In placental abruption the placenta separates from the uterine wall before the baby is born, causing bleeding behind the placenta and cutting the oxygen supply to the fetus. Key risk factors include high blood pressure, cocaine use, smoking and abdominal trauma.
Key symptoms
- Vaginal bleeding with abdominal or back pain
- Painful, frequent contractions
- Bleeding that can stay hidden behind the placenta and look smaller than the real loss
- Less fetal movement
What you find on exam
- Firm, tender, tense uterus
- Signs of shock out of proportion to the visible bleeding
- Continuous fetal heart rate monitoring: late decelerations or bradycardia
- Blood pressure check for preeclampsia
Tests
- Diagnosis is clinical; ultrasound often misses an abruption
- Blood count, type and crossmatch
- Coagulation tests and fibrinogen to look for DIC
- Rh status; Kleihauer-Betke test if Rh negative
Treatment basics
- Two large IV lines, fluids and blood products; correct clotting problems
- Fetal distress or unstable mother: emergency delivery, usually by cesarean
- Mild abruption, preterm and stable: close monitoring and betamethasone
- Rh immune globulin if Rh negative
Red flags
- Shock, heavy bleeding or a board-hard uterus
- Abnormal fetal heart rate or fetal death
- Low fibrinogen or oozing from IV sites (DIC)
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.