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 Stabilization and Assessment
Establish large-bore intravenous access immediately and activate massive transfusion protocol without waiting for laboratory confirmation if significant bleeding is present. 1 This approach is critical because waiting for laboratory results before initiating transfusion significantly increases maternal morbidity. 1
Obtain baseline laboratory studies including complete blood count, type and crossmatch, coagulation panel, and platelet count, but do not delay treatment for results. 1 Monitor fibrinogen levels closely, as declining levels indicate consumption (normal pregnancy levels are elevated, so "normal" values may actually represent depletion). 1
Maintain maternal temperature above 36°C as clotting factors function poorly at lower temperatures. 1, 2
Delivery Decision Algorithm
Immediate Cesarean Delivery Indicated:
- Maternal hemodynamic instability (proceed regardless of gestational age) 1
- Fetal compromise on heart rate tracing 1
- Massive hemorrhage requiring rapid delivery 1
Vaginal Delivery May Be Attempted:
- Abruption at or near term with reassuring maternal and fetal status 1
- Fetal demise has occurred (vaginal delivery is preferable) 3
- Stable maternal hemodynamics with continuous monitoring 4
Conservative Management (Rare, Highly Selected Cases):
- Extreme prematurity (<28 weeks) with stable maternal hemodynamics 5
- Stable fetal status on continuous monitoring 5
- Less than 50% placental involvement 3
- Caveat: This approach carries significant risk and requires intensive monitoring with immediate delivery capability, as abruption involving more than 50% of the placenta is frequently associated with fetal death. 3
Hemorrhage Management Protocol
Transfuse blood products in a fixed 1:1:1 ratio (packed red blood cells:fresh frozen plasma:platelets) when massive transfusion is needed. 1, 2 Some protocols use 1:1:1 to 1:2:4 ratios. 2
Administer tranexamic acid to reduce blood loss. 1, 2
Alert the anesthesia team and consider general anesthesia for rapid delivery. 1
Bring cell salvage technology to the operating room if available. 1
Critical Intraoperative Considerations
If placenta accreta spectrum is encountered, do not attempt forced placental removal as this triggers profuse hemorrhage. 2, 6 Leave the placenta in situ and proceed with cesarean hysterectomy if hemorrhage is uncontrolled. 1, 6
If surgical expertise is inadequate, pause the case temporarily until optimal surgical experience arrives rather than proceeding with suboptimal conditions. 1, 2
Surgical hemorrhage control techniques to attempt before hysterectomy include uterine compression sutures, hypogastric artery ligation, pelvic packing, and interventional radiology embolization. 1
Postoperative Management
Transfer to intensive care unit for severe abruption 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 closely: volume status, urine output, blood loss, and hemodynamics continuously in the early postoperative period. 1, 6
Resource-Limited Settings
In centers with limited resources, consider stabilization with temporary measures (abdominal packing, tranexamic acid infusion, transfusion with locally available products) and immediate transfer to a tertiary care center if the patient is stable. 1, 2 Do not delay transfer if local resources are inadequate. 1
Common Pitfalls to Avoid
Delaying massive transfusion protocol activation worsens outcomes—initiate early based on clinical presentation, not laboratory values. 1, 2
Attempting forced placental removal when accreta is present leads to catastrophic hemorrhage. 2, 6
Proceeding with inadequate surgical expertise may worsen outcomes—mobilize appropriate resources or transfer. 2