SUPERStudy: Placental Abruption 

By usmlevideoss

Introduction: Placental abruption, or abruptio placentae, is a serious obstetric condition in which the placenta partially or completely detaches from the uterine wall before delivery, typically after 20 weeks of gestation. This separation can compromise the exchange of oxygen and nutrients between the mother and fetus, posing significant risks to both.

Risk Factors for Placental Abruption: prior abruption, increased age and parity, preeclampsia, chronic hypertension, chorioamnionitis, preterm ruptured membranes, multifetal gestation, low birthweight, hydramnios, cigarette smoking, single umbilical artery, cocaine use, uterine leiomyoma, subchorionic hematoma, and abdominal injury, such as from a car accident or fall.

Epidemiology: 1 in 150 pregnancies 

Pathogenesis: The pathogenesis of placental abruption involves the premature separation of the placenta from the uterine wall, typically initiated by bleeding into the decidua basalis. This hemorrhage disrupts the attachment between the placenta and uterus, leading to the formation of a retroplacental hematoma. The hematoma expands, exacerbating the separation and further disrupting maternal-fetal circulation. The separation impairs oxygen and nutrient transfer to the fetus and can trigger maternal hemodynamic instability, contributing to the clinical complications of placental abruption. Excess amounts of thromboplastin escape into the maternal circulation and defibrination occurs. Profound coagulopathy and acute hypovolemia from blood loss can occur in the mother, especially when the abruption is severe enough to kill the fetus. 

Clinical Manifestations 

  • Vaginal bleeding (may be absent in concealed abruption)
  • Severe abdominal pain or back pain
  • Uterine tenderness or rigidity
  • Frequent uterine contractions 
  • Signs of fetal distress or decreased fetal movement
  • Hypotension or shock in severe cases

Complications

For the mother, placental abruption can cause significant blood loss, disseminated intravascular coagulation (DIC), acute respiratory distress syndrome or even maternal shock. For the fetus, it increases the risk of preterm birth, growth restriction, hypoxia, or stillbirth.

Diagnosis 

Clinical history and physical examination 

Ultrasound: separation of the placenta from the endometrium, with hemorrhage into the subplacental space (between the uterus and the placenta).

Tocometry: increased uterine contractility and signs of fetal distress.

Treatment 

Placental abruption is an obstetrical emergency, and timely intervention is critical to minimize adverse outcomes.

Treatment depends on the severity of the abruption and gestational age. 

Mild cases may be managed conservatively with close monitoring

Severe cases:  Key Steps in Management:

1.Maternal Stabilization

Airway, Breathing, Circulation (ABC): Ensure airway patency and provide oxygen to optimize maternal and fetal oxygenation. Monitor vital signs continuously.

Fluid Resuscitation: Administer intravenous (IV) fluids to restore intravascular volume and maintain hemodynamic stability. Use isotonic crystalloids (e.g., normal saline, lactated Ringer’s).

Blood Products:

  • Transfuse packed red blood cells (PRBCs) to maintain hemoglobin >7–8 g/dL.
  • Administer fresh frozen plasma (FFP) to correct coagulation factor deficiencies.
  • Provide platelets if the count falls below 50,000/μL, especially if surgery is planned.
  • Administer cryoprecipitate if fibrinogen levels are <100–150 mg/dL.

2.Immediate Delivery

  • Delivery is essential to stop the source of bleeding (placental abruption) and manage DIC effectively.
    • Cesarean section: Preferred if there is fetal distress or the cervix is not favorable for vaginal delivery.
    • Vaginal delivery: May be attempted if the fetus is already demised or the cervix is favorable, and the mother is stable.

3.Address Coagulopathy

  • Treat the DIC by:
    • Replenishing depleted clotting factors and fibrinogen with blood products.
    • Monitoring and maintaining adequate platelet count, fibrinogen levels (>200 mg/dL), and correcting coagulopathy.

SUPERPoint:

Placental abruption is a life-threatening obstetric emergency characterized by the premature separation of the placenta from the uterine wall, leading to vaginal bleeding, severe abdominal pain, uterine tenderness, and fetal distress. Risk factors include hypertension, trauma, smoking, and cocaine use, with immediate management focusing on maternal stabilization and delivery if indicated.

 

SUPERFormula:

Pregnant female with abrupt vaginal bleeding + abdominal pain or back pain + uterine tenderness + retroplacental hematoma on ultrasound = Placental Abruption