Background

Abruptio placentae is defined as the premature separation of the placenta from the uterus.
Patients with abruptio placentae, also called placental abruption, typically present with bleeding,
uterine contractions, and fetal distress. A significant cause of third-trimester bleeding associated
with fetal and maternal morbidity and mortality, placental abruption must be considered
whenever bleeding is encountered in the second half of pregnancy.
[1]
Placental abruption is
demonstrated in the image below. (ee !linical."
Placental abruption seen after delivery.
Complications
#emorrhage into the decidua basalis occurs as the placenta separates from the uterus. $aginal
bleeding usually follows, although the presence of a concealed hemorrhage in which the blood
pools behind the placenta is possible. (ee %or&up."
#ematoma formation further separates the placenta from the uterine wall, causing compression
of these structures and compromise of blood supply to the fetus. 'etroplacental blood may
penetrate through the thic&ness of the uterine wall into the peritoneal cavity, a phenomenon
&nown as !ouvelaire uterus. (he myometrium in this area becomes wea&ened and may rupture
with increased intrauterine pressure during contractions. A myometrium rupture immediately
leads to a life-threatening obstetric emergency. (ee (reatment."
Classification of placental abruption
!lassification of placental abruption is based on e)tent of separation (ie, partial vs complete" and
location of separation (ie, marginal vs central". (ee !linical." !linical classification is as
follows*
!lass + - Asymptomatic
!lass 1 - ,ild (represents appro)imately -./ of all cases"
!lass 0 - ,oderate (represents appro)imately 01/ of all cases"
!lass 2 - evere (represents appro)imately 0-/ of all cases"
A diagnosis of class + is made retrospectively by finding an organi3ed blood clot or a depressed
area on a delivered placenta.
!lass 1 characteristics include the following*
4o vaginal bleeding to mild vaginal bleeding
lightly tender uterus
4ormal maternal 5P and heart rate
4o coagulopathy
4o fetal distress
!lass 0 characteristics include the following*
4o vaginal bleeding to moderate vaginal bleeding
,oderate to severe uterine tenderness with possible tetanic contractions
,aternal tachycardia with orthostatic changes in 5P and heart rate
6etal distress
#ypofibrinogenemia (ie, 7+-07+ mg8d9"
!lass 2 characteristics include the following*
4o vaginal bleeding to heavy vaginal bleeding
$ery painful tetanic uterus
,aternal shoc&
#ypofibrinogenemia (ie, : 17+ mg8d9"
!oagulopathy
6etal death
;o to <mergent ,anagement of Abruptio Placentae for complete information on this topic.
Etiology
(he primary cause of placental abruption is usually un&nown, but multiple ris& factors have been
identified.
[0, 2]
#owever, only a few events have been closely lin&ed to this condition.
'is& factors in abruptio placentae include the following*
,aternal hypertension - ,ost common cause of abruption, occurring in appro)imately
--/ of all cases
,aternal trauma (eg, motor vehicle collision [,$!], assaults, falls" - !auses 1.7-=.-/ of
all cases
!igarette smo&ing
Alcohol consumption
!ocaine use
hort umbilical cord
udden decompression of the uterus (eg, premature rupture of membranes, delivery of
first twin"
'etroplacental fibromyoma
'etroplacental bleeding from needle puncture (ie, postamniocentesis"
>diopathic (probable abnormalities of uterine blood vessels and decidua"
[-]
Previous placental abruption
!horioamnionitis
[7]
Prolonged rupture of membranes (0- h or longer"
,aternal age 27 years or older
,aternal age younger than 0+ years
,ale fetal se)
9ow socioeconomic status
<levated second trimester maternal serum alpha-fetoprotein (associated with up to a 1+-
fold increased ris& of abruption"
ubchorionic hematoma
[?]
Cigarette smoking/tobacco abuse
!igarette smo&ing increases a patient@s overall ris& of placental abruption.
[1]
A prospective cohort study showed the ris& of abruption to be increased by -+/ for each year of
smo&ing prior to pregnancy.
>n addition to the increased ris& of abruption caused by tobacco abuse, the perinatal mortality
rate of infants born to women who smo&e and have an abruption is increased.
[., =]
Cocaine (powder or crack) abuse
(he hypertension and increased levels of catecholamines caused by cocaine abuse are thought to
be responsible for a vasospasm in the uterine blood vessels that causes placental separation and
abruption. #owever, this hypothesis has not been definitively proven.
(he rate of abruption in patients who abuse cocaine has been reported to be appro)imately 12-
27/ and may be dose-dependent.
