Placental abruption

Background

- premature separation of placenta from uterus

- amount of external bleeding may not correlate with severity of

abruption since bleeding may be concealed.

- fetal death by hypoxia. can also cause fetal blood loss, maternal Rh

sens, amniotic fluid embolism, DIC.

-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 organized

contractions. Mat BP normal, fibrinogen normal at 450 mg/%, normal

fetal heart rate.

Risk Factors

- mat hypertension

- eclampsia, preeclampsia

- h/o prev abruption

- ut distension from multiple gestations, hydramnios, tumors

- vascular dz- collagen vasc, DM, CRF

- smoking

- 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

SYMPTOMS

- abd pain, ut contractions, vag bleeding. possibly also mat hypoTN,

tachycardia, ARDS, ATN, DIC- (bruising, hematuria)

LABS

- Thrombomodulin (marker for endothelial cell damage) is elevated

- 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

- will still fail to detect 50% of cases

- can measure gest age if mom unsure- if near term do crash c seciton.

- will see if hematoma is subchorionic, retroplacental or

preplacental- will not change management other that to rule out

placenta previa

Treatment

- stable/ grade 1- admit for observation and elective delivery

- 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.

- xfuse saline, blood, ffp, platelets as needed.

- emergent c section if near term. if preterm, use tocolytics- mag

sulfate and terbutaline to prevent ut contractions and prevent labor