Placental abruption: Difference between revisions
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==Background==
==Background==
# premature separation of placenta from uterus
*Premature separation of placenta from uterus
# amount of external bleeding may not correlate with severity of abruption since bleeding may be concealed.
*Usually occurs spontaneously but also associated w/ trauma (even minor trauma)
# fetal death by hypoxia. can also cause fetal blood loss, maternal Rh sens, amniotic fluid embolism, DIC.
*Must be considered in pts who p/w painful vaginal bleeding near term
# 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.
# 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
# GRADE 1/ MILD- spotting with limited ut irritabillity- no organizedcontractions. Mat BP normal, fibrinogen normal at 450 mg/%, normalfetal heart rate.


==Risk Factors==
==Risk Factors==
# mat hypertension
#HTN
# eclampsia, preeclampsia
#Trauma
# h/o prev abruption
##Smoking
# ut distension from multiple gestations, hydramnios, tumors
#Advanced maternal age
# vascular dz- collagen vasc, DM, CRF
#Cocaine abuse
# smoking
#History of C-section or other uterine sx
# coccaine- increases BP
# microangiopathic hemolytic anemia
# premature rupture of membranes
# uterine blunt trauma- mva, domestic violence
# short umbilical cord
# advanced mat age,
# male fetal gender
# short umbilical cord


==Diagnosis==
==Diagnosis==
===Symptoms===
*Abruption may be complete, partial, or concealed
abd pain, ut contractions, vag bleeding.  possibly also mat hypoTN,tachycardia, ARDS, ATN, DIC- (bruising, hematuria)
**Amount of external bleeding may not correlate with severity
*Signs/Symptoms:
**Pain vaginal bleeding
**Severe uterine pain
**Uterine contractions
**Hypotension
**N/V
**Back pain


===Labs===
==Work-Up==
# Thrombomodulin (marker for endothelial cell damage) is elevated
#Type + Cross
# 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.
#CBC
# normal fibrinogen is 450, at 300 see spont bleeding at puncture sites, at 150- mother has already lost 2L
#DIC panel
# DIC panel- fibrinogen, platelets, pt/ptt, raised D- dimer- from fibrin degredation
#US
##Sp, not Sn
##Can r/o previa


===UTZ===
==Treatment==
# will still fail to detect 50% of cases
#Fluid resuscitation
# can measure gest age if mom unsure- if near term do crash c seciton.
#Tranfuse blood products (as needed)
# will see if hematoma is subchorionic, retroplacental or preplacental- will not change management other that to rule out placenta previa
#Emergent OB/GYN consult
##If unavailable consider C-section in ED


==Treatment==
==Complications==
# stable/ grade 1- admit for observation and elective delivery
#Maternal
# 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.
##Hemorrhagic shock
# xfuse saline, blood, ffp, platelets as needed.
##DIC
# emergent c section if near term. if preterm, use tocolytics- mag sulfate and terbutaline to prevent ut contractions and prevent labor
##Uterine rupture
##Multi-organ failure
#Neonatal
##Neurodevelopmental abnormalities
##Death
 
==Source==
Tintinalli


[[Category:OB/GYN]]
[[Category:OB/GYN]]

Revision as of 01:10, 25 August 2011

Background

  • Premature separation of placenta from uterus
  • Usually occurs spontaneously but also associated w/ trauma (even minor trauma)
  • Must be considered in pts who p/w painful vaginal bleeding near term

Risk Factors

  1. HTN
  2. Trauma
    1. Smoking
  3. Advanced maternal age
  4. Cocaine abuse
  5. History of C-section or other uterine sx

Diagnosis

  • Abruption may be complete, partial, or concealed
    • Amount of external bleeding may not correlate with severity
  • Signs/Symptoms:
    • Pain vaginal bleeding
    • Severe uterine pain
    • Uterine contractions
    • Hypotension
    • N/V
    • Back pain

Work-Up

  1. Type + Cross
  2. CBC
  3. DIC panel
  4. US
    1. Sp, not Sn
    2. Can r/o previa

Treatment

  1. Fluid resuscitation
  2. Tranfuse blood products (as needed)
  3. Emergent OB/GYN consult
    1. If unavailable consider C-section in ED

Complications

  1. Maternal
    1. Hemorrhagic shock
    2. DIC
    3. Uterine rupture
    4. Multi-organ failure
  2. Neonatal
    1. Neurodevelopmental abnormalities
    2. Death

Source

Tintinalli

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