ABRUPTIO PLACENTA

Premature separation of the otherwise normally implanted placenta.

Sher's grades:
1. Minimal or no bleeding: detected as retroplacental clot after delivery of viable fetus.
2. Viable fetus with bleeding and tender irritable uterus.
3. Type A with dead fetus and no coagulopathy; type B with dead fetus and coagulopathy (about30% of grade 3's)

SIGNS AND SYMPTOMS

• Second or third trimester vaginal bleeding greater than one pad or tampon per hour.
• Back pain, abdominal pain
• Uterine tenderness, hypertonia, or high frequency contractions
• Blood loss may be concealed; clinical signs of shock may occur with little vaginal bleeding.
• Since blood volumes increase in pregnancy, volume lost may exceed 30% before signs of shock or hypovolemia.
Vital signs may be preserved even with significant loss.
• Fetal distress or demise
• Idiopathic preterm labor with or without fetalmg/dl (1.0-1.5 g/L) before PTT will rise
• distress.

CAUSES
• Cocaine use and abuse
• Trauma of variable amounts; especially blunt abdominal trauma in which external signs of trauma may be
incongruent with fetal injury (motor vehicle accidents or domestic violence
• Sudden decompression of over-distended uterus as in hydramnion or twin gestation.

RISK FACTORS:
• Prior abruption (increases risk 10-fold)
• Maternal smoking
• Severe small for gestational age birth
• Alcohol abuse
• Hypertension: pregnancy-induced and chronic
• Uterine anomalies
• Advance maternal age
• Increased risk if hypertensive and parity > 3
• Preterm rupture of membranes, especially if bleeding occurs during observation interval
• Vaginal bleeding before spontaneous rupture of membrane

LABORATORY:
• Blood type, Rh, Coombs
• CBC with platelet count
• Prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen levels
• Cross match at least three units

DRUGS THAT MAY ALTER LAB RESULTS:

• Those affect clotting parameters
• RHoD immune globulin less than 12 weeks prior may affect antibody test

Disorders that may alter lab results:

• Fibrinogen levels climb to 350-500 mg/dl (3.5-5.5 g/L) in third trimester and must fall to 100-150 mg/dl (1.0-1.5
g/L) before PTT will rise
• Fibrin split or degradation products are elevated in pregnancy and are not very helpful in assessing disseminated
intravascular coagulation(DIC)

PATHOLOGICAL FINDINGS
• Normocytic normochromic anemia with acute bleeding
• Elevated PT, PTT, fibrinogen levels below 100-150 mg/dL (1.0-1.5 g/L), platelets 20,000-50,000 if fetal-maternal
transfusion has occurred
• Positive antibodu if RhoD isosensitization has occurred

SPECIAL TEST
• Kleihauer-Betke for fetal-maternal transfusion
• Bedside clot test with red top tube of maternal blood with poor or non-clotting blood after 7-10 minutes indicating
coagulopathy
• Apt test for fetal blood origin: mix vaginal blood with small amount tap water to cause hemolysis, centrifuge
several minutes, mix pink hemoglobin containing super-natant with 1 cc 1% sodium hydroxide (NaOH) for each 5
cc supernatant, reading color in two minutes with fetal Hgb staying pink and adult turning yellow-brown
• Wright stain vaginal blood, observe for nucleated RBC’s - usually of fetal origin
• Lecithin/sphingomyelin (L/S) ratio if delay of delivery is an option and length of pregnancy is preterm
IMAGING
• Alhough ultrasound may show sonolucent retroplacen-tal clot, rounded placenta margin or thickened placenta, it
is often not defi nitive - especially with posterior place-ment or mild abruption

DIAGNOSTIC PROCEDURES
• External uterine monitoring often shows elevated base-line pressure and frequent low amplitude contractions

TREATMENT
• History and physical exam with past medical history, allergies, prior ultrasounds this gestation, and time of last
meal
• In general, severe abruption best managed by delivery of fetus
• Sher’s grade 1 - usual labor protocol
• Sher’s grade 2 - rapid delivery most often by cesarean section
• Sher’s grade 3 - vaginal delivery preferable if mother stable
• In trauma monitor inpatient at least 4 hours for evidence of fetal insult, abruption, fetal-maternal transfusion
• Early aggressive restoration of maternal physiology to protect fetus and maternal organs from hypoperfusion/DIC
• Stabilize vitals, keep Hct >30, urine output >30 cc/hr
• Bedrest with external fetal and labor monitoring, if fetus is viable
• Large bore 16-18 gauge IV crystalloid infusion, central line placement only after coagulation status has been
assessed
• Transfusions of whole blood may be necessary
• Follow hemoglobin/hematocrit (H/H) and coagulation status every 1-2 hours
• Place intrauterine pressure catheter (IUPC) since fetal risk climbs with elevated pressure
• Role of amniotomy to prevent amniotic fluid embolism is debatable but will speed delivery
• Positioning on left side may enhance venous return and cardiac output
• Oxygen for all patients
• If trauma without compromise after observation or small abruption and preterm may observe outpatient
encouraging reduction of risk factors

SURGICAL MEASURES
• May need cesarean section after maternal stabilization if fetus viable and situation urgent

ACTIVITY:
• Bedrest until status defined

DIET:
• NPO until status defined and cesarean section possibility ruled out

PATIENT EDUCATION:
• Call physician or proceed to hospital whenever bleeding more than one pad occurs, or if severe uterine or back
pain occurs

DRUG(S) OF CHOICE
• Oxygen
• Saline or Ringer’s lactate
• Whole blood and packed RBC’s to keep hematocrit > 30
• May use oxytocin (Pitocin) augmentation to speed delivery
• Tocolytics like terbutaline may be used in mild non-compromising preterm abruption
• Rho(D) immune globulin for RhoD negative mother if undelivered or indicated after delivery
• 300 mcg RhoD immune globulin/15 cc fetal blood transfused, if Kleihauer-Betke test returns positive
• Fresh frozen plasma and platelet transfusions for coagulopathy with cryoprecipitate and fibrinogen given if
indicated

CONTRAINDICATIONS:
• Tocolytics should be withheld in preterm labor until abruption ruled out and fetal status defined
PRECAUTIONS:
• Suffusion of blood into myometrium with weakening may increase risk of uterine rupture with oxytocin (Pitocin)
augmentation
• Cryoprecipitate and fibrinogen may represent greater transfusion infection transmission risk

PATIENT MONITORING:
• If not delivered, monitor for intrauterine growth retardation (IUGR)
• See regularly and assess for preterm labor

PREVENTION/AVOIDANCE:
• Eliminate risk factors when possible
POSSIBLE COMPLICATIONS:
• Infection transfusion risks: Hepatitis, cytomegalovirus infection, HIV and others
• Sensitization from blood product transfusion

EXPECTED COURSE/PROGNOSIS
• 0.5% to 1% fetal mortality and 30-50% perinatal mortality
• With trauma and abruption 1% maternal and 30-70% fetal mortality
• Labor typically more rapid but hypotonus from blood suffusion may occur