What is the management approach for abruptio placenta (placental abruption)?

Management of Placental Abruption (Abruptio Placentae)

Placental abruption requires immediate assessment of maternal hemodynamic stability and fetal status to determine whether urgent delivery is indicated, with the route and timing of delivery determined by gestational age, severity of bleeding, and maternal-fetal compromise. 1

Initial Assessment and Diagnosis

Clinical diagnosis is paramount—do not wait for ultrasound confirmation to act. 2 The classic presentation includes vaginal bleeding, abdominal pain, uterine contractions, and abnormal fetal heart rate patterns, though clinical manifestations vary widely. 1, 3

• Ultrasound has limited diagnostic value for placental abruption—the diagnosis is primarily clinical based on symptoms and physical examination findings. 2
• Obtain baseline laboratory studies immediately at bleeding onset: complete blood count with platelet count, prothrombin time, partial thromboplastin time, and fibrinogen levels (normally elevated in pregnancy). 4
• Perform continuous fetal heart rate monitoring to detect fetal compromise. 1
• Do not delay treatment waiting for laboratory results—manage based on clinical presentation initially. 4

Management Algorithm Based on Severity and Gestational Age

Severe Abruption with Maternal or Fetal Compromise (Any Gestational Age)

Proceed immediately to delivery, typically by cesarean section. 2, 1

• Severe abruption is defined by the presence of disseminated intravascular coagulation, hypovolemic shock, need for blood transfusion, nonreassuring fetal status, or fetal death. 5
• Activate massive transfusion protocol and prepare for potential coagulopathy. 1
• Transfuse packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 fixed ratio when managing acute hemorrhage. 4
• Maintain maternal temperature above 36°C, as clotting factors function poorly below this threshold. 4
• If estimated blood loss exceeds 1,500 mL, re-dose prophylactic antibiotics. 4

Abruption with Fetal Demise

Vaginal delivery is preferable when fetal death has occurred. 2

• Manage disseminated intravascular coagulopathy aggressively with blood component therapy. 2
• Monitor fibrinogen levels closely—transfuse cryoprecipitate if fibrinogen falls below 100 mg/dL. 4
• Maintain close hemodynamic monitoring and have a low threshold for intervention if maternal status deteriorates. 1

Abruption at Term or Near-Term (≥34 Weeks) with Stable Maternal-Fetal Status

Conservative management with goal of vaginal delivery may be reasonable if both mother and fetus remain stable with reassuring monitoring. 2, 1

• Continuous fetal heart rate monitoring is mandatory. 1
• Maintain intravenous access and have blood products immediately available. 1
• Proceed to cesarean delivery promptly if maternal hemodynamic instability develops or fetal status becomes nonreassuring. 2
• Nearly half of abruptions occur at term gestations, where neonatal outcomes are generally favorable with rapid intervention. 1

Abruption at Extremely Preterm Gestations (<34 Weeks) with Stable Status

Expectant management may be considered in highly selected stable cases with close monitoring. 2, 6

• This approach requires continuous maternal-fetal surveillance in a hospital setting. 6
• Deliver immediately if any maternal or fetal deterioration occurs. 2
• The risk-benefit calculation must weigh prematurity complications against ongoing abruption risks. 2

Hemorrhage Management Specifics

Blood Product Transfusion Thresholds

• Packed red blood cells: Transfuse for hematocrit <18% or <30% in unstable patients with active bleeding. 4
• Platelets: Transfuse for platelet count <50,000/mm³. 4
• Fresh frozen plasma: Transfuse for INR >2× normal or aPTT >1.5× normal. 4
• Cryoprecipitate: Transfuse for fibrinogen <100 mg/dL. 4

Massive Transfusion Protocol

• Transfuse in 1:1:1 ratio (packed RBCs:FFP:platelets) during active massive hemorrhage. 4
• Consider tranexamic acid to reduce blood loss. 7
• Avoid acidosis, which impairs coagulation cascade function. 4

Postoperative and Post-Delivery Monitoring

• Intensive care unit monitoring is often warranted given risks of ongoing bleeding, fluid overload from resuscitation, and potential multiorgan complications. 4
• Maintain vigilance for continued bleeding with a low threshold for reoperation if ongoing hemorrhage is suspected. 4, 7
• Monitor for complications including renal failure, infection, pulmonary edema, and disseminated intravascular coagulopathy. 4

Critical Pitfalls to Avoid

• Never delay delivery in cases of severe abruption with maternal or fetal compromise while attempting conservative management. 2, 1
• Do not rely on ultrasound to rule out abruption—clinical diagnosis takes precedence. 2
• Do not wait for laboratory results before initiating resuscitation and delivery planning in unstable patients. 4
• Abruption involving more than 50% of the placenta is frequently associated with fetal death and requires immediate intervention. 2
• Severe abruption carries a 4-fold increased risk of serious maternal complications compared to no abruption, with rate ratios of 2- to 7-fold higher for individual complications. 5

Risk Stratification

Abruption occurs in 0.6% to 1.2% of all pregnancies, with risk factors including prior abruption (strongest predictor), hypertension, preeclampsia, smoking, cocaine use, trauma, advanced maternal age, multifetal gestation, and thrombophilias. 2, 1 Most cases cannot be predicted or prevented, but outcomes can be optimized through rapid recognition and appropriate intervention. 2