Management of Placental Abruption: Correct Statement
The correct answer is (b): Vital signs should be checked to assess for circulatory stability. This is the fundamental first step in managing placental abruption, as maternal hemodynamic status directly determines the urgency and mode of delivery 1, 2.
Why Each Statement is True or False
Statement B (CORRECT): Vital Signs for Circulatory Stability
- Establishing maternal hemodynamic stability is the cornerstone of placental abruption management 1, 2
- The American College of Obstetricians and Gynecologists recommends immediate assessment of vital signs, blood loss, and urine output to determine clinical severity 1
- Maternal hemodynamic instability mandates proceeding to immediate delivery regardless of gestational age 1, 2
- Large-bore intravenous access should be established immediately upon presentation, with early activation of massive transfusion protocol if significant bleeding is present 1, 2
Statement A (INCORRECT): Ultrasound Dependency
- The diagnosis of placental abruption is primarily clinical, not ultrasound-dependent 3, 4, 5
- Ultrasound has limited sensitivity for detecting abruption and cannot rule out the diagnosis 3
- Clinical manifestations including vaginal bleeding, abdominal pain, uterine contractions, and abnormal fetal heart rate patterns are the diagnostic foundation 4, 5
- Ultrasound may show retroplacental hematoma or placental separation, but absence of these findings does not exclude abruption 3
Statement C (INCORRECT): Amniotomy Contraindication
- Amniotomy is NOT contraindicated in placental abruption; in fact, it may be beneficial in certain scenarios 3
- When vaginal delivery is planned (particularly in cases of fetal demise), amniotomy can facilitate labor progression 3
- The key is that amniotomy decisions depend on the overall clinical picture: maternal stability, fetal status, and gestational age 3, 4
Statement D (INCORRECT): Cesarean for Fetal Demise
- In cases of fetal demise from placental abruption, vaginal delivery is actually preferable, not cesarean 3
- Cesarean delivery is indicated for fetal compromise (when the fetus is alive) or maternal instability requiring rapid delivery 1
- When fetal death has occurred, vaginal delivery avoids the additional maternal morbidity of surgery while allowing for adequate management of potential disseminated intravascular coagulopathy 3, 6
- Emergency cesarean is reserved for maternal hemodynamic instability or uncontrolled hemorrhage, not simply for fetal demise 1, 2
Clinical Management Algorithm
Based on maternal hemodynamic status:
- Unstable patient: Immediate delivery (cesarean if rapid delivery needed) regardless of fetal status or gestational age 1, 2
- Stable patient with live fetus: Mode and timing based on gestational age, fetal heart rate pattern, and severity of bleeding 4, 5
- Stable patient with fetal demise: Vaginal delivery preferred with aggressive management of coagulopathy 3, 6
Critical Pitfalls to Avoid
- Never delay treatment waiting for laboratory results - initiate transfusion protocols based on clinical presentation first 1
- Never perform digital cervical examination until placenta previa is excluded, as this can trigger catastrophic hemorrhage 7
- Maintain maternal temperature above 36°C as clotting factors function poorly at lower temperatures 1, 2, 7
- Monitor fibrinogen levels closely as declining levels indicate consumption and predict need for transfusion 1