11/14/24, 10\:50 AM Placental Abruption

Placental Abruption

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Placental abruption\: cause of antepartum haemorrhage (bleeding > 24 weeks gestation); de
of a normally sited placenta from the uterine wall, leading to maternal haemorrhage.
Incidence\: 0.3% to 1% of births.
Aetiology\: Occurs more frequently in the last trimester; can be concealed (bleeding within the uterus) or revealed (visible
vaginal bleeding).
Risk factors\: previous placental abruption, pre-eclampsia, fetal complications (growth restriction, non-vertex presentations,
polyhydramnios), advanced maternal age, multiparity, low BMI, assisted reproductive techniques, intrauterine infection,
premature rupture of membranes, abdominal trauma, smoking, drug misuse (cocaine, amphetamines).
Clinical features\:
History\: sudden constant pain, dark red vaginal bleeding (>24 weeks gestation), rupture of membranes, provoking factors,
fetal movements, smoking/drug use, obstetric history, medical history, conception history (IVF).
Examination\: no digital vaginal exam, speculum exam for cervical dilation, ruptured membranes, infection; abdominal
tenderness,
'woody' or 'tense' uterus, signs of shock.
Fetal wellbeing\: CTG at 26+ weeks or fetal heart auscultation if less than 26 weeks.
Di
Placenta praevia\: painless, bright red bleeding.
Vasa praevia\: vaginal bleeding, rupture of membranes, fetal deterioration.
Uterine rupture\: usually in labour with a history of caesarean section.
Early labour\: small bleeding, intermittent pain.
Malignant lesions (e.g., carcinoma).
Benign lesions (e.g., cervical ectropion).
Infections (e.g., chlamydia).
Investigations\:
Placental abruption is a clinical diagnosis.
Bedside\: CTG, handheld doppler/USS for fetal heartbeat if under 26 weeks.
Laboratory\: FBC, U&Es, LFTs, group and save/crossmatch, clotting pro
Imaging\: ultrasound to con
Management\:
ABCDE assessment and resuscitation.
Fetal distress\: emergency caesarean section.
No fetal distress \< 36 weeks\: observe closely, steroids, no tocolysis, determine delivery based on gestation.
No fetal distress > 36 weeks\: deliver vaginally.
In-utero fetal death\: induced vaginal delivery or caesarean section if maternal compromise.
Administer anti-D within 72 hours if rhesus D negative.
Complications\:
Maternal\: postpartum haemorrhage (PPH), clotting problems (e.g., DIC), organ dysfunction (e.g., renal failure).
Fetal\: intrauterine growth restriction (IUGR), hypoxia, premature birth, stillbirth.
Prognosis\: high perinatal mortality rate; responsible for 15% of perinatal deaths.
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A comprehensive topic overview

Introduction

Placental abruption is a cause of antepartum haemorrhage (de
premature separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the
intervening space.
Placental abruption occurs in 0.3% to 1% of births.

Aetiology

The cause of placental abruption is not known. Abruption is more likely to occur in the last trimester, particularly during the
last few weeks prior to birth.
Placental abruption can be either concealed (bleeding remains within the uterus and is not visible) or revealed (visible
vaginal bleeding).
Figure 1. Revealed (with external
bleeding) and concealed (with internal
bleeding) placental abruption.
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Risk factors

Risk factors for placental abruption include\:
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Previous history of placenta abruption
Pre-eclampsia
Fetal complications\: fetal growth restriction, non-vertex presentations, polyhydramnios
Advanced maternal age
Multiparity
Low maternal body mass index (BMI)
Pregnancy following assisted reproductive techniques
Intrauterine infection
Premature rupture of membranes
Abdominal trauma (both accidental and resulting from domestic violence)
Smoking and drug misuse (cocaine and amphetamines) during pregnancy

Clinical features

History

weeks gestation).
The typical presentation of placental abruption is sudden constant pain with or without dark red vaginal bleeding (>24
Other important areas to cover in the history include\:
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Rupture of membranes\: if has occurred, consider vasa praevia
Provoking factors (e.g. post-coital)
Fetal movements
Risk factors (e.g. smoking/drug use)
Obstetric history\: previous pregnancies, delivery mode, gestation and complications
Past medical history
Conception history\: IVF

Clinical examination

A digital vaginal examination should not be performed, as this may trigger heavy bleeding in uncon
praevia.
A careful speculum examination is useful to look for cervical dilatation, ruptured membranes and investigate for infection.
Typical clinical
Abdominal tenderness\: constant pain is consistent with abruption
Uterus feels ‘woody’ or ‘tense’ (typical of placental abruption)
Signs of shock (if signi
abruption
Fetal wellbeing should be checked with a cardiotocograph (CTG) at 26 weeks gestation or above, otherwise auscultate the
fetal heart only.

