From the Guidelines
Placental abruption is a medical emergency that requires immediate delivery, and women with a history of this condition are at increased risk of future cardiovascular disease-related morbidity and mortality. The symptoms of placental abruption include vaginal bleeding, abdominal pain, uterine tenderness, and contractions, with the bleeding being concealed or visible in approximately 80% of cases 1. Patients often experience sudden-onset, severe abdominal pain that may be constant or accompanied by uterine contractions. The uterus typically feels firm and tender on examination. Other symptoms include fetal distress, maternal hypotension, and signs of hypovolemic shock in severe cases.
Key Considerations
- Risk factors for placental abruption include hypertension, trauma, previous abruption, advanced maternal age, smoking, cocaine use, and multiple gestations.
- The severity of symptoms correlates with the extent of placental separation, with complete abruption being a medical emergency requiring immediate delivery.
- Diagnosis is primarily clinical, supported by ultrasound findings, though ultrasound may miss up to 50% of abruptions.
- Laboratory findings may show anemia, coagulopathy, and elevated D-dimer levels in severe cases.
- Any pregnant woman presenting with vaginal bleeding and abdominal pain should be promptly evaluated for placental abruption, as prompt assessment and risk factor management beyond the postpartum period are crucial to reduce the risk of future cardiovascular disease-related morbidity and mortality 1.
From the Research
Definition and Incidence of Placental Abruption
- Placental abruption is the premature separation of the placenta from its uterine attachment before the delivery of a fetus 2.
- It complicates about 1% of pregnancies and is a leading cause of vaginal bleeding in the latter half of pregnancy 3.
- The incidence of placental abruption is estimated to be around 0.4% to 1.2% of all pregnancies 2, 4.
Risk Factors for Placental Abruption
- Risk factors for abruption include prior abruption, smoking, trauma, cocaine use, multifetal gestation, hypertension, preeclampsia, thrombophilias, advanced maternal age, preterm premature rupture of the membranes, intrauterine infections, and hydramnios 3, 5.
- Maternal hypertensive disorders, maternal tobacco and cocaine use, age and parity, multiple gestations, maternal thrombophilias, and an unexplained elevated maternal serum alphafetoprotein are also associated with an increased risk of abruption 5.
Diagnosis and Management of Placental Abruption
- The diagnosis of abruption is a clinical one, and ultrasonography and the Kleihauer-Betke test are of limited value 3.
- The management of abruption should be individualized on a case-by-case basis depending on the severity of the abruption and the gestational age at which it occurs 3.
- In cases where fetal demise has occurred, vaginal delivery is preferable, and disseminated intravascular coagulopathy should be managed aggressively 3.
- A management algorithm for acute abruption that incorporates blood loss, vital signs, and urine output, among other factors, has been proposed 2.
Complications and Outcomes of Placental Abruption
- Placental abruption is an important cause of perinatal mortality and morbidity, and the maternal effect of abruption depends primarily on its severity, whereas its effect on the fetus is determined both by its severity and the gestational age at which it occurs 3.
- Abruption involving more than 50% of the placenta is frequently associated with fetal death 3.
- Traumatic placental abruptions, such as those resulting from blunt abdominal trauma, can have severe consequences for both the mother and fetus, including fetal demise 6.