[41] Placental Abruption

Question 1

What is placental abruption?

Answer 1

Where all or part of the placenta separates from the wall of the uterus prematurely

Question 2

Why is placental abruption clinically important?

Answer 2

Because it is an important cause of antepartum haemorrhage

Question 3

What causes placental abruption?

Answer 3

Thought to occur following a rupture of the maternal vessels within the basal layer of the endometrium

Question 4

What is the result of the rupture of maternal vessels within the basal layer of the endometrium?

Answer 4

It causes blood to accumulate and splits the placental attachment from the basal layer

Question 5

What is the result of the placental detachment from the basal layer?

Answer 5

It means the detached portion of the placenta is unable to function, leading to rapid fatal compromise

Question 6

What are the 2 main types of placental abruption?

Answer 6

• Revealed

- Concealed

Question 7

What is revealed placental abruption?

Answer 7

When bleeding tracks down from the site of placental separation and drains through the cervix, resulting in vaginal bleeding

Question 8

What is concealed placental abruption?

Answer 8

When the bleeding remains in the uterus, and typically forms a clot retroplacentally

Question 9

What problem can concealed placental abruption cause?

Answer 9

The bleeding is not visible, but can be severe enough to cause systemic shock

Question 10

What are the risk factors for placental abruption?

Answer 10

• 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

Question 11

How does placental abruption typically present?

Answer 11

With painful vaginal bleeding (may not be visible in concealed)

Question 12

What may be found on examination in placental abruption?

Answer 12

Uterus may be woody (tense all the time) and painful on palpation

Question 13

What are the differential diagnoses for placental abruption?

Answer 13

• Placenta praevia
• Marginal placental bleeding
• Vasa praevia
• Uterine rupture
• Local genital causes

Question 14

What is marginal placental bleeding?

Answer 14

Small, partial abruption of the placenta that is large enough to cause revealed bleeding, but not large enough to cause maternal or fetal compromise

Question 15

What local genital causes are differentials for placental abruption?

Answer 15

• Benign/malignant lesions

- Infections

Question 16

What should be done regarding investigations if major bleeding is suspected?

Answer 16

Perform investigations and resuscitate simultaneously

Question 17

What investigations should be done in suspected placental abruption?

Answer 17

• Bloods
• Assessment of fetal wellbeing
• Imaging

Question 18

What bloods should be done in suspected placental abruption?

Answer 18

• FBC
• Clotting profile
• Kleihauer test
• G&S
• Cross match
• U&Es and LFTs

Question 19

When should a Kleihauer test be done in suspected placental abruption?

Answer 19

If the women is rhesus negative

Question 20

How should fetal well-being be assessed in suspected placental abruption if the mother is above 26 weeks?

Answer 20

CTG

Question 21

When should imaging be done in suspected placental abruption?

Answer 21

When the patient is stable

Question 22

What may be seen on ultrasound in placental abruption?

Answer 22

Retroplacental haematoma

Question 23

What is the value of ultrasound in placental abruption?

Answer 23

Has a good positive predictive value

Question 24

What is the limitation of ultrasound in placental abruption?

Answer 24

Poor negative predictive value, and should not be used to exclude abruption

Question 25

What should be done in any women presenting with significant antepartum haemorrhage?

Answer 25

They should be resuscitated with an A-E approach

Question 26

What should maternal resuscitation not be delayed for?

Answer 26

To determine fetal viability

Question 27

What is the ongoing management of placental abruption dependant on?

Answer 27

The health of the fetus

Question 28

When is an emergency delivery indicated in placental abruption?

Answer 28

When there is maternal and/or fetal compromise

Question 29

How is emergency delivery performed in placental abruption?

Answer 29

Usually C-section, unless spontaneous delivery is imminent or operative vaginal birth is achievable

Question 30

Is C-section indicated in placental abruption if there is in-utero fetal death?

Answer 30

May be indicated if there is maternal compromise

Question 31

How should placental abruption be managed when there is haemorrhage at term without maternal or fetal compromise?

Answer 31

Induction of labour

Question 32

Why should induction of labour be performed when there is haemorrhage caused by placental abruption at term without compromise?

Answer 32

To avoid further bleeding

Question 33

When might conservative management for placental abruption be used?

Answer 33

For some partial or marginal abruption not associated with maternal or fetal compromise

Question 34

What does the decision regarding if conservative management for placental abruption is suitable depend on?

Answer 34

Gestation and amount of bleeding

Question 35

What should be done if the women is rhesus D negative and presents with placental abruption?

Answer 35

Anti-D should be given within 72 hours of the onset of bleeding