2006-Jul-24
by JACK DANIELS
Abruptio placentae refers to separation of the normally located placenta after the 20th week of gestation and prior to birth.
What is it?
- The placenta joins you to your baby. It is attached to the inside wall of your uterus (womb). It is also called the "afterbirth." It usually comes out right after your baby is born. The placenta is the filter that brings food and oxygen to your baby. It also takes away waste and carbon dioxide. Carbon dioxide is what we breathe out.
- Abruptio placenta is also called placental abruption. It is when the placenta breaks away from the wall of the uterus (womb). The placenta may break all the way or just part of the way. If the placenta breaks part of the way, it may break away in the center, or along an edge. If the placenta breaks away in the center and all the edges remain in contact with the wall of your uterus, you may not know you are bleeding. This is called internal bleeding. If the placenta breaks along an edge, you may see vaginal bleeding. This is called an external bleeding. This can be a very serious problem to you and your baby. The baby may be cut off from his/her oxygen (air) and food supply and could die. You could lose a lot of blood.
Signs & Symptoms
The signs of abruptio placenta may be different in each woman. You may have vaginal bleeding, abdominal (belly pain), or back pain. You may have contractions of your uterus. This is when your abdomen tightens and then relaxes when you are in labor. Or your uterus may feel tight all the time.
Patients usually present with the following symptoms:
Vaginal bleeding - 80%
Abdominal or back pain and uterine tenderness - 70%
Fetal distress - 60%
Abnormal uterine contractions (eg, hypertonic, high frequency) - 35%
Idiopathic premature labor - 25%
Fetal death - 15%
Placental abruption is mainly a clinical diagnosis based on findings of vaginal bleeding, abdominal pain, uterine tenderness, uterine contractions, and fetal distress. Severe uterine pain and tenderness with mild vaginal bleeding in a patient with hypertension (HTN) indicates placental abruption.
Classification of placental abruption is based on extent of separation (ie, partial vs complete) and location of separation (ie, marginal vs central). Clinical characteristics include the following:
- Class 0 is asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.
- Class 1 is mild and represents approximately 48% of all cases. Characteristics include the following:
No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress
- Class 2 is moderate and represents approximately 27% of all cases. Characteristics include the following:
No vaginal bleeding to moderate vaginal bleeding
Moderate-to-severe uterine tenderness with possible tetanic contractions
Maternal tachycardia with orthostatic changes in BP and heart rate
Fetal distress
Hypofibrinogenemia (ie, 50-250 mg/dL)
- Class 3 is severe and represents approximately 24% of all cases. Characteristics include the following:
No vaginal bleeding to heavy vaginal bleeding
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, 150 mg/dL)
Coagulopathy
Fetal death
Causes:
Maternal hypertension - Most common cause of abruption, occurring in approximately 44% of all cases
Maternal trauma (eg, motor vehicle accidents MVA, assaults, falls) - Causes 1.5-9.4% of all cases
Cigarette smoking
Alcohol consumption
Cocaine use
Short umbilical cord
Sudden decompression of the uterus (eg, premature rupture of membranes, delivery of first twin)
Retroplacental fibromyoma
Retroplacental bleeding from needle puncture (ie, postamniocentesis)
Advanced maternal age
Idiopathic (probable abnormalities of uterine blood vessels and decidua)
Treatment:
- Provide emergency care at the advanced life support (ALS) level to all patients with suspected placental abruption. This care includes the following:
- Continuous monitoring of vital signs
- Continuous, high-flow, supplemental oxygen
- One or 2 large-bore IV lines with normal saline (NS) or lactated Ringer (LR) solution
- Monitor amount of vaginal bleeding
Monitoring of fetal heart
Treatment of hemorrhagic shock, if needed
Emergency Department Care: ED care depends on stage of gestation and severity of symptoms.
Closely observe the patient.
Administer supplemental oxygen.
Perform fetal monitoring.
Administer IV fluids.
Perform aggressive fluid resuscitation to maintain adequate perfusion, if needed.
Monitor vital signs and urine output.
Crossmatch 4 units of packed red blood cells. Transfuse, if necessary.
Perform amniotomy to decrease intrauterine pressure, extravasation of blood into the myometrium, and entry of thromboplastic substances into the circulation.
Immediately deliver the fetus by cesarean delivery if the mother or fetus becomes unstable.
Treatment of coagulopathy or disseminated intravascular coagulation (DIC) may be necessary. Some degree of coagulopathy occurs in about 30% of severe cases of placental abruption. The best treatment for DIC as a complication of placental abruption is immediate delivery.
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