Placental abruption: Difference between revisions

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==Background==
==Background==
[[File:2910 The Placenta-02.jpg|thumb|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===
*[[Hypertension]]- Most common
*[[Trauma]]
*Smoking
*Advanced maternal age <ref>Rosen's</ref>
*Multiparity
*[[Preeclampsia]]
*Prior placental abruption
*Thrombophilia
*[[Cocaine]] abuse
*History of C-section or other uterine symptoms


- premature separation of placenta from uterus
==Clinical Features==
*Painful [[vaginal bleeding]] (may be absent if retro-placental)
**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


- amount of external bleeding may not correlate with severity of
==Differential Diagnosis==
{{Abdominal Pain Pregnancy DDX}}


abruption since bleeding may be concealed.
==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


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


sens, amniotic fluid embolism, DIC.
==Complications==
===Maternal===
*[[Hemorrhagic shock]]
*[[DIC]]
*[[Uterine rupture]]
*Multi-organ failure


-GRADE 3/ COMPLETE- mod to severe bleeding with painful tetanic
===Neonatal===
*Neurodevelopmental abnormalities
*Death: 67 to 75% rate of fetal mortality


uterine contractions.  maternal hypotension and tachycardia.  DIC with
==See Also==
*[[Vaginal Bleeding (Main)]]
*[[Trauma in pregnancy]]


fibrinogen levels less than 150 mg/%, representing a blood loss of 2L.
==References==
<references/>


Maternal coagulopathy with thrombocytopenia, clooting factor,
[[Category:OBGYN]]
 
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
 
 
 
 
 
[[Category:OB/GYN]]

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