Rosen & Barkin's 5-Minute Emergency Medicine Consult (547 page)

TREATMENT

• Patients with abruption may be in shock and need full resuscitative measures
  
• Transport in the left lateral recumbent position
  

• Airway, breathing, circulation (ABCs), oxygen
  
• Cardiac monitor
  
• Placement of large-bore IVs
  
• IV crystalloid resuscitation
  

• Maternal cardiac and tocographic monitoring
  
• Continuous fetal monitoring
  
• Transfuse PRBCs, fresh frozen plasma (FFP), cryoprecipitate, and platelets as indicated (may require massive transfusion protocol)
  
• Immediate OB/GYN consultation
  
• Foley catheter for close monitoring of urine output
  
• Tocolysis is generally contraindicated
  
• If abruption is suspected in the setting of trauma, maternal stabilization is of primary importance:
  
  • All indicated radiographs should be performed as needed
    

• Rh-immunoglobulin in Rh-negative women:
  
  • 300 μg IM in women at ≥12 wk gestation
    
  • Higher doses if indicated by results of Kleihauer–Betke test
    
• Blood products as indicated
  

Consider with obstetrician recommendation:

• Magnesium sulfate if tocolysis is indicated
  
• Steroids for fetal lung maturation if gestational age between 24 and 34 wk
  

FOLLOW-UP

• Patients with placental abruption must be admitted for maternal and fetal monitoring
  
• Admit to ICU if DIC, amniotic fluid embolism, or significant hemorrhage (known or suspected)
  
• Victims of multiple trauma with abruption should be admitted and managed in accordance with trauma protocols
  
• Transportation to higher trauma or obstetric level of care is appropriate if the patient is stable for transfer or appropriate care unavailable at existing facility
  

• Trauma patients with no evidence of abruption or other significant injury may be discharged after 4–6 hr of normal maternal and fetal monitoring
  
• Discharge instructions include pelvic rest, no intercourse, no heavy lifting, no prolonged standing
  
• Discharge decision should be made in consultation with OB/GYN and include close follow-up
  

All cases of confirmed or suspected abruption require immediate obstetric consultation

• Primarily a clinical diagnosis: No single test reliably confirms or rules out placental abruption
  
• Hypotension typically occurs late in the course of hypovolemic shock in pregnancy
  
• Anticipate a consumptive coagulopathy and consider the need for blood products early in presentation
  
• Abruption may be associated with severe preeclampsia, causing a hypovolemic patient to be normotensive:
  
  • Maintain a high index of suspicion for preeclampsia in patients with severe abruption and no obvious cause
    

• Ananth CV, Kinzler WL. Placental abruption: Clinical features and diagnosis. In:
  UpToDate
  . Rose BD, ed. Waltham, MA: UpToDate; 2012.
  
• Ananth CV, Oyelese Y, Yeo L, et al. Placental abruption in the United States, 1979 through 2001: Temporal trends and potential determinants.
  Am J Obstet Gynecol
  . 2005;192:191–198.
  
• Elasser DA, Ananth CV, Prasad V, et al. Diagnosis of placental abruption: Relationship between clinical and histopathological findings.
  Eur J Obstet Gynecol Repro Biol
  . 2010;148:125–130.
  
• Kopelman TR, Berardoni NE, Manriquez M, et al. The ability of computed tomography to diagnose placental abruption in the trauma patient.
  J Trauma Acute Care Surg
  . 2013;74:236–241.
  
• Oyelese Y, Ananth CV. Placental abruption: Management. In:
  UpToDate
  . Rose BD, ed. Waltham, MA: UpToDate; 2012.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Placenta Previa
  
• Trauma in Pregnancy
  
• Vaginal Bleeding in Pregnancy
  
• DIC
  

CODES

• 641.20 Premature separation of placenta, unspecified as to episode of care or not applicable
  
• 641.21 Premature separation of placenta, delivered, with or without mention of antepartum condition
  
• 641.23 Premature separation of placenta, antepartum condition or complication
  

BASICS

• Placental tissue overlying or proximate to the internal cervical os
  
• Uterine enlargement and cervical dilation cause placental vessels near the cervix to tear, resulting in vaginal bleeding
  
• >90% of placenta previa diagnosed before 20 weeks will migrate and have normal placental location at term
  
• If placenta covers the internal os by >20 mm, then previa is expected at birth
  
• Increased amount of placental overlap (>15–23 mm) predicts placenta previa present at birth
  
• Causes 20% of all antepartum hemorrhage
  
• Classifications:
  
  • Complete placenta previa: Cervical os is completely covered by placenta
    
  • Partial placenta previa: Cervical os is partially covered by placenta
    
  • Marginal placenta previa: Edge of placenta is at margin of cervical os
    
  • Low-lying placenta: Placenta edge is within 2 cm to cervical os
    

• Unknown etiology
  
• Incidence: 4/1,000 births = 0.4% of pregnancies at term
  
• Maternal mortality: 0.03%
  
• Perinatal morbidity and mortality: Triple, due to preterm delivery
  
• Factors affecting location of implantation:
  
  • Increased number of curettages from spontaneous or induced abortions
    
  • Abnormal endometrial vascularization
    
  • Delayed ovulation
    
• Risk factors:
  
  • Multiparity (5% grand multiparous patients vs. 0.2% nulliparous)
    
  • Multiple gestation
    
  • Prior C-section (up to 3× increase, increases with number or prior C-sections)
    
  • Increased maternal age (0.7% age <19 yr, 1% age ≥35 yr)
    
  • Previous placenta previa (4–8% recurrence)
    
  • Smoking (2–4 times increase)
    
  • Male fetus (14% increase)
    
  • Assisted fertilization
    
  • Residence at higher altitude
    
  • Asian maternal race
    
  • Unexplained elevated maternal serum alpha fetal protein (MSAFP)
    
• Associated conditions:
  
  • Congenital anomalies
    
  • Abnormal fetal presentation
    
  • Preterm premature rupture of the membranes
    
  • Amniotic fluid embolism; associated with pathologies of the placenta
    
  • Vasa previa: Fetal vessels course through membranes and cover os
    
  • Placenta accreta, increta, percreta (growth of placenta into uterine wall) occur in 5–10% of patients with placenta previa; sustained bleeding may require C-section hysterectomy
    

DIAGNOSIS