[1+]
Trauma
Abdominal trauma is a maAor ris& factor for placental abruption.
,otor vehicle accidents often cause abdominal trauma. (he lower seat belt should e)tend across
the pelvis, not across the midabdomen, where the fetus is located.
(rauma may also be due to domestic abuse or assault, both of which are underreported.
Thrombophilia
%hile it was previously thought that patients who e)perienced early or severe abruptions were at
increased ris& of having a specific thrombophilia, this is no longer thought to be the case and
screening of patients with an abruption is no longer recommended.
Epidemiology
Frequency
nited !tates
(he freBuency of abruptio placentae in the Cnited tates is appro)imately 1/, and a severe
abruption leading to fetal death occurs in +.10/ of pregnancies (1*.2+".
Epidemiology
(he freBuency of abruptio placentae in the Cnited tates is appro)imately 1/, and a severe
abruption leading to fetal death occurs in +.10/ of pregnancies (1*.2+".
Abruptio placentae also occurs in about 1/ of all pregnancies throughout the world.
"ace predilection
Placental abruption is more common in African American women than in white or 9atin
American women. #owever, whether this is the result of socioeconomic, genetic, or combined
factors remains unclear.
#ge predilection
An increased ris& of placental abruption has been demonstrated in patients younger than 0+ years
and those older than 27 years.
$rognosis
>f the bleeding continues, fetal and maternal distress may
develop. 6etal and maternal death may occur if
appropriate interventions are not underta&en.
(he severity of fetal distress correlates with the degree of
placental separation. >n near-complete or complete
abruption, fetal death is inevitable unless an immediate
cesarian delivery is performed.
[11]
>f an abruption occurs, the ris& of perinatal mortality is
reported as 11= per 1,+++ people in the Cnited tates, but
this can depend on the e)tent of the abruption and the
gestational age of the fetus.
[10, 12]
(his rate is higher in
patients with a significant smo&ing history.
!urrently, placental abruption is responsible for
appro)imately ?/ of maternal deaths.
%orbidity associated with abruptio placentae
6etal morbidity is caused by the insult of the abruption
itself and by issues related to prematurity when early
delivery is reBuired to alleviate maternal or fetal distress.
,aternal morbidity may include the following*
(ransfusion-related morbidity
!lassic cesarean delivery with need for repeat
cesarean deliveries
#ysterectomy
[1-]
,aternal and fetal complications include issues related to
(1" cesarean delivery, (0" hemorrhage8coagulopathy, and
(2" prematurity.
Cesarean deli&ery
!esarean delivery is often necessary if the patient is far from her delivery date or if significant
fetal compromise develops. >f significant placental separation is present, the fetal heart rate
tracing typically shows evidence of fetal decelerations and even persistent fetal bradycardia.
A cesarean delivery may be complicated by infection, additional hemorrhage, the need for
transfusion of blood products, inAury of the maternal bowel or bladder, and8or hysterectomy for
uncontrollable hemorrhage. >n rare cases, death occurs.
'emorrhage/coagulopathy
Disseminated intravascular coagulation (D>!" may occur as a seBuela of placental abruption.
Patients with a placental abruption are at higher ris& of developing a coagulopathic state than
those with placenta previa. (he coagulopathy must be corrected to ensure adeBuate hemostasis in
the case of a cesarean delivery.
$rematurity
Delivery is reBuired in cases of severe abruption or when significant fetal or maternal distress
occurs, even in the setting of profound prematurity. >n some cases, immediate delivery is the
only option, even before the administration of corticosteroid therapy in these premature infants.
All other problems and complications associated with a premature infant are also possible.
"ecurrence
(he ris& of recurrence of abruptio placentae is reportedly --10/. >f the patient has abruptio
placentae in 0 consecutive pregnancies, the ris& of recurrence rises to 07/.
>f the abruption is severe and results in the death of the fetus, the ris& of a recurrent abruption
and fetal demise is 1/.
$atient Education
<ducate patients about reversible ris& factors, especially smo&ing, before further pregnancies.
Euestion the patient regarding possible trauma from abuse.
'istory
ymptoms may include vaginal bleeding, contractions, abdominal tenderness, and decreased
fetal movement. <liciting any history of trauma, such as assault, abuse, or motor vehicle
accident, is important.
A Buic& review of the patient@s prenatal course, such as a &nown history of placenta previa, may
help lead to the correct diagnosis.
[17]
(he patient should also be as&ed if she has had a placental
abruption in a previous pregnancy.
Euestioning the patient about cocaine abuse, hypertension, trauma, or tobacco abuse is also
crucial.
