What is the management for placental abruption (abruption) at 28 weeks and 5 days gestation?

Management of Placental Abruption at 28 Weeks and 5 Days

Immediate delivery is indicated for placental abruption at 28 weeks and 5 days due to the significant risks of maternal hemorrhage, coagulopathy, and fetal compromise.

Initial Assessment and Stabilization

• Establish maternal hemodynamic status:

  • Continuous monitoring of vital signs
  • Assess severity of bleeding (visible and concealed)
  • Evaluate for signs of shock or coagulopathy

• Establish two large-bore IV access lines and send blood samples for:

  • Complete blood count
  • Coagulation profile (PT, PTT, fibrinogen)
  • Type and cross-match for potential transfusion 1

• Fetal assessment:

  • Continuous electronic fetal monitoring
  • Ultrasound evaluation to assess:
    • Extent of abruption
    • Fetal viability and heart rate
    • Estimated fetal weight

Management Algorithm

For Stable Mother and Viable Fetus with Reassuring Status:

1. Administer antenatal corticosteroids for fetal lung maturation 2, 1

   • Complete course if time permits, but do not delay delivery if maternal or fetal condition deteriorates

2. Administer magnesium sulfate for fetal neuroprotection 2

   • Indicated at this gestational age (28+5 weeks) when delivery is anticipated

3. Prepare for delivery:

   • Alert multidisciplinary team including:
     • Maternal-fetal medicine
     • Neonatology
     • Anesthesiology
     • Blood bank 1

4. Mode of delivery:

   • Cesarean delivery is typically indicated for significant abruption at this gestational age
   • Vaginal delivery may be considered only if:
     • Abruption is mild
     • Mother is stable
     • Fetal status is reassuring
     • Labor is progressing rapidly 3

For Unstable Mother or Non-Reassuring Fetal Status:

1. Immediate cesarean delivery

   • Do not delay for completion of steroid course
   • Prepare for potential massive transfusion

2. Blood product management:

   • Initiate massive transfusion protocol if needed
   • Transfuse packed red blood cells, fresh frozen plasma, and platelets in a fixed ratio
   • Monitor for and aggressively treat disseminated intravascular coagulation (DIC) 2, 4

3. Defer cord clamping for at least 30 seconds if neonatal condition permits 2

   • For infants 28-33+6 weeks, intact cord milking is a reasonable alternative if immediate resuscitation is not needed

Special Considerations

• Coagulopathy management:

  • Closely monitor fibrinogen levels (target >200 mg/dL)
  • Consider cryoprecipitate if fibrinogen remains low despite FFP
  • Consider tranexamic acid for ongoing hemorrhage 4

• Postpartum monitoring:

  • Continue close hemodynamic monitoring for at least 24 hours
  • Maintain vigilance for delayed hemorrhage
  • Monitor for signs of end-organ damage (renal failure, respiratory distress) 2

Common Pitfalls to Avoid

1. Underestimating blood loss:

   • Concealed hemorrhage can be substantial
   • Clinical signs may lag behind actual volume depletion

2. Delayed delivery:

   • Attempting prolonged conservative management at this gestational age with significant abruption increases maternal and fetal risks 3, 5

3. Inadequate blood product preparation:

   • Ensure adequate blood products are available before proceeding with delivery
   • Communicate early with blood bank 1

4. Failure to recognize DIC:

   • Monitor coagulation parameters frequently
   • Treat aggressively to prevent progression to multi-organ failure 4

Follow-up Care

• Postpartum thromboprophylaxis assessment
• Evaluation for underlying causes of abruption (hypertension, thrombophilias)
• Psychological support for trauma of emergent delivery and preterm birth
• Counseling regarding recurrence risk in future pregnancies (5-15%) 6