Placental abruption: Difference between revisions
| Line 18: | Line 18: | ||
==Clinical Features== | ==Clinical Features== | ||
*Painful vaginal bleeding (may be absent if | *'''Painful'' vaginal bleeding (may be absent if retro-placental) | ||
**Characteristically dark and the amount is often insignificant | **Characteristically dark and the amount is often insignificant | ||
**But up to 20% have no vaginal bleeding or pain | **But up to 20% have no vaginal bleeding or pain | ||
| Line 24: | Line 24: | ||
*Uterine contractions | *Uterine contractions | ||
*Hypotension | *Hypotension | ||
* | *Nausea and vomiting | ||
*Back pain | *Back pain | ||
*Premature labor | *Premature labor | ||
Revision as of 22:40, 22 April 2015
Background
- Premature separation of placenta from uterus
- Usually occurs spontaneously but also associated w/ trauma (even minor trauma)
- Usually occurs at >15 weeks gestation
- Must be considered in pts who p/w painful vaginal bleeding near term
- Abruption may be complete, partial, or concealed
- Amount of external bleeding may not correlate with severity
Risk Factors
- HTN
- Trauma
- Smoking
- Advanced maternal age [1]
- Prior placental abruption
- Thrombophilia
- Cocaine abuse
- History of C-section or other uterine sx
Clinical Features
- 'Painful vaginal bleeding (may be absent if retro-placental)
- Characteristically dark and the amount is often insignificant
- But up to 20% have no vaginal bleeding or pain
- Severe uterine pain
- Uterine contractions
- Hypotension
- Nausea and vomiting
- Back pain
- Premature labor
- Fetal distress
- Increasing fundal height
Differential Diagnosis
Abdominal Pain in Pregnancy
The same abdominal pain differential as non-pregnant patients, plus:
<20 Weeks
- Ectopic pregnancy
- First trimester abortion
- Complete abortion
- Threatened abortion
- Inevitable abortion
- Incomplete abortion
- Missed abortion
- Septic abortion
- Round ligament stretching
- Incarcerated uterus
- Malposition of the uterus
>20 Weeks
- Labor/Preterm labor
- Placental abruption
- Placenta previa
- Vasa previa
- Uterine rupture
- Vaginal trauma
- HELLP syndrome
- Cholestasis of pregnancy
- Chorioamnionitis
- Incarcerated uterus
- Acute fatty liver of pregnancy
- Malposition of the uterus
- Placenta accreta
- Placenta increta
- Placenta percreta
Any time
- Hemorrhagic ovarian cyst
- Fibroid degeneration or torsion
- Ovarian torsion
- Constipation
Work-Up
- Type & Cross
- CBC
- Platelets
- PT/INR
- PTT
- Fibrinogen
- D-dimer
- Fibrin Degraded Products
- Pelvic US
- Sp, not Sn (as low as 24% sensitive)
- Cannot be used alone to rule-out placental abruption if negative
- Can rule-out placenta previa
- If available, obtain fetal heart monitoring
- Consider Ultrasound: FAST if trauma
Treatment
- Fluid resuscitation
- Transfuse blood products (as needed)
- Emergent OB/GYN consult
- If unavailable consider C-section in ED
- Consider minimum 6 hours observation even if abruption not identified, if mechanism is concerning
Complications
Maternal
- Hemorrhagic shock
- DIC
- Uterine rupture
- Multi-organ failure
Neonatal
- Neurodevelopmental abnormalities
- Death: 67 to 75% rate of fetal mortality
Sources
- ↑ Rosen's