6reBuency of symptoms in placental abruption is as follows*
$aginal bleeding - .+/
Abdominal or bac& pain and uterine tenderness - 1+/
6etal distress - ?+/
Abnormal uterine contractions (eg, hypertonic, high freBuency" - 27/
>diopathic premature labor - 07/
6etal death - 17/
(aginal bleeding
$aginal bleeding is present in .+/ of patients diagnosed with placental abruptions.
5leeding may be significant enough to Aeopardi3e fetal and maternal health in a relatively short
period.
'emember that 0+/ of abruptions are associated with a concealed hemorrhage, and the absence
of vaginal bleeding does not e)clude a diagnosis of abruptio placentae.
Contractions/uterine tenderness
!ontractions and uterine hypertonus are part of the classic triad observed with placental
abruption.
Cterine activity is a sensitive mar&er of abruption and, in the absence of vaginal bleeding, should
suggest the possibility of an abruption, especially after some form of trauma or in a patient with
multiple ris& factors.
)ecreased fetal mo&ement
(his may be the presenting complaint.
Decreased fetal movement may be due to fetal Aeopardy or death.
$hysical E*amination
(he physical e)amination of a patient who is bleeding must be targeted at determining the origin
of the hemorrhage. imultaneously, the patient must be stabili3ed Buic&ly. %ith placental
abruption, a relatively stable patient may rapidly progress to a state of hypovolemic shoc&.
Do not perform a digital e)amination on a pregnant patient with vaginal bleeding without first
ascertaining the location of the placenta. 5efore a pelvic e)amination can be safely performed,
an ultrasonographic e)amination should be performed to e)clude placenta previa.
[1?]
>f placenta
previa is present, a pelvic e)amination, either with a speculum or with bimanual e)amination,
may initiate profuse bleeding.
(aginal bleeding
5leeding may be profuse and come in FwavesF as the patient@s uterus contracts.
A fluid the color of port wine may be observed when the membranes are ruptured.
Contractions/uterine tenderness
Cterine contractions are a common finding with placental abruption.
!ontractions progress as the abruption e)pands, and uterine hypertonus may be noted.
!ontractions are painful and palpable.
Cterine hyperstimulation may occur with little or no brea& in uterine activity between
contractions
!hock
Patients may present with hypovolemic shoc&, with or without vaginal bleeding, because a
concealed hemorrhage may be present.
As with any hypovolemic condition, blood pressure drops as the pulse increases, urine output
falls, and the patient progresses from an alert to an obtunded state as the condition worsens.
#bsence of fetal heart sounds
(his occurs when the abruption progresses to the point of fetal death.
!igns of possible fetal +eopardy
igns of possible fetal Aeopardy include the following*
Prolonged fetal bradycardia
'epetitive, late decelerations
Decreased short-term variability
Fundal height
(his may increase rapidly because of an e)panding intrauterine hematoma.
)iagnostic Considerations
!onditions to consider in the differential diagnosis of abruptio placentae include, along with
those in the ne)t section, the following*
9abor with bloody show
$asa previa
$aginal trauma
,alignancy (rare"
$aginitis
Acute appendicitis
Preterm labor
Acute appendicitis
)ifferential )iagnoses
5lunt Abdominal (rauma in <mergency ,edicine
Disseminated >ntravascular !oagulation in <mergency ,edicine
<ctopic Pregnancy in <mergency ,edicine
#emorrhagic hoc& in <mergency ,edicine
#ypovolemic hoc&
Gvarian !ysts in <mergency ,edicine
Gvarian (orsion in <mergency ,edicine
Placenta Previa
Preeclampsia
Pregnancy (rauma
#pproach Considerations
>npatient admission for testing and possible delivery is reBuired if abruptio placentae is
considered li&ely.
;o to <mergent ,anagement of Abruptio Placentae for complete information on this topic.
Transfer considerations
(ransfer of the patient to an intensive care unit (>!C" may be necessary, before or after delivery,
if shoc& develops that reBuires invasive central monitoring or if operative complications are
encountered.
(ransfer to a facility with a neonatal >!C is needed if the fetus is preterm and appropriate
facilities are not available. (his should be accomplished after delivery if delivery is reBuired to
stabili3e the mother.
,nitial %anagement of #bruptio $lacentae
5egin continuous e)ternal fetal monitoring for the fetal heart rate and contractions.
Gbtain intravenous access using 0 large-bore intravenous lines.
>nstitute crystalloid fluid resuscitation for the patient.
(ype and crossmatch blood.
5egin a transfusion if the patient is hemodynamically unstable after fluid resuscitation.
!orrect coagulopathy, if present.
