In a patient with placental abruption, which statement is true regarding management?

Management of Placental Abruption: Key Clinical Truths

Direct Answer to the Question

Vital signs should be checked to assess for circulatory stability (option b) is the correct statement. 1 Establishing hemodynamic status is the immediate priority in placental abruption, as maternal instability dictates the urgency and mode of delivery.

Why the Other Options Are Incorrect

Option A: Ultrasound Dependency (FALSE)

• The diagnosis of placental abruption is fundamentally clinical, not ultrasound-dependent 2, 3
• Ultrasound has limited diagnostic value for abruption—clinical presentation (vaginal bleeding, abdominal pain, uterine contractions) drives the diagnosis 2, 4
• Sonographic findings may be absent even in severe cases, making clinical assessment paramount 2

Option C: Amniotomy Contraindication (FALSE)

• Amniotomy is not contraindicated in placental abruption management
• In fact, when vaginal delivery is pursued (particularly in cases of fetal demise), amniotomy may facilitate delivery 2
• The key is matching delivery route to maternal stability and fetal status, not avoiding specific interventions 1

Option D: Emergency Cesarean for Fetal Demise (FALSE)

• When fetal demise has occurred, vaginal delivery is actually preferable 2, 4
• The American College of Obstetricians and Gynecologists recommends aggressive resuscitation with expeditious vaginal delivery as the goal when the fetus is dead 4
• Cesarean delivery in the setting of fetal demise exposes the mother to unnecessary surgical risks without fetal benefit 2
• Emergency cesarean is reserved for maternal hemodynamic instability requiring rapid delivery, not simply because of fetal death 1

The Correct Approach: Hemodynamic Assessment First

Immediate Stabilization Protocol

• Establish large-bore intravenous access immediately for rapid fluid and blood product administration 1, 5
• Activate massive transfusion protocol early without waiting for laboratory results if significant bleeding is present 1, 5
• Maintain maternal temperature above 36°C, as clotting factors function poorly at lower temperatures 1, 5

Clinical Decision Algorithm Based on Maternal Status

• If maternal hemodynamic instability is present: Proceed to immediate delivery regardless of gestational age 1, 5
• If maternal status is stable with fetal demise: Pursue vaginal delivery with aggressive resuscitation 2, 4
• If maternal status is stable with viable fetus showing compromise: Cesarean delivery is indicated 1

Laboratory Assessment (Secondary to Clinical Action)

• Obtain baseline studies including complete blood count, type and crossmatch for at least 4 units, coagulation panel, fibrinogen level, and platelet count 1, 5
• Do not wait for laboratory results before initiating treatment—clinical presentation drives management 1
• Monitor fibrinogen levels closely, as declining levels indicate consumption and worsening disseminated intravascular coagulopathy 1

Critical Pitfalls to Avoid

• Never delay transfusion protocols waiting for laboratory confirmation—this significantly increases maternal morbidity 1
• Never perform cesarean delivery solely because of fetal demise—this increases maternal surgical risk without benefit 2
• Never rely on ultrasound to rule out abruption—a negative ultrasound does not exclude the diagnosis 2, 3
• Never attempt forced placental removal if placenta accreta spectrum is encountered—this triggers profuse hemorrhage 1, 5

Hemorrhage Management Specifics

• Transfuse in a fixed 1:1:1 ratio of packed red blood cells:fresh frozen plasma:platelets when massive transfusion is needed 1, 5
• Consider tranexamic acid to reduce blood loss 1, 5
• Have cell salvage technology available if possible during cesarean delivery 5

Postoperative Vigilance

• Transfer severe cases to intensive care unit for monitoring of ongoing bleeding, fluid overload, renal failure, liver failure, and disseminated intravascular coagulopathy 1, 5
• Maintain a low threshold for reoperation if ongoing bleeding is suspected 1, 5