
When bleeding tracks down from the site of placental separation and drains through the cervix, resulting in vaginal bleeding
What is concealed placental abruption?
When the bleeding remains in the uterus, and typically forms a clot retroplacentally
What problem can concealed placental abruption cause?
The bleeding is not visible, but can be severe enough to cause systemic shock
What are the risk factors for placental abruption?
- Placental abruption in previous pregnancy
- Pre-eclampsia and other hypertensive disorders
- Abnormal lie of the baby, e.g. transverse
- Polyhydramnios
- Abdominal trauma
- Smoking or drug use, e.g. cocaine
- Bleeding in the first trimester, particularly if haematoma seen inside the uterus on the first trimester scan
- Underlying thrombophilia
- Multiple pregnancy
How does placental abruption typically present?
With painful vaginal bleeding (may not be visible in concealed)
What may be found on examination in placental abruption?
Uterus may be woody (tense all the time) and painful on palpation
What are the differential diagnoses for placental abruption?
- Placenta praevia
- Marginal placental bleeding
- Vasa praevia
- Uterine rupture
- Local genital causes
What is marginal placental bleeding?
Small, partial abruption of the placenta that is large enough to cause revealed bleeding, but not large enough to cause maternal or fetal compromise
What local genital causes are differentials for placental abruption?
- Benign/malignant lesions
- Infections
What should be done regarding investigations if major bleeding is suspected?
Perform investigations and resuscitate simultaneously
What investigations should be done in suspected placental abruption?
- Bloods
- Assessment of fetal wellbeing
- Imaging
What bloods should be done in suspected placental abruption?
- FBC
- Clotting profile
- Kleihauer test
- G&S
- Cross match
- U&Es and LFTs
When should a Kleihauer test be done in suspected placental abruption?
If the women is rhesus negative
How should fetal well-being be assessed in suspected placental abruption if the mother is above 26 weeks?
CTG
When should imaging be done in suspected placental abruption?
When the patient is stable
What may be seen on ultrasound in placental abruption?
Retroplacental haematoma
What is the value of ultrasound in placental abruption?
Has a good positive predictive value
What is the limitation of ultrasound in placental abruption?
Poor negative predictive value, and should not be used to exclude abruption
What should be done in any women presenting with significant antepartum haemorrhage?
They should be resuscitated with an A-E approach
What should maternal resuscitation not be delayed for?
To determine fetal viability
What is the ongoing management of placental abruption dependant on?
The health of the fetus
When is an emergency delivery indicated in placental abruption?
When there is maternal and/or fetal compromise
How is emergency delivery performed in placental abruption?
Usually C-section, unless spontaneous delivery is imminent or operative vaginal birth is achievable
Is C-section indicated in placental abruption if there is in-utero fetal death?
May be indicated if there is maternal compromise
How should placental abruption be managed when there is haemorrhage at term without maternal or fetal compromise?
Induction of labour
Why should induction of labour be performed when there is haemorrhage caused by placental abruption at term without compromise?
To avoid further bleeding
When might conservative management for placental abruption be used?
For some partial or marginal abruption not associated with maternal or fetal compromise
What does the decision regarding if conservative management for placental abruption is suitable depend on?
Gestation and amount of bleeding
What should be done if the women is rhesus D negative and presents with placental abruption?
Anti-D should be given within 72 hours of the onset of bleeding
