Placental Abruption

Background

• Separation of the placenta before the delivery of the foetus.
• Significant cause of perinatal mortality/morbidity (mortality can be as high as 15%)
• Accounts for 30% of antepartum haemorrhage (~6.5/1000 births)
• Two main forms
  • Concealed (20% are totally concealed; most cases will have some degree of concealment)- where the haemorrhage is confined within the uterus; usually more serious
  • Revealed (80%)
• Also commonly classed as
  • Major (separation of more than 1/3 of the placenta; true emergency as there is a high risk of maternal and foetal mortality)
  • Minor

Risk factors/Causes

• Trauma (e.g. road traffic accident; can also be iatrogenic after external cephalic version)
• Pre-eclampsia
• Multiparity
• Polyhydramnios (stretched uterus)
• Previous placental abruption (there is also some evidence to suggest that previous C-section can increase the risk)
• Raised maternal serum AFP in the absence of foetal malformation
• Smoking/cocaine use

Presentation

• Major
  • Abdominal Pain and shock (which is often disproportionate to visible blood loss)
  • The uterus is often ‘woody’ hard, due to tonic contraction; and the foetal parts cannot be felt
  • The chances of the foetus surviving is small, CTG may reveal deceleration of the foetal heart and foetal hypoxia, more commonly foetal death
• Minor
  • Often not diagnosed until after the delivery
  • Mild abdominal pain with vaginal bleeding and uterine tenderness (usually maximal over one area)

Investigations

• Clinical diagnosis in the emergency setting so often no investigations are required.  USS, in any case, is rarely helpful as blood clot and placenta can be hard to differentiate

Management

• ABCDE- resuscitation of the mother
  • Particularly fluid resuscitation and remember to send bloods for group and save or even cross-match if the patient requires blood
• + foetal monitoring
  • if the foetus is still alive, immediate C-section should be performed to improve the chances of it surviving
  • if the foetus is dead, the women can be allowed to deliver vaginally (which may occur rapidly) or have a C-section (if labour does not occur)