Management of Placental Abruption
Placental abruption requires immediate evaluation and management at a level III or IV maternal care center with a comprehensive multidisciplinary team to optimize maternal and fetal outcomes. 1
Clinical Presentation and Diagnosis
- Placental abruption is the premature separation of the placenta from the uterine wall before delivery of the fetus
- Classic presentation includes:
- Vaginal bleeding (may be absent in concealed abruption)
- Abdominal pain
- Uterine contractions/tetany
- Abnormal fetal heart rate patterns
- Diagnosis is primarily clinical, with ultrasound having limited sensitivity 2, 3
- Severity assessment should consider:
- Maternal hemodynamic stability
- Amount of blood loss
- Coagulation status
- Fetal condition
Initial Management
Maternal stabilization:
- Establish two large-bore IV access
- Fluid resuscitation
- Blood typing and cross-matching
- Complete blood count, coagulation studies
- Continuous maternal vital sign monitoring
Fetal assessment:
- Continuous electronic fetal monitoring
- Ultrasound for fetal viability and estimated gestational age
Activate multidisciplinary team:
- Maternal-fetal medicine specialist
- Anesthesiologist
- Blood bank personnel
- Neonatologist
Management Algorithm Based on Clinical Presentation
Severe Abruption with Maternal/Fetal Compromise:
- Immediate delivery regardless of gestational age 3
- Cesarean delivery if:
- Fetal distress with viable fetus
- Severe maternal hemorrhage
- Hemodynamic instability
- Coagulopathy
Moderate Abruption with Stable Maternal/Fetal Status:
- At term (≥37 weeks): Proceed with delivery
- Near-term (34-36 weeks): Delivery after corticosteroid administration if time permits
- Preterm (<34 weeks) with stable condition: Consider conservative management with:
- Hospitalization
- Corticosteroids for fetal lung maturity
- Close maternal and fetal monitoring
- Delivery for worsening maternal or fetal status
Abruption with Fetal Demise:
- Vaginal delivery is preferred unless maternal instability requires immediate intervention 2
- Aggressive management of coagulopathy
- Monitor for and treat disseminated intravascular coagulation (DIC)
Blood Component Therapy
- Implement massive transfusion protocol with ratio of 1:1:1 to 1:2:4 (packed red cells:fresh frozen plasma:platelets) 1
- Monitor and maintain fibrinogen levels >200 mg/dL
- Consider tranexamic acid (1g IV) within 3 hours of delivery, repeated after 30 minutes if bleeding persists 1
- Utilize cell salvage if available
Management of Complications
Disseminated Intravascular Coagulation (DIC):
- Aggressive replacement of blood products
- Fresh frozen plasma for coagulation factors
- Cryoprecipitate for fibrinogen replacement
- Platelet transfusion if <50,000/μL
Postpartum Hemorrhage:
- Uterotonic agents (oxytocin, methylergonovine, carboprost)
- Intrauterine balloon tamponade
- Surgical interventions if needed (B-Lynch suture, uterine artery ligation)
- Hysterectomy for refractory bleeding
Postpartum Care
- Close monitoring for ongoing bleeding
- Serial hemoglobin/hematocrit measurements
- Vigilance for complications:
- Renal failure
- Sheehan syndrome
- Infection
- Thromboembolism
Prevention in Future Pregnancies
- Smoking cessation
- Control of hypertensive disorders
- Avoidance of cocaine and other substances
- Close monitoring in subsequent pregnancies due to 5-15% recurrence risk 2
Common Pitfalls and Caveats
- Concealed abruption: May present without vaginal bleeding but with abdominal pain and fetal distress
- Underestimation of blood loss: Clinical estimation often underestimates actual blood loss
- Delayed recognition of coagulopathy: Serial coagulation studies are essential
- Failure to prepare for massive transfusion: Early activation of massive transfusion protocol is critical
- Conservative management risks: Close monitoring is essential as rapid deterioration can occur