Placental Abruption

Question 1

Placenta Abruption defined

Answer 1

premature separation of placenta from uterine wall resulting in hemorrhage between uterine wall and placenta

Question 2

% of abruption by GA

Answer 2

50%: before labor and after 30 wks GA
30%: after delivery
15%: during labor

Question 3

Sequelae of placenta abruption

Answer 3

premature delivery
uterine tetany
DIC
shock (hypovolemic)

Question 4

Predisposing factors for placenta abruption

Answer 4

Abruption previous hx.
Advanced maternal age
Alcohol >14 drinks/wk
Circumvallate placenta
Cocaine
Collagen Vascular Dz.
DM
HTN
Methamphetamine use
Multiparity
Uterine distension
Multigravity
Polyhydramnios
Short Umbilical cord
Smoking
Vascular deficiency

Question 5

Precipitating factors for placenta abruption

Answer 5

Delivery of 1st twin
External/internal version
MVA
Abdominal trauma
Sudden uterine volume loss
PPROM
ROM w/ polyhydramnios
Trauma

Question 6

Placental abruption %

Answer 6

0.5 - 1.5 % of pregnancies

30% of 3T bleeding

15% of perinatal mortality

Question 7

What is the most common factor associated with increased risk of abruption?

Answer 7

HTN (chronic, pre-eclampsia, cocaine/meth)

Question 8

Risk of abruption in future pregnancies after

1 abruption:

2+ abruptions:

Answer 8

1) 10%

2) 25%

Question 9

Classical presentation of placental abruption

Answer 9

3T vaginal bleeding assoc. w/ severe abdominal pain and frequent, strong contractions/increased uterine tone (i.e. firm, tender uterus), abdominal/back pain, fetal distress or demise, Couvelaire uterus at C-section

Can also be painless if it’s a posterior placenta.

Question 10

What would you see on a tocometer that might lead you to think placental abruption?

What might you see on fetal monitoring?

Answer 10

small, frequent contractions and tetanic contractions

nonreassuring tracing secondary to hypoxia

Question 11

What is a Couvelaire uterus?

Answer 11

bluish-purple tone of the myometrium secondary to abrupted blood that has infiltrated up to the serosa, especially at the cornua

Question 12

How is placental abruption diagnosed?

Answer 12

Primarily clinically.

US is done to r/o previa since both present similarly, but negative findings on US do NOT exclude abruption

Retroplacental clot seen on US

Question 13

Since placental abruption is a common cause of consumptive coagulopathy, what findings would you see?

Answer 13

Fibrinogen

Question 14

What is an important consequence of intravascular coagulation?

Answer 14

Activation of plasminogen to plasmin (which lyses fibrin microemboli to maintain circulatory patency)

Question 15

Treatment of Placental Abruption

Answer 15

Most abruptions are small and do not necessitate immediate delivery.

Intensive resuscitation with blood products, crystalloid fluids, prompt delivery to control hemorrhage

1) Stabilize the pt. (Hospitalize pt., continuous fetal monitoring, 2 large-bore IV access, CBC/T&C/PT/PTT/Fibrinogen/D-dimer, RhoGAM for RhNeg,
2) Prepare for possibility of future hemorrhage (Lactated Ringers, preparation of cross-matched blood –> O- in an emergency, FFP, Cryoprecipitate
3) Prepare for preterm delivery (Bethamethasone for fetal lung maturity, Tocolysis to try to prolong to wk 34)
4) Deliver if bleeding is life threatening/non-reassuring fetal testing (Vaginal delivery preferred as long as bleeding controlled and no signs of fetal distress)