Critical Alerts

• Placental abruption is a leading cause of third-trimester bleeding and perinatal mortality
• Concealed abruption may present with minimal vaginal bleeding despite massive hemorrhage
• DIC occurs in 10-20% of severe abruptions
• Fetal mortality approaches 20-40% with significant abruptions
• Immediate delivery is indicated for maternal instability or fetal distress

Key Diagnostics

• Clinical diagnosis primarily - do not delay management for imaging
• Continuous fetal monitoring (CTG/EFM)
• CBC, coagulation panel (PT, PTT, fibrinogen, D-dimer)
• Type and crossmatch (anticipate massive transfusion)
• Ultrasound (may show retroplacental clot, but sensitivity only 25-50%)

Emergency Treatments

• Large-bore IV access (two 16-18G IVs)
• Fluid resuscitation: Crystalloid, then blood products
• Activate massive transfusion protocol if hemodynamically unstable
• Correct coagulopathy: FFP, cryoprecipitate (target fibrinogen >200 mg/dL)
• Immediate obstetric consultation: Delivery decision critical
• Emergency cesarean section if fetal distress or maternal instability

Placental abruption (abruptio placentae) is the premature separation of a normally implanted placenta from the uterine wall before delivery of the fetus. It is a significant cause of maternal and fetal morbidity and mortality and can occur at any time after 20 weeks of gestation.

Classification by Severity

Epidemiology

• Incidence: 0.4-1% of pregnancies
• Recurrence risk: 5-15% (up to 25% with prior severe abruption)
• Mortality:
  • Maternal: 1-2%
  • Fetal: 20-40% (depending on severity)

Types of Abruption

Revealed (External)

• Blood dissects between membranes and uterus
• Exits through cervix
• Vaginal bleeding correlates better with blood loss

Concealed (Internal)

• Blood trapped behind placenta
• No or minimal vaginal bleeding
• Underestimates true blood loss (up to 2L hidden)

Mixed

• Combination of revealed and concealed
• Most common presentation

Maternal Critical Findings

Fetal Critical Findings

High-Risk Features

Factors Predicting Poor Outcome

• Concealed retroplacental clot >60 mL
• Fibrinogen <150 mg/dL
• Class 3 hemorrhagic shock
• Fetal bradycardia or absent heart rate
• Gestational age <34 weeks

Other Causes of Third-Trimester Bleeding

Comparison: Abruption vs Previa

Initial Assessment

Systematic Approach

1. ABCs - maternal stabilization first
2. Confirm fetal heart tones
3. Assess vaginal bleeding (amount, character)
4. Abdominal examination (uterine tenderness, tone)
5. Avoid digital cervical exam until previa excluded

Laboratory Studies

Fetal Monitoring

Continuous Electronic Fetal Monitoring (EFM)

• Essential for all suspected abruptions
• Identify fetal distress early
• Guide timing of delivery

Interpretation

Imaging

Ultrasound

• Sensitivity only 25-50% for abruption
• May show:
  • Retroplacental clot (hypoechoic)
  • Elevated placental edge
  • Subchorionic collection
• Normal ultrasound does NOT exclude abruption
• Useful to exclude placenta previa

Clinical Diagnosis

• Placental abruption is primarily a CLINICAL diagnosis
• Do not delay treatment for imaging

ICU Admission Criteria

• Hemodynamic instability requiring ongoing resuscitation
• DIC or significant coagulopathy
• Postpartum hemorrhage with ongoing transfusion needs
• Multi-organ dysfunction
• Couvelaire uterus with atony risk

Labor and Delivery Admission

• All confirmed or suspected placental abruptions
• Continuous fetal and maternal monitoring
• Immediate OR availability

Post-Delivery Monitoring

Maternal

• Serial hematocrit
• Coagulation parameters
• Urine output
• Vital signs
• Fundal tone (risk of atony)

Neonatal

• Depends on gestational age and condition at delivery
• NICU involvement for preterm or distressed newborn
• Assess for anemia (may need transfusion)

Follow-up Recommendations

Understanding Placental Abruption

• Placental abruption occurs when the placenta separates early
• It is a serious condition requiring immediate medical care
• Treatment focuses on stabilizing mother and baby
• Delivery may be needed urgently depending on severity

Signs of Complications

Return Immediately If:

• Heavy vaginal bleeding (soaking pad in 1 hour)
• Severe abdominal or back pain
• Decreased or absent fetal movement
• Dizziness, lightheadedness
• Fever or chills

Future Pregnancies

• Recurrence risk is 5-15% (higher with severe abruption)
• Close monitoring recommended in subsequent pregnancies
• Avoid risk factors (smoking, cocaine, uncontrolled hypertension)
• Regular prenatal care is essential

Risk Factor Modification

Modifiable Risk Factors

• Stop smoking
• Avoid cocaine and other recreational drugs
• Control blood pressure
• Maintain regular prenatal visits

Preterm Abruption

Considerations

• Balance fetal immaturity vs abruption severity
• Antenatal corticosteroids if 24-34 weeks and delivery not imminent
• Magnesium sulfate for neuroprotection if <32 weeks
• NICU consultation early

Expectant Management (Mild Abruption, Stable)

• Possible if:
  • Hemodynamically stable
  • Reassuring fetal status
  • <34 weeks with no indication for immediate delivery
• Requires:
  • Continuous monitoring initially
  • Close observation
  • Immediate OR availability

Hypertensive Disorders

• Preeclampsia/eclampsia increases abruption risk 3-5 fold
• Management of abruption may be complicated by:
  • Existing coagulopathy (HELLP)
  • Renal dysfunction
  • Hepatic dysfunction
• Magnesium sulfate for seizure prophylaxis

Previous Cesarean Section

• Increased risk of placental abnormalities
• May have previa or accreta spectrum
• Higher complexity surgery if needed

Trauma in Pregnancy

• Abruption is major cause of fetal death after trauma
• Can occur with minor trauma
• Monitor 4-24 hours depending on severity
• Fetal monitoring for at least 4 hours

Performance Indicators

Documentation Requirements

• Estimated blood loss (vaginal and concealed)
• Fetal heart rate and pattern
• Uterine examination (tone, tenderness)
• Coagulation status
• Transfusion products given
• Delivery decision rationale
• Neonatal and maternal outcomes

Diagnostic Pearls

1. Clinical diagnosis - don't delay for imaging
2. Concealed abruption may have minimal external bleeding
3. Maternal tachycardia may be the first sign of significant hemorrhage
4. Normal ultrasound does NOT exclude abruption
5. Increasing fundal height suggests concealed hemorrhage

Management Pearls

1. Fibrinogen is the most depleted factor - replace early
2. 1:1:1 ratio of blood products in massive transfusion
3. Early obstetric involvement is essential
4. Fetal demise changes management - vaginal delivery usually possible
5. Couvelaire uterus increases risk of postpartum atony

Disposition Pearls

1. All suspected abruptions require admission
2. Do not delay cesarean for coagulopathy - correct simultaneously
3. Close postpartum monitoring - atony risk increased
4. Counsel about recurrence before discharge
5. Neonatal team involvement essential for preterm or distressed infant