Intraoperative Management of Revealed Placental Abruption
When placental abruption is revealed intraoperatively, immediate implementation of a systematic hemorrhage management protocol is essential, including rapid mobilization of blood products in a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets, while simultaneously proceeding with definitive surgical management. 1
Initial Recognition and Resource Mobilization
- Immediately alert the anesthesia team and consider conversion to general anesthesia if not already in place 2
- Establish additional large-bore intravenous access for rapid fluid and blood product administration 1, 2
- Activate massive transfusion protocol early rather than waiting for laboratory results 1, 2
- Order blood products and consider cell salvage technology if available 1, 2
- Alert critical care personnel and notify blood bank of potential ongoing needs 1, 2
Hemorrhage Management
- Transfuse blood products in a fixed ratio (1:1:1 to 1:2:4) of packed red blood cells:fresh frozen plasma:platelets 1, 3
- Consider administration of tranexamic acid to reduce blood loss 1, 2
- Maintain patient temperature above 36°C as clotting factors function poorly at lower temperatures 4
- Monitor for development of disseminated intravascular coagulation (DIC) 1, 5
- Assess ongoing blood loss clinically rather than waiting for laboratory results 1
Surgical Management
- If placental abruption is accompanied by placenta accreta spectrum, avoid attempts at forced placental removal which can trigger profuse hemorrhage 1, 4
- For cases with extensive placental involvement and ongoing hemorrhage, proceed with hysterectomy as judiciously as possible 1, 3
- For focal placental adherence, consider removal of the placenta followed by repair of the resulting defect 1
- In stable patients with focal adherence, consider conservative management with placental removal and Bakri balloon insertion 3
- Inspect for and repair any uterine rupture that may accompany the abruption 6
Multidisciplinary Approach
- If the center lacks appropriate resources for definitive management, consider stabilization and transfer (if patient is stable) 1, 2
- For complex cases involving bladder invasion, consider ureteric stent placement and urologic surgery consultation 4
- Mobilize appropriate resources concurrently with ongoing surgical management 1
Immediate Postoperative Considerations
- Plan for intensive hemodynamic monitoring in the early postoperative period, preferably in an ICU setting 1
- Maintain vigilance for ongoing bleeding with a low threshold for reoperation if suspected 1
- Monitor for complications including renal failure, liver failure, infection, pulmonary edema, and DIC 1, 5
- Be alert for signs of Sheehan syndrome (postpartum pituitary necrosis) in cases with significant hypoperfusion 1, 2
Common Pitfalls and Caveats
- Delaying activation of massive transfusion protocol can worsen outcomes; initiate early 1, 2
- Attempting forced placental removal when placenta accreta is present can lead to catastrophic hemorrhage 1, 4
- Failure to recognize concurrent uterine rupture can result in uncontrolled bleeding 6
- Underestimating blood loss can lead to inadequate resuscitation; use objective measures when possible 7
- Inadequate surgical expertise may worsen outcomes; pause the case to mobilize appropriate expertise if needed 1