PLACENTAL ABRUPTION

Question 1

Consideration for the Critically Ill Placental Abruption

Answer 1

Maternal Resuscitation takes precedence

Treat hypotension in normal fashion

Place patient in LATERAL TILT POSITION or manually displace the uterus to the left

Initiate a massive transfusion protocol if hemodynamic stability is not achieved with 2-4 units of packed red blood cells (PRBC)

Assess Fetal Heart Rate

Immediately notify Obstetrics or Neonatology / Pediatrics

Definitive Treatment for the unstable patient is Delivery

Question 2

DDx

Answer 2

Placental Abruption
Placentia Previa
Vasa Previa
Prelabour Rupture of Membranes
Preeclampsia/Eclampsia

Normal Labour with Bloody Show
GU Trauma

Question 3

Clinical Features

Answer 3

Painful or painless vaginal bleeding (80-90%)

May have a history of trauma, vascular risk factors

May have abdominal pain or only back pain

May have contractions

Uterus may be tender and/or hypertonic (firm)

Question 4

Investigations

Answer 4

Type and Cross

CBC

Cr

Coags

Fibrinogen Level

Transpelvic ultrasound: sensitivity (50-60%) is NOT sufficient to exclude the diagnosis. May show a retroplacental hematoma

Question 5

Management

Answer 5

Check Fetal Heart Rate

Consult Obstetrics Immediately

Indications for emergency delivery:
Materal Instability
Fetal Distress
Abruption nearing term (>34 weeks)

If contractions consider:
Nifedipine

If 23+0 and 36+6 weeks GA give:
Betamethasone 12 mg IM q 24 h x 2 doses
Dexamethasone 6 mg IM q 12 h x 4 doses

If 23-32 weeks GA:
MgSO4 4 g IV x 1 over 30 minutes

RhoGAM 300 μg as a one-time IM to Rh-negative women

Close Monitoring for Hypoveolemic / Hemorrhagic Shock / ARDS

Monitor CBC, Coags, Fibrinogen for DIC

Question 6

Complications

Answer 6

Maternal:
Hemorrhage
DIC
Hypoveolemic Shock
ARDS
Renal Failure
Peripartum Hysterectomy
Death

Fetal:
Intrauterine growth restriction oligohydramnios prematurity
hypoxemia
stillbirth

Question 7

Disposition

Answer 7

Admission to labour and delivery unit