How should abruptio placentae be initially stabilized and managed based on gestational age, fetal status, and maternal stability?

Management of Placental Abruption

Immediate Stabilization

Establish large-bore intravenous access immediately and activate massive transfusion protocol without waiting for laboratory results if significant bleeding is present. 1

Resuscitation Priorities

• Secure two large-bore IV lines (18-gauge or larger) for rapid administration of crystalloid, blood products, and medications. 1
• Activate massive transfusion protocol early based on clinical presentation—do not delay for laboratory confirmation, as waiting significantly increases maternal morbidity. 1
• Maintain maternal core temperature above 36°C throughout resuscitation and surgery, because clotting factors function poorly in hypothermia. 1
• Obtain baseline laboratories immediately: complete blood count, type and crossmatch for at least 4 units packed red blood cells, coagulation panel (PT/PTT), fibrinogen level, and platelet count. 1

Hemorrhage Management Protocol

• Transfuse blood products in a fixed 1:1:1 ratio of packed red blood cells : fresh frozen plasma : platelets when massive transfusion is required. 1, 2
• Administer tranexamic acid (1 gram IV over 10 minutes, followed by 1 gram over 8 hours if needed) to reduce blood loss—give within 3 hours of bleeding onset for maximum benefit. 1
• Monitor fibrinogen levels closely: normal pregnancy values are 400–600 mg/dL; declining levels indicate consumption and predict coagulopathy. 1

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Management Algorithm Based on Clinical Severity

Maternal Hemodynamic Instability (Hypotension, Shock, Ongoing Hemorrhage)

Proceed to immediate delivery regardless of gestational age when maternal hemodynamic instability is present. 1

• Cesarean delivery is the route of choice when maternal instability or fetal compromise requires rapid delivery. 1
• Alert anesthesia for general endotracheal anesthesia—neuraxial techniques worsen hypotension in the setting of major hemorrhage and should be avoided. 1
• Notify blood bank, activate cell salvage if available, and alert critical care team before entering the operating room. 1
• Do not delay surgery to optimize circumstances if the mother is unstable; however, if placenta accreta spectrum is suspected and the patient can be temporarily stabilized, pause until optimal surgical expertise (gynecologic oncology, urology, interventional radiology) arrives. 1

Fetal Compromise with Maternal Stability

• Deliver emergently by cesarean section if Category III fetal heart rate tracing or prolonged severe variable or late decelerations are present, even if the mother is hemodynamically stable. 1
• Continuous fetal monitoring is mandatory until delivery in all cases of suspected abruption. 3, 4

Fetal Demise

Vaginal delivery is preferable when fetal demise has occurred, unless maternal instability or coagulopathy necessitates cesarean delivery. 1, 3

• Augment labor with oxytocin to expedite delivery and minimize blood loss. 3
• Monitor closely for disseminated intravascular coagulopathy (DIC): check fibrinogen, platelets, PT/PTT every 2–4 hours during labor. 3, 4
• Prepare for cesarean delivery if labor does not progress or if maternal condition deteriorates. 3

Stable Mother and Fetus at Preterm Gestation (<34 Weeks)

• Conservative management with close monitoring may be considered in highly selected cases where bleeding is minimal, vital signs are stable, and fetal heart rate tracing is reassuring. 3, 5
• Administer antenatal corticosteroids for fetal lung maturity if gestational age is 24–34 weeks and delivery is not imminent. 3
• Continuous inpatient monitoring is required: serial vital signs, quantification of bleeding, continuous or frequent intermittent fetal monitoring, and serial laboratory assessment (hemoglobin, coagulation studies). 4, 5
• Deliver immediately if any deterioration occurs: increased bleeding, maternal tachycardia or hypotension, abnormal fetal heart rate, or laboratory evidence of coagulopathy. 4, 5

Stable Mother and Fetus at Term (≥37 Weeks)

• Proceed with delivery promptly—conservative management is not appropriate at term. 4, 5
• Vaginal delivery may be attempted if the cervix is favorable, fetal heart rate tracing is reassuring, and bleeding is minimal. 3, 4
• Cesarean delivery is indicated for unfavorable cervix, abnormal fetal heart rate, or moderate-to-severe bleeding. 3, 4

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Intraoperative Considerations

Surgical Technique

• Inspect the uterus after entering the abdomen to assess the extent of abruption and plan the uterine incision. 2
• If placenta accreta spectrum is encountered, leave the placenta in situ—do not attempt manual removal, as this triggers profuse hemorrhage. 1, 2
• Proceed to cesarean hysterectomy if hemorrhage is uncontrolled despite uterotonic agents, uterine compression sutures, or other conservative measures. 1, 2

Adjunctive Hemorrhage Control Techniques

• Uterine compression sutures (B-Lynch, Cho, or Hayman), hypogastric artery ligation, pelvic packing, and interventional radiology embolization may be attempted before hysterectomy in stable patients. 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 6

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Postoperative Management

Intensive Monitoring

Transfer to intensive care unit for severe abruption cases, given risks of ongoing bleeding, fluid overload, acute kidney injury, acute respiratory distress syndrome, and DIC. 1, 2

• Monitor volume status, urine output (goal ≥0.5 mL/kg/hour), blood loss, and hemodynamics closely in the first 24–48 hours. 1
• Maintain a low threshold for reoperation if ongoing bleeding is suspected (persistent tachycardia, hypotension, declining hemoglobin despite transfusion, increasing abdominal distension). 1, 2

Complications to Monitor

• Disseminated intravascular coagulopathy: check fibrinogen, platelets, PT/PTT, and D-dimer every 4–6 hours until stable. 1, 3
• Acute kidney injury: monitor creatinine and urine output; consider nephrology consultation if oliguria persists despite adequate resuscitation. 1
• Sheehan syndrome (postpartum pituitary necrosis): maintain vigilance in patients who experienced severe hypotension or required massive transfusion. 1
• Unrecognized ureteral, bladder, or bowel injury: especially after difficult cesarean hysterectomy. 1

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Common Pitfalls and Caveats

• Do not wait for laboratory results to activate massive transfusion protocol—clinical presentation (ongoing bleeding, hypotension, tachycardia) should trigger immediate action. 1
• Do not attempt manual placental removal if placenta accreta spectrum is present—this causes catastrophic hemorrhage. 1, 2
• Do not use neuraxial anesthesia in hemodynamically unstable patients—general anesthesia is safer when major hemorrhage is present. 1
• Do not delay delivery at term or near-term gestations for conservative management—abruption at ≥34 weeks warrants prompt delivery once maternal and fetal status are assessed. 4, 5
• Do not underestimate concealed hemorrhage—up to 20% of abruptions present with minimal or no vaginal bleeding despite significant retroplacental clot and maternal hypovolemia. 4, 5