Management of Abruptio Placenta in a Stable Mother During Delivery
For a stable mother with placental abruption during delivery, proceed with expeditious delivery—vaginal delivery is preferred if fetal demise has occurred, while cesarean delivery is indicated for a viable fetus with any signs of fetal compromise or if rapid delivery is needed. 1
Initial Stabilization and Assessment
Even in a stable mother, immediate preparation for potential deterioration is essential:
- Establish large-bore intravenous access for rapid fluid and blood product administration 1
- Obtain baseline laboratory studies including complete blood count, type and crossmatch, coagulation panel, platelet count, and fibrinogen levels 1
- Alert the anesthesia team, blood bank, and critical care team immediately 1
- Order blood products without delay—do not wait for laboratory results if significant bleeding is present, as this significantly increases maternal morbidity 1
- Maintain maternal temperature above 36°C, as clotting factors function poorly at lower temperatures 1
Delivery Decision Algorithm
The mode and timing of delivery depends on fetal status:
If Fetal Demise Has Occurred
- Vaginal delivery is preferable in cases where fetal demise has occurred 1
- Aggressive resuscitation and expeditious vaginal delivery are the goals when the fetus is dead 2
If Fetus is Viable
- Cesarean delivery is indicated for fetal compromise (abnormal fetal heart rate patterns occur in 57% of cases) or maternal instability requiring rapid delivery 1, 3
- Emergency cesarean section should be performed without delay—the mean time for delivery should be minimized 3
- Do not delay delivery even in stable patients, as clinical deterioration can occur rapidly 3
Hemorrhage Management Protocol
Prepare for massive hemorrhage even if the mother appears stable:
- Activate massive transfusion protocol early without waiting for laboratory results if significant bleeding is present 1
- Transfuse in a fixed 1:1:1 ratio of packed red blood cells:fresh frozen plasma:platelets when massive transfusion is needed 1
- Consider tranexamic acid to reduce blood loss 1
- Monitor fibrinogen levels closely, as declining levels indicate consumption (fibrinogen is normally elevated in pregnancy) 1
Intraoperative Considerations
During cesarean delivery:
- General anesthesia should be considered and the anesthesia team alerted in advance 1
- Bring cell salvage technology to the operating room if available 1
- If uncontrolled hemorrhage occurs, consider uterine compression sutures, hypogastric artery ligation, pelvic packing, or interventional radiology embolization 1
- If placenta accreta spectrum is unexpectedly encountered, leave the placenta in situ and consider cesarean hysterectomy if hemorrhage is uncontrolled 1
Postoperative Management
Close monitoring is critical even after successful delivery:
- 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
- Maintain a low threshold for reoperation if ongoing bleeding is suspected 1
- Monitor for complications including renal failure, liver failure, infection, unrecognized ureteral/bladder/bowel injury, pulmonary edema, and disseminated intravascular coagulation 1
- Be vigilant for Sheehan syndrome (postpartum pituitary necrosis) given the potential for hypoperfusion 1
Critical Pitfalls to Avoid
- Do not wait for laboratory confirmation before initiating treatment—clinical presentation should guide immediate management 1
- Do not delay delivery in stable patients who came from home, as these cases have significantly lower umbilical artery pH and worse fetal outcomes compared to hospitalized patients 3
- Do not rely on ultrasound for diagnosis—ultrasound reveals placental abruption in only 24% of cases, making this primarily a clinical diagnosis 3, 4
- Do not underestimate the risk of disseminated intravascular coagulopathy, which should be managed aggressively 5, 2