Management of Placental Abruption
Immediate delivery is indicated for placental abruption with maternal hemodynamic instability or fetal compromise, regardless of gestational age, with concurrent activation of massive transfusion protocol before laboratory results return. 1
Initial Resuscitation and Stabilization
Establish large-bore intravenous access immediately for rapid fluid and blood product administration upon suspicion of placental abruption. 1 The priority is clinical stabilization, not waiting for diagnostic confirmation.
Activate massive transfusion protocol early without waiting for laboratory results if significant bleeding is present. 1, 2 This is a critical decision point—delaying activation worsens outcomes. 2
Essential Laboratory Studies
Obtain baseline studies immediately, including:
- Complete blood count with platelet count
- Type and crossmatch for at least 4-6 units
- Coagulation panel (PT, PTT)
- Fibrinogen levels (normally elevated in pregnancy; declining levels indicate consumption) 1
Do not delay treatment waiting for these results—treat based on clinical presentation initially. 3
Temperature and Metabolic Management
Maintain maternal temperature above 36°C as clotting factors function poorly at lower temperatures. 1, 2 This is a commonly overlooked but critical intervention. Avoid acidosis as well. 3
Delivery Decision Algorithm
Immediate Delivery Indications (Regardless of Gestational Age)
Proceed to immediate delivery when any of the following are present:
- Maternal hemodynamic instability (hypotension, tachycardia, signs of shock) 1
- Fetal compromise (non-reassuring fetal heart rate tracing) 4
- Maternal disseminated intravascular coagulation 4
- Ongoing significant hemorrhage 1
Cesarean delivery is the route of choice for fetal compromise or maternal instability requiring rapid delivery. 1
Conservative Management (Rare, Selected Cases Only)
Conservative management may be considered only in extremely preterm gestations (<28 weeks) when all of the following criteria are met:
- Maternal hemodynamic stability maintained
- Fetal well-being reassuring on continuous monitoring
- No evidence of coagulopathy
- Ability to perform emergency cesarean within minutes 5, 6
This approach carries substantial risk and requires intensive monitoring in a tertiary care facility. 5 Most cases will ultimately require delivery within days to weeks. 5
Hemorrhage Management Protocol
Transfusion Strategy
Transfuse in a fixed 1:1:1 ratio of packed red blood cells:fresh frozen plasma:platelets when massive transfusion is needed. 1, 2 Do not wait for laboratory-guided transfusion in acute hemorrhage—use the protocol-driven approach. 3
Consider tranexamic acid administration to reduce blood loss, particularly if given within 3 hours of bleeding onset. 1, 2
Monitor fibrinogen levels closely as they are normally elevated in pregnancy (400-600 mg/dL), and declining levels indicate consumption coagulopathy. 1 Fibrinogen <200 mg/dL requires aggressive replacement with cryoprecipitate or fibrinogen concentrate.
Antibiotic Redosing
Re-dose prophylactic antibiotics if estimated blood loss exceeds 1,500 mL to maintain adequate tissue levels during prolonged surgery. 3
Intraoperative Considerations
Unexpected Placenta Accreta Spectrum
If placenta accreta spectrum is encountered during delivery for abruption (rare but possible):
- Leave the placenta in situ—do not attempt forced removal 2
- Avoid attempts at manual placental removal which can trigger catastrophic hemorrhage 2
- Proceed with cesarean hysterectomy if hemorrhage is uncontrolled 1, 2
Surgical Hemorrhage Control Techniques
If bleeding continues after delivery, employ the following in sequence:
- Uterine compression sutures (B-Lynch, Cho)
- Uterine artery ligation
- Hypogastric artery ligation
- Pelvic packing
- Interventional radiology embolization (if patient stable enough for transfer) 1
Maintain a low threshold for hysterectomy in uncontrolled hemorrhage—do not delay definitive surgery attempting multiple temporizing measures. 2
Postoperative Management
Intensive care unit monitoring is mandatory for severe abruption cases given risks of:
- Ongoing bleeding
- Fluid overload from massive resuscitation
- Acute renal failure
- Acute respiratory distress syndrome
- Sheehan syndrome (postpartum pituitary necrosis) 3, 1, 2
Maintain a low threshold for reoperation if ongoing bleeding is suspected—clinical deterioration, increasing abdominal distension, or persistent transfusion requirements warrant immediate re-exploration. 1, 2
Vigilance for Complications
Monitor closely for:
- Unrecognized ureteral, bladder, or bowel injury
- Disseminated intravascular coagulation
- Renal failure
- Liver dysfunction
- Pulmonary edema 3
Common Pitfalls to Avoid
Delaying massive transfusion protocol activation is the most common error—activate early based on clinical suspicion, not laboratory confirmation. 2
Attempting vaginal delivery in unstable patients or those with fetal compromise wastes critical time—proceed directly to cesarean delivery. 1
Inadequate surgical expertise worsens outcomes—if the facility lacks appropriate resources, pause the case to mobilize expertise or consider stabilization and transfer if the patient is stable enough. 2 However, most patients with severe abruption are too unstable for transfer and require immediate intervention at the presenting facility. 2
Forced placental removal when abnormal placentation is present leads to catastrophic hemorrhage—if the placenta does not separate easily, leave it in situ and proceed with hysterectomy. 2