premature separation of a normally implanted placenta after 20 weeks OF gestation incidence = 0.5-1.5% Classificati...
- premature separation of a normally implanted placenta after 20 weeks OF gestation
- incidence = 0.5-1.5%
Classification
- total (fetal death inevitable) vs. partial
- external/revealed/apparent; blood dissects downward toward cervix
- Internal/concealed (20%); blood dissects upward toward fetus
- most are mixed
unknown, but associated with
- maternal hypertension (chronic or PIH) in 50% of abruptions
- multiparity
- previous abruption (recurrence rate 10%)
- PROM
- maternal age > 35 (felt to reflect parity)
- maternal vascular disease
- cigarette smoking
- alcohol consumption
- uterine distension (polyhydramnios, multiple gestation)
- short cord
- trauma
- Sudden decompression of the uterus (twins)
- uterine anomaly, fibroids
- perinatal mortality 25-60%
- prematurity
- intrauterine hypoxia
- < 1% maternal mortality
- DIC (in 20% of abruptions)
- acute renal failure
- anemia hemorrhagic shock
- pituitary necrosis (Sheehan syndrome)
- amniotic fluid embolus
- PAINFUL vaginal bleeding; blood may be bright red or dark or clotted
- uterine tenderness and increased tone
- degree of anemia may not correlate with degree of observed blood loss
- fetal distress; loss of variability, late decelerations
- 15% present with fetal demise
- clinical
- U/S NOT helpful except to rule out placenta previa
Initial management
- maternal stabilization, IV hydration
- fetal monitoring
- monitor maternal vitals, urine output
- blood for hemoglobin, platelets, PT/PTT, fibrinogen, FDP, cross and type
- blood products on hand (red cells, platelets, cryoprecipitate) because of DIC risk
- Rhogam if Rh negative
Mild abruption and GA < 36 weeks
- close observation of fetal well-being and amount of bleeding
- limited physical activity
- serial Hct to assess concealed bleeding
- delivery when fetus is mature or when hemorrhage dictates
Mild abruption and GA > 36 weeks
- stabilization and delivery
- hydrate and restore blood loss and correct coagulation defect if present
- vaginal delivery if no evidence of fetal or maternal distress and if cephalic presentation OR with dead fetus
- labour must progress actively
Severe abruption and live fetus
- C-section if fetal or maternal distress develops with fluid/blood replacement, labour fails to progress or non-cephalic fetal presentation
