Signs and Symptoms
History
- 20+ wk of pregnancy
- Vaginal bleeding (>80%, usually painful)
- Abdominal or back pain (>50%)
- Uterine cramps, tenderness, frequent contractions, or tetany
- Nausea, vomiting
- Otherwise unexplained preterm labor
- History of recent trauma
- Smoking history
- Recent drug use, particularly cocaine or other sympathomimetics
- Prior abruption or other risk factors
- Gestational hypertension
- Estimated gestational age
- Prenatal care history
Physical Exam
- Signs of shock may be present
- Uterine tenderness frequently present
- Vaginal bleeding (absent in 20-25%)
- Petechiae, bleeding, and other signs of DIC
- Decreased fetal heart tones and movement
- Fetal bradycardia or nonreassuring fetal heart rate tracings
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- Sterile vaginal exam must be performed with caution to avoid tissue injury, especially if placenta previa suspected:
- Assess for presence of amniotic fluid (nitrazine paper turns blue; ferning of fluid on glass slide)
- Evaluate for vaginal or cervical lacerations
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Essential Workup
- Large-bore IV access
- Blood type, Rh, and cross-match
- Rapid hemoglobin determination
- Determine fetal heart tones by Doppler
- Fetal monitoring to detect signs of early fetal distress
- Uterine tocographic monitoring
Diagnostic Tests & Interpretation
Diagnosis is primarily clinical, supportive tests include:
Lab
- Blood type and Rh
- CBC
- PT/PTT
- Fibrinogen levels (normally 450 in latter half of pregnancy) and fibrin split products
- Fibrinogen <200 mg/dL and platelets <100,000/μL highly suggestive of abruption
- Kleihauer-Betke if mother is Rh-negative (significant fetal-to-maternal hemorrhage more likely in traumatic abruption)
Imaging
- US demonstrates evidence of abruption in only 50% of cases (false-negative common)
- MRI is more sensitive than US but remains infrequently used due to feasibility, cost, and low likelihood of changing management plan
- If abdomen/pelvis CT scan done as part of maternal trauma evaluation, evidence of abruption may be visible (must ask the radiologist to evaluate specifically)
Differential Diagnosis
- Placenta previa
- Vasa previa
- Bleeding during labor
- Vaginal or cervical lacerations
- Uterine rupture
- Preterm labor
- Ovarian torsion
- Pyelonephritis
- Cholelithiasis/cholecystitis
- Appendicitis
- Other blunt intra-abdominal or pelvic injuries
Prehospital
- Patients with abruption may be in shock and need full resuscitative measures
- Transport in the left lateral recumbent position
Initial Stabilization/Therapy
- Airway, breathing, circulation (ABCs), oxygen
- Cardiac monitor
- Placement of large-bore IVs
- IV crystalloid resuscitation
ED Treatment/Procedures
- Maternal cardiac and tocographic monitoring
- Continuous fetal monitoring
- Transfuse PRBCs, fresh frozen plasma (FFP), cryoprecipitate, and platelets as indicated (may require massive transfusion protocol)
- Immediate OB/GYN consultation
- Foley catheter for close monitoring of urine output
- Tocolysis is generally contraindicated
- If abruption is suspected in the setting of trauma, maternal stabilization is of primary importance:
- All indicated radiographs should be performed as needed
Medication
First Line
- Rh-immunoglobulin in Rh-negative women:
- 300 mcg IM in women at ≥12 wk gestation
- Higher doses if indicated by results of Kleihauer-Betke test
- Blood products as indicated
Second Line
Consider with obstetrician recommendation:
- Magnesium sulfate if high risk of preterm birth for fetal neuroprotection
- Steroids for fetal lung maturation if gestational age between 24-34 wk
- Delivery of fetus depending on stability of fetus, stability of mother, and gestational age
Disposition
Admission Criteria
- Patients with placental abruption must be admitted for maternal and fetal monitoring
- Admit to ICU if DIC, amniotic fluid embolism, or significant hemorrhage (known or suspected)
- Victims of multiple trauma with abruption should be admitted and managed in accordance with trauma protocols
- Transportation to higher trauma or obstetric level of care is appropriate if the patient is stable for transfer or appropriate care unavailable at existing facility
Discharge Criteria
- Trauma patients with no evidence of abruption or other significant injury may be discharged after 4-6 hr of normal maternal and fetal monitoring
- Discharge instructions include pelvic rest, no intercourse, no heavy lifting, no prolonged stand ing
- Discharge decision should be made in consultation with OB/GYN and include close follow-up
Issues for Referral
All cases of confirmed or suspected abruption require immediate obstetric consultation
- AnanthCV, KinzlerWL. Placental abruption: Clinical features and diagnosis . UpToDate. 2017.www.uptodate.com. Accessed October 29, 2017.
- ChisholmA, PeiserBS. Placental abruption. EBSCO Information Services, Ipswich, MA: Dynamed; 2016. www.dynamed.com. Accessed October 29, 2017.
- CreangaAA, BergCJ, SyversonC, et al. Pregnancy-related mortality in the United States, 2006-2010 . Obstet Gynecol. 2015;125(1):5-12.
- KopelmanTR, BerardoniNE, ManriquezM, et al. The ability of computed tomography to diagnose placental abruption in the trauma patient . J Trauma Acute Care Surg. 2013;74:236-241.
- OyeleseY, AnanthCV. Placental abruption: Management . UpToDate. 2018. www.uptodate.com/contents/placental-abruption-management.
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