What is the management plan for a stable mother with abruptio placenta during delivery?

Management of Abruptio Placenta in a Stable Mother During Delivery

For a stable mother with placental abruption during delivery, proceed with immediate delivery via cesarean section if the fetus is viable and alive, or expeditious vaginal delivery if fetal demise has occurred, while simultaneously establishing large-bore IV access, activating massive transfusion protocol early, and maintaining maternal temperature above 36°C. 1

Immediate Stabilization and Preparation

Vascular Access and Resuscitation

• Establish large-bore intravenous access immediately for rapid fluid and blood product administration 1
• Activate massive transfusion protocol early without waiting for laboratory results, as delayed initiation significantly increases maternal morbidity 1
• Order blood products immediately and notify the blood bank given the frequent need for large-volume transfusion 1

Critical Laboratory Assessment

• Obtain baseline studies including complete blood count, type and crossmatch, coagulation panel (PT, PTT), fibrinogen levels, and platelet count 1
• Monitor fibrinogen levels closely, as they are normally elevated in pregnancy and declining levels indicate consumption 1

Temperature Management

• Maintain maternal temperature above 36°C, as clotting factors function poorly at lower temperatures 1, 2

Delivery Decision Algorithm

For Viable Fetus with Maternal Stability

• Proceed to immediate cesarean delivery regardless of gestational age when the diagnosis is clear and the fetus is alive and viable 3
• Cesarean section is indicated for fetal compromise (present in 57% of abruption cases) or when rapid delivery is needed 1, 4
• The mean time for delivery should be minimized; studies show a mean of 18.7 minutes from decision to delivery 4

For Fetal Demise

• Aggressive resuscitation followed by expeditious vaginal delivery is the preferred approach when the fetus is dead 3
• Vaginal delivery is preferable in cases where fetal demise has occurred 5

Anesthetic Considerations

Team Mobilization

• Alert the anesthesia team immediately and consider general anesthesia for rapid delivery 1
• Alert critical care personnel and bring cell salvage technology to the operating room if available 1

Hemorrhage Management Protocol

Transfusion Strategy

• Transfuse in a fixed 1:1:1 ratio of packed red blood cells:fresh frozen plasma:platelets when massive transfusion is needed 1
• Alternative ratios of 1:1:1 to 1:2:4 may be used based on institutional protocols 2
• Consider tranexamic acid administration to reduce blood loss 1, 2

Coagulopathy Management

• Disseminated intravascular coagulopathy should be managed aggressively 6
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 7

Intraoperative Surgical Considerations

If Placenta Accreta Spectrum Encountered

• If placenta accreta spectrum is unexpectedly encountered, leave the placenta in situ 1, 2
• Rapid uterine closure and proceeding to hysterectomy should be considered if hemorrhage is uncontrolled 5, 1
• Avoid attempts at forced placental removal, as this causes profuse hemorrhage 7, 1

Additional Hemorrhage Control Techniques

• Consider uterine compression sutures, hypogastric artery ligation, pelvic packing, or interventional radiology embolization if bleeding persists 1

Postoperative Management

Intensive Monitoring

• Transfer to intensive care unit for close monitoring of volume status, urine output, blood loss, and hemodynamics 1
• Maintain vigilance for ongoing bleeding with a low threshold for reoperation if suspected 7, 1

Complications Surveillance

• Monitor for renal failure, liver failure, infection, unrecognized ureteral/bladder/bowel injury, pulmonary edema, and disseminated intravascular coagulation 5, 1
• Be vigilant for Sheehan syndrome (postpartum pituitary necrosis) given the potential for hypoperfusion 5, 2

Critical Pitfalls to Avoid

• Do not delay delivery waiting for laboratory results or complete workup; clinical presentation should guide immediate management 1
• Do not attempt manual placental removal if resistance is encountered, as this indicates possible accreta spectrum and will cause catastrophic hemorrhage 7, 1
• Do not underestimate blood loss; placental abruption is a leading cause of maternal mortality, and severe cases have a 4.29-fold increased risk of serious maternal complications compared to non-abruption cases 8
• Ultrasound has limited value in diagnosing abruption (only 23.9% sensitivity in one study), so rely on clinical diagnosis 6, 4