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| Abruptio placentae |
Premature separation of otherwise normally implanted placenta. Sher's grades:
1: minimal or no bleeding; detected as retroplacental clot after delivery of viable fetus.
2: viable fetus with bleeding and tender irritable uterus.
3: type A with dead fetus and no coagulopathy; type B with dead fetus and coagulopathy (about 30% of grade 3's).
It is a second or third trimester vaginal bleeding greater than one pad or tampon per hour. Patient usually complained of back pain, abdominal pain, uterine tenderness, hypertonia, or high frequency contractions. Blood loss may be concealed; clinical signs of shock may occur with little vaginal bleeding. Since blood volumes increase in pregnancy, volume lost may exceed 30% before signs of shock or hypovolemia. Vital signs may be preserved even with significant loss.Fetal distress or demise. Idiopathic preterm labor with or without fetal distress Causes are cocaine use and abuse, trauma of variable amounts; especially blunt abdominal trauma in which external signs of trauma may be incongruent with fetal injury (motor vehicle accidents or domestic violence), sudden decompression of over-distended uterus as in hydramnios or twin gestation
RISK FACTORS:
•Prior abruption
•Maternal smoking
•Severe small for gestational age birth
•Alcohol abuse
•Hypertension: pregnancy-induced and chronic
•Increased risk if hypertensive and parity > 3
•Preterm rupture of membranes, especially if bleeding occurs during observation interval
•Vaginal bleeding before spontaneous rupture of membranes
LABORATORY:
•Blood type, Rh, Coombs
•CBC with platelet count
•Prothrombin time (PT) , partial thromboplastin time (PTT), fibrinogen levels
•Cross match at least three units
SPECIAL TESTS:
•Kleihauer-Betke for fetal-maternal transfusion
•Bedside clot test with red top tube of maternal blood with poor or non-clotting blood after 7-10 minutes indicating coagulopathy
•Apt test for fetal blood origin: mix vaginal blood with small amount tap water to cause hemolysis, centrifuge several minutes, mix pink hemoglobin containing supernatant with 1 cc 1% sodium hydroxide (NaOH) for each 5 cc supernatant, reading color in two minutes with fetal Hgb staying pink and adult turning yellow-brown
•Wright stain vaginal blood, observe for nucleated RBC's - usually of fetal origin
•Lecithin/sphingomyelin (L/S) ratio if delay of delivery is an option and length of pregnancy is preterm
IMAGING:
•Although ultrasound may show sonolucent retroplacental clot, rounded placenta margin or thickened placenta, it is often not definitive - especially with posterior placement or mild abruption
DIAGNOSTIC PROCEDURES:
•External uterine monitoring often shows elevated baseline pressure and frequent low amplitude contractions
GENERAL MEASURES:
•History and physical exam with past medical history, allergies, prior ultrasounds this gestation, and time of last meal
•In general, severe abruption best managed by delivery of fetus
•Sher's grade 1 - usual labor protocol
•Sher's grade 2 - rapid delivery most often by cesarean section
•Sher's grade 3 - vaginal delivery preferable if mother stable
•In trauma monitor inpatient at least 4 hours for evidence of fetal insult, abruption, fetal-maternal transfusion
•Early aggressive restoration of maternal physiology to protect fetus and maternal organs from hypoperfusion/DIC
•Stabilize vitals, keep Hct >30, urine output >30 cc/hr
•Bedrest with external fetal and labor monitoring, if fetus is viable
•Large bore 16-18 gauge IV crystalloid infusion, central line placement only after coagulation status has been assessed
•Transfusions of whole blood may be necessary
•Follow hemoglobin/hematocrit (H/H) and coagulation status every 1-2 hours
•Place intrauterine pressure catheter (IUC) since fetal risk climbs with elevated pressure
•Role of amniotomy to prevent amniotic fluid embolism is debatable but will speed delivery
•Positioning on left side may enhance venous return and cardiac output
•Oxygen for all patients
•If trauma without compromise after observation or small abruption and preterm may observe outpatient encouraging reduction of risk factors
SURGICAL MEASURES:
May need cesarean section after maternal stabilization if fetus viable and situation urgent
ACTIVITY:
Bedrest until status defined
DIET:
NPO until status defined and cesarean section possibility ruled out
POSSIBLE COMPLICATIONS:
•Infection transfusion risks: Hepatitis, cytomegalovirus infection, HIV and others
•Sensitization from blood product transfusion
EXPECTED COURSE AND PROGNOSIS:
•0.5% to 1% fetal mortality and 30-50% perinatal mortality
•With trauma and abruption 1% maternal and 30-70% fetal mortality
•Labor typically more rapid but hypotonus from blood suffusion may occur |
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