Placental abruption: Difference between revisions
 
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==Background==
==Background==
# premature separation of placenta from uterus
[[File:2910 The Placenta-02.jpg|thumb|Normal placental anatomy.]]
# amount of external bleeding may not correlate with severity of abruption since bleeding may be concealed.
*Premature separation of placenta from uterus
# fetal death by hypoxia. can also cause fetal blood loss, maternal Rh sens, amniotic fluid embolism, DIC.
*Usually occurs spontaneously but also associated with trauma (even minor trauma)
# GRADE 3/ COMPLETE- mod to severe bleeding with painful tetanic uterine contractions.  maternal hypotension and tachycardia.  DIC with fibrinogen levels less than 150 mg/%, representing a blood loss of 2L. Maternal coagulopathy with thrombocytopenia, clooting factor, fibrinogen depletion. fetal death common.
*Usually occurs at >15 weeks gestation
# GRADE 2/ PARTIAL- ex ut bleeding mild to mod, uterine irritability with tetanic comtractions at times, maternal orthostatic hypotension, fibrinogen levels 150- 250 mg/%, fetal distress with compromised fetal heart rate patterns
*Must be considered in patients who presenting with painful vaginal bleeding near term
# GRADE 1/ MILD- spotting with limited ut irritabillity- no organizedcontractions. Mat BP normal, fibrinogen normal at 450 mg/%, normalfetal heart rate.
*Abruption may be complete, partial, or concealed
**Amount of external bleeding may not correlate with severity


==Risk Factors==
===Risk Factors===
# mat hypertension
*[[Hypertension]]- Most common
# eclampsia, preeclampsia
*[[Trauma]]
# h/o prev abruption
*Smoking
# ut distension from multiple gestations, hydramnios, tumors
*Advanced maternal age <ref>Rosen's</ref>
# vascular dz- collagen vasc, DM, CRF
*Multiparity
# smoking
*[[Preeclampsia]]
# coccaine- increases BP
*Prior placental abruption
# microangiopathic hemolytic anemia
*Thrombophilia
# premature rupture of membranes
*[[Cocaine]] abuse
# uterine blunt trauma- mva, domestic violence
*History of C-section or other uterine symptoms
# short umbilical cord
# advanced mat age,
# male fetal gender
# short umbilical cord


==Diagnosis==
==Clinical Features==
===Symptoms===
*Painful [[vaginal bleeding]] (may be absent if retro-placental)
abd pain, ut contractions, vag bleeding.  possibly also mat hypoTN,tachycardia, ARDS, ATN, DIC- (bruising, hematuria)
**Characteristically dark and the amount is often insignificant
**Up to 20% have no vaginal bleeding or pain
*Severe uterine/[[pelvic pain]]
*Uterine contractions
*[[Hypotension]]
*[[Nausea and vomiting]]
*[[Back pain]]
*[[Premature labor]]
*Fetal distress
*Increasing fundal height


===Labs===
==Differential Diagnosis==
# Thrombomodulin (marker for endothelial cell damage) is elevated
{{Abdominal Pain Pregnancy DDX}}
# DIC- triggered by massive hem.  stumulates production of tissue thromboplastin causing extensive microvascular clotting; these small clots stumulate the fibrinolytic cascade which leads to  cosumpiton of platelets, fibrinogen and other clotting factors.
# normal fibrinogen is 450, at 300 see spont bleeding at puncture sites, at 150- mother has already lost 2L
# DIC panel- fibrinogen, platelets, pt/ptt, raised D- dimer- from fibrin degredation


===UTZ===
==Evaluation==
# will still fail to detect 50% of cases
*Type & Cross
# can measure gest age if mom unsure- if near term do crash c seciton.
*CBC
# will see if hematoma is subchorionic, retroplacental or preplacental- will not change management other that to rule out placenta previa
*Platelets
*PT/INR
*PTT
*Fibrinogen
** Strongly correlates with severity of hemorrhage (≤ 200 mg/dL has 100% PPV for severe bleed)
*[[D-dimer]]
*Fibrin Degraded Products
*[[Pelvic US]]
**Specific, not Sensitive (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 [[FAST exam]] if trauma


==Treatment==
==Management==
# stable/ grade 1- admit for observation and elective delivery
*[[Fluid resuscitation]]
# if pt with large concealed hem, are at risk for ut rupture. tx c decompression of  of ut cavity by amniotomy- only do if all other resuscitative measures are failing.
*[[Transfuse blood]] products (as needed)
# xfuse saline, blood, ffp, platelets as needed.
*Emergent OB/GYN consult
# emergent c section if near term. if preterm, use tocolytics- mag sulfate and terbutaline to prevent ut contractions and prevent labor
**If unavailable consider C-section in ED
*Consider minimum 6 hours observation even if abruption not identified, if mechanism is concerning


[[Category:OB/GYN]]
==Complications==
===Maternal===
*[[Hemorrhagic shock]]
*[[DIC]]
*[[Uterine rupture]]
*Multi-organ failure
 
===Neonatal===
*Neurodevelopmental abnormalities
*Death: 67 to 75% rate of fetal mortality
 
==See Also==
*[[Vaginal Bleeding (Main)]]
*[[Trauma in pregnancy]]
 
==References==
<references/>
 
[[Category:OBGYN]]

Latest revision as of 19:24, 14 December 2022

Background

Normal placental anatomy.
  • Premature separation of placenta from uterus
  • Usually occurs spontaneously but also associated with trauma (even minor trauma)
  • Usually occurs at >15 weeks gestation
  • Must be considered in patients who presenting with painful vaginal bleeding near term
  • Abruption may be complete, partial, or concealed
    • Amount of external bleeding may not correlate with severity

Risk Factors

Clinical Features

Differential Diagnosis

Abdominal Pain in Pregnancy

The same abdominal pain differential as non-pregnant patients, plus:

<20 Weeks

>20 Weeks

Any time

Evaluation

  • Type & Cross
  • CBC
  • Platelets
  • PT/INR
  • PTT
  • Fibrinogen
    • Strongly correlates with severity of hemorrhage (≤ 200 mg/dL has 100% PPV for severe bleed)
  • D-dimer
  • Fibrin Degraded Products
  • Pelvic US
    • Specific, not Sensitive (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 FAST exam if trauma

Management

  • 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

Neonatal

  • Neurodevelopmental abnormalities
  • Death: 67 to 75% rate of fetal mortality

See Also

References

  1. ↑ Rosen's
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