Placental abruption

Background

1. premature separation of placenta from uterus
2. amount of external bleeding may not correlate with severity of abruption since bleeding may be concealed.
3. fetal death by hypoxia. can also cause fetal blood loss, maternal Rh sens, amniotic fluid embolism, DIC.
4. 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.
5. 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
6. GRADE 1/ MILD- spotting with limited ut irritabillity- no organizedcontractions. Mat BP normal, fibrinogen normal at 450 mg/%, normalfetal heart rate.

Risk Factors

1. mat hypertension
2. eclampsia, preeclampsia
3. h/o prev abruption
4. ut distension from multiple gestations, hydramnios, tumors
5. vascular dz- collagen vasc, DM, CRF
6. smoking
7. coccaine- increases BP
8. microangiopathic hemolytic anemia
9. premature rupture of membranes
10. uterine blunt trauma- mva, domestic violence
11. short umbilical cord
12. advanced mat age,
13. male fetal gender
14. short umbilical cord

Diagnosis

Symptoms

abd pain, ut contractions, vag bleeding. possibly also mat hypoTN,tachycardia, ARDS, ATN, DIC- (bruising, hematuria)

Labs

1. Thrombomodulin (marker for endothelial cell damage) is elevated
2. 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.
3. normal fibrinogen is 450, at 300 see spont bleeding at puncture sites, at 150- mother has already lost 2L
4. DIC panel- fibrinogen, platelets, pt/ptt, raised D- dimer- from fibrin degredation

UTZ

1. will still fail to detect 50% of cases
2. can measure gest age if mom unsure- if near term do crash c seciton.
3. will see if hematoma is subchorionic, retroplacental or preplacental- will not change management other that to rule out placenta previa

Treatment

1. stable/ grade 1- admit for observation and elective delivery
2. 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.
3. xfuse saline, blood, ffp, platelets as needed.
4. emergent c section if near term. if preterm, use tocolytics- mag sulfate and terbutaline to prevent ut contractions and prevent labor

[[Category:OB/GYN