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

Management of Placental Abruption

Establish large-bore IV access immediately, activate massive transfusion protocol without waiting for laboratory results if significant bleeding is present, and proceed to delivery based on maternal hemodynamic stability and fetal status. 1

Initial Stabilization and Assessment

Immediate resuscitation takes priority over diagnostic workup:

• Obtain two large-bore IV lines (18-gauge or larger) for rapid fluid and blood product administration 1
• Activate massive transfusion protocol early if significant bleeding is evident—do not wait for laboratory confirmation 1
• Maintain maternal temperature above 36°C as clotting factors function poorly at lower temperatures 1, 2
• Draw baseline labs: complete blood count, type and crossmatch for at least 4 units, coagulation panel, fibrinogen level, and platelet count 1, 2

Clinical diagnosis is paramount: Ultrasound has limited sensitivity for detecting abruption, though identification of retroplacental clot correlates with worse perinatal outcomes 3. Color or power Doppler showing an area contiguous with the placenta but without blood flow suggests acute clot 3. The diagnosis remains primarily clinical based on vaginal bleeding, abdominal pain, uterine contractions, and abnormal fetal heart rate patterns 4, 5.

Management Algorithm Based on Clinical Severity

Maternal Hemodynamic Instability or Uncontrolled Hemorrhage

Proceed to immediate delivery regardless of gestational age 1, 2:

• Cesarean delivery is indicated for maternal instability requiring rapid delivery or non-reassuring fetal heart rate patterns 1, 2
• Alert anesthesia team and consider general anesthesia 1
• Bring cell salvage technology to the operating room if available 1, 2
• Do not delay for laboratory results—clinical presentation drives management 1

Stable Maternal Status with Reassuring Fetal Status

At or near term (≥34 weeks):

• Conservative management with goal of vaginal delivery may be reasonable if both mother and fetus remain stable 6
• Continuous fetal monitoring is essential 6
• Maintain low threshold for expeditious cesarean delivery if deterioration occurs 6

Previable or extremely preterm gestations:

• Conservative management with close monitoring may be considered in selected stable cases 6, 7
• Counsel regarding pregnancy termination for maternal indications due to significant maternal morbidity and mortality risks 2
• Rapid delivery should occur if maternal or fetal deterioration develops 6

Hemorrhage Management Protocol

Transfusion strategy:

• Transfuse packed red blood cells, fresh frozen plasma, and platelets in fixed 1:1:1 ratio when massive transfusion is needed 1, 2
• Consider tranexamic acid administration to reduce blood loss 1, 2
• Monitor fibrinogen levels closely—declining levels indicate consumption despite normally elevated pregnancy values 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 8

Intraoperative Considerations

Surgical approach:

• If placenta accreta spectrum is encountered, leave placenta in situ—forced removal triggers profuse hemorrhage 1, 2
• Consider cesarean hysterectomy if hemorrhage is uncontrolled 1
• Alternative hemorrhage control techniques include uterine compression sutures, hypogastric artery ligation, pelvic packing, and interventional radiology embolization 1

Postoperative Management

Intensive monitoring is critical:

• Transfer to intensive care unit for severe cases given risks of ongoing bleeding, fluid overload, renal failure, liver failure, and disseminated intravascular coagulopathy 1, 2
• Maintain low threshold for reoperation if ongoing bleeding is suspected 1, 2
• Monitor volume status, urine output, blood loss, and hemodynamics closely 1

Transfer Considerations for Limited-Resource Settings

Do not delay transfer if local resources are inadequate:

• Stabilize with temporary measures: abdominal packing if needed, tranexamic acid infusion, and transfusion with locally available products 1, 2
• Arrange immediate transfer to tertiary care center with multidisciplinary expertise if patient is hemodynamically stable 2
• Do not proceed with surgery until circumstances are optimized—patience is critical 1

Common Pitfalls

Avoid these critical errors:

• Waiting for laboratory results before initiating transfusion protocols significantly increases maternal morbidity 1
• Attempting forced placental removal when accreta spectrum is encountered causes catastrophic hemorrhage 1, 2
• Delaying massive transfusion protocol activation in the setting of obvious significant bleeding 1
• Allowing maternal hypothermia, which impairs coagulation cascade function 1, 2