Administer 'h immune globulin if the patient is 'h-negative.
(aginal )eli&ery
(his is the preferred method of delivery for a fetus that has died secondary to placental
abruption.
(he ability of the patient to undergo vaginal delivery depends on her remaining
hemodynamically stable.
Delivery is usually rapid in these patients secondary to increased uterine tone and contractions.
Cesarean )eli&ery
!esarean delivery is often necessary for fetal and maternal stabili3ation.
%hile cesarean delivery facilitates rapid delivery and direct access to the uterus and its
vasculature, it can be complicated by the patient@s coagulation status. 5ecause of this, a vertical
s&in incision, which has been associated with less blood loss, is often used when the patient
appears to have D>!.
(he type of uterine incision is dictated by the gestational age of the fetus, with a vertical or
classic uterine incision often being necessary in the preterm patient.
>f hemorrhage cannot be controlled after delivery, a cesarean hysterectomy may be reBuired to
save the patient@s life.
5efore proceeding to hysterectomy, other procedures, including correction of coagulopathy,
ligation of the uterine artery, administration of uterotonics (if atony is present", pac&ing of the
uterus, and other techniBues to control hemorrhage, may be attempted.
,n&asi&e %onitoring
>f the patient is hemodynamically unstable, either before or after delivery, invasive monitoring in
an >!C may be reBuired.
)ietary %odification
(he patient should be restricted to nothing by mouth (4PG" if emergent delivery is a possibility.
#cti&ity
Preterm patients diagnosed with a chronic abruption may be started on a modified bedrest
regimen and monitored closely for any signs of maternal or fetal distress that could necessitate
delivery. Again, consultation with ,6, specialists is advised for conservative management of
abruptio placentae.
,npatient and -utpatient %edications in #bruptio $lacentae
>npatient and outpatient medications may include the following*
Prenatal vitamins
>ron supplements
tool softeners if the patient is hemodynamically stable and is &ept in an inpatient setting
for monitoring
)eterrence and $re&ention of #bruptio $lacentae
<limination of correctable ris& factors can decrease the ris& of recurrence in subseBuent
pregnancies.
(wo of the most notable correctable factors are smo&ing and cocaine abuse. <ducation about the
ris&s of these behaviors and about cessation or rehabilitation programs may help to prevent
future abruptions.
>f a patient has been abused, preventing further abuse is an important consideration.
5ecause of the potential association with thrombophilias with abruptio placentae, a patient found
to have a thrombophilia who had a severe or early abruption, especially with death of the fetus, is
usually treated with heparin anticoagulation therapy during the following pregnancy and for ?
wee&s@ postpartum, although, at present, little evidence has demonstrated that this measure
decreases the ris& of recurrence.
Consultations
A maternal-fetal medicine (,6," specialist should be consulted if a mild abruption is diagnosed
or the diagnosis is Buestionable. >n the case of a preterm fetus in which tocolysis is considered
li&ely, consulting an ,6, specialist may be prudent.
Pediatricians or neonatal intensive care specialists should be consulted if the fetus is considered
viable, usually at 0- wee&s@ gestation, and delivery is anticipated.
%edication !ummary
(ocolysis is considered controversial in the management of placental abruption and is considered
only in patients (1" who are hemodynamically stable, (0" in whom no evidence of fetal Aeopardy
e)ists, and (2" in whom a preterm fetus may benefit from corticosteroids or delay of delivery.
<ven in patients meeting these criteria, consultation with an ,6, specialist is important.
(ocolysis must be underta&en with caution, because maternal or fetal distress can develop
rapidly. >n general, either magnesium sulfate or nifedipine (but not both" is used for tocolysis and
beta-sympathomimetic agents are avoided, as the latter may cause significant undesirable
cardiovascular effects, such as tachycardia, which may mas& clinical signs of blood loss in these
patients.
Tocolytics
Class !ummary
(ocolytics may allow for the effective administration of glucocorticoids to the preterm fetus to
accelerate fetal lung maturation. >n chronic abruption, these drugs may also help to delay
delivery to a gestational age when complications of prematurity are less severe.
$iew full drug information
.ifedipine (#dalat/ $rocardia/ .ifediac CC/ .ifedical 01)

4ifedipine is a calcium channel bloc&er. (he theory behind its use as a tocolytic is that by
bloc&ing an influ) of calcium into uterine muscle cells, it will decrease contractions, which are
dependent on calcium.
$iew full drug information
%agnesium sulfate

(his is the drug of choice for tocolysis in patients with placental abruption.
Updated: Jun 3, 2013
http://emedicine.medscape.com/article/252810-medication#showall