Placental Abruption

Question 1

What is placental abruption?

Answer 1

Separation of the placenta from the uterine wall before delivery (>24 weeks; if <24w, miscarriage)

o Pathology – as placenta separates, retroperitoneal bleeding results in further detachment

o Haemorrhage may be concealed (20%) or revealed (80%)

o Occurs in 1-2% of all pregnancie

Question 2

What is the aetiology of Placental abruption?

Answer 2

idiopathic or may occur secondary to raised pressure on maternal side or mechanical trauma

Question 3

What are the RFs of placental abruption?

Answer 3

however, 70% of abruption occurs in low-risk pregnancies (i.e. no risk factors)

HTN 
Previous APH 
PPROM
Abdominal trauma 
Smoking, cocaine 
Polyhydramnios, multiple pregnancy 
IUGR
PET

Question 4

What are the S/S of placental abruption?

Answer 4

o Constant abdominal pain ± PV bleeding (if revealed – 80%), SUSTAINED contractions

o On examination:

§ General – shock
Abdomen – hypertonic “woody” tender uterus

§ Speculum – assess bleeding 
Vaginal exam (NOT in praevia) – cervical dilatation

Question 5

What are the Ix of placental abruption?

Answer 5

Praevia = bleed, no pain; abruption = bleed, pain

o Bloods – FBC, clotting, U&E, crossmatch

o USS – exclude praevia – abruption unlikely to be present unless very large

Question 6

What is the management of placental abruption?

Answer 6

o Mild -> if preterm and stable: conservative management with close monitoring -> IOL at term

§ Admit for at least 48 hours or until bleeding stops

§ Anti-D Ig followed by Kleihauer test

o Severe -> ABC, emergency CS, 2x wide bore cannulae, fluids, blood transfusions, correct coagulopathies

§ FBC, G&S, crossmatch, Kleihauer test (and anti-D if needed), steroids (between 24-34+6w)

§ CTG (if >27w), consider IOL if foetal compromise, TVUSS (query placenta praevia)

Question 7

What complications may occur in placental abruption?

Answer 7

o Maternal – haemorrhage (APH, PPH), DIC, renal failure, “Couvelaire uterus” (extravasation of blood into myometrium and beneath the peritoneum -> very hard uterus)

o Foetal – birth asphyxia, death If unsure if praevia, DO NOT BIMANUAL

o Prognosis

§ Maternal – mortality 0.5% in severe abruption

§ Foetal – mortality 3.3% in severe abruption