Di

Possible di
Placenta praevia\: usually painless, bright red bleeding
Vasa praevia\: where fetal blood vessels run near the internal cervical os (involves the characteristic triad of vaginal
bleeding, rupture of membranes and fetal deterioration)
Uterine rupture\: usually occurs in labour with a history of previous caesarean section
Early labour can sometimes present with a small amount of bleeding and intermittent abdominal pain
Malignant lesions (e.g. carcinoma)
Benign lesions (e.g. cervical ectropion)\: common
Infections (e.g. chlamydia)

Investigations

Placental abruption is a clinical diagnosis and there are no sensitive or reliable diagnostic tests available.
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Bedside investigations

Relevant bedside investigations include\:
Cardiotocograph (CTG)\: should be performed in women above 26 weeks gestation to assess fetal wellbeing. Abruption
can result in fetal hypoxia and abnormalities of the fetal heart rate pattern. Under 26 weeks handheld doppler or USS
should be performed to assess for a fetal heartbeat.

Laboratory investigations

Relevant laboratory investigations include\:
FBC, U&Es, LFTs\: baseline blood tests
Group and save/crossmatch\: if large volumes of blood loss patient may require transfusion
Clotting pro\: important in the context of bleeding
Kleihauer test\: required if the woman is rhesus negative

Imaging

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Relevant imaging investigations include\:
Ultrasound\: women presenting with antepartum haemorrhage should have an ultrasound scan performed to con
exclude placenta praevia if the placental site is not already known. Ultrasound has limited sensitivity in the identi
of retroplacental haemorrhage.

Management

Management of an antepartum haemorrhage due to placental abruption includes a rapid ABCDE assessment and
resuscitation. Maternal resuscitation should not be delayed to determine fetal viability.
De
Fetal distress\: emergency caesarean section
No fetal distress \< 36 weeks\: observe closely, steroids, no tocolysis, gestational age determines delivery
No fetal distress >36 weeks\: deliver vaginally
In cases of in-utero fetal death, induced vaginal delivery or caesarean section may be indicated due to maternal
compromise.
In all cases, anti-D should be administered within 72 hours of the onset of bleeding if the woman is rhesus D negative.

Complications

Maternal complications of placental abruption include\:
Postpartum haemorrhage (PPH)
Blood clotting problems (e.g. DIC)
Organ dysfunction due to blood loss (e.g. renal failure)
Fetal complications of placental abruption include\:
Intrauterine growth restriction (IUGR) due to lack of nutrients
Hypoxia
Premature birth
Stillbirth

Prognosis

Placental abruption is associated with a high perinatal mortality rate and is responsible for 15% of perinatal deaths.

References

Ananth CV, Keyes KM, Hamilton A, et al. A n i n t e r n a t i o n a l c o n t r a s t o f r a t e s o f p l a c e n t a l a b r u p t i o n \: a n a ge- p e r i o d-c o h o r t
a n a l y s i s . PLoS One. 2015 May 27;10(5)\:e0125246.
Tikkanen M. P l a c e n t a l a b r u p t i o n \: e p i d e m i o l o g y , r i s k f a c t o r s a n d c o n s e q u e n c e s . Acta Obstet Gynecol Scand. 2011
Feb;90(2)\:140-9.
Blausen. P l a c e n t a l a b r u p t i o n c o n c e a l e d v s . r e v e a l e d . WikiJournal of Medicine. Licence\: [CC BY]
Pariente G, Wiznitzer A, Sergienko R, Mazor M, Holcberg G, Sheiner E. P l a c e n t a l a b r u p t i o n \: c r i t i c a l a n a l y s i s o f r i s k f a c t o r s a n d
p e r i n a t a l o u t c o m e s . Journal of Maternal, Fetal and Neonatal Medicine. 2010;24\:698–702.
RCOG. A n t e p a r t u m H a e m o r r h a g e . Green-top Guideline No.63. Nov 2011. Page 8. Available from\: [LINK]

Reviewer

Dr Rachel Greenwood
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Obstetrics & Gynaecology Registrar

Related notes

Amniotic Fluid Embolism
Antenatal Screening for Down’s Syndrome
Antepartum Haemorrhage (APH)
Breech Presentation
Caesarean Section

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Contents

Introduction
Aetiology
Risk factors
Clinical features
Di
Investigations
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