PLACENTAL ABRUPTION

Etiopathogenesis:
- Separation of the placenta-either partially or totally-from its implantation site before delivery is described
by the Latin term abruptio placentae.
- Rending asunder of the placenta
o Denotes sudden accident that is a clinical characteristic of most cases
- Premature separation of the normally implanted placenta- most descriptive
- Initiated by hemorrhage into the decidua basalis decidua splits, leaving a thin layer adhered to the
myometrium
o Begins as a decidual hematoma expands to case separation and compression of adjacent
placenta
o Rupture of decidual spiral artery and then expanding retroplacental hematoma
- Early stages: clinical sx may be absent
- Bleeding can lead to external hemorrhage or concealed hemorrhage (delayed diagnosis translates into
greater maternal and fetal hazards; likelihood of consumptive coagulopathy is elevated [ due to increased
pressure within the intervillous space, caused by the expanding retroplacental clot, forces more placental
thromboplastin into the maternal circulation])
deined severe
abruption as displaying one or more of the following: ( 1 ) maternal
sequelae that include disseminated intravascular coagulation,
shock, transfusion, hysterectomy, renal failure, or death; (2) fetal complications such as nonreassuring
fetal status, growth restriction, or death; or
(3) neonatal outcomes that include death,
- preterm delivery, or growth restriction.

TRAUMATIC ABRUPTION (ch 47, p 928)

- external trauma- usually from motor vehicle accidents or aggravated assault
- fetomaternal hemorrhage- more common with trauma because of concomitant placental tears or “fractures”

CHRONIC ABRUPTION
- observed assoc between some abnormally elevated MSA markers and subsequent abruption
- correlated first- and second trimester bleeding with third tri placental abruption
- some cases, chronic abruption-oligohydramnios sequence (CAOS)

Frequency: most of increase in cases in black women

- variations in management of early-onset preeclampsia

Perinatal morbidity and mortality

- perinatal outcomes are influenced by gestational age and frequency of placental abruption rises across
the third trimester
- perinatal mortality and morbidity are more common in earlier abruptions
- major fetal congenital anomalies have greater assoc with placental abruption
- neonatal deaths common following placental abruption

Predisposing factors
- demographics: advancing maternal age, great parity (conflicting data), race and ethnicity, familial
association ( if a woman had a severe abruption, the risk for her sister was doubled)
- pregnancy-assoc HTN:
o frequency of placental abruption in treated chronically HTNsive women (1%) was threefold
higher than the baseline (0.3 percent)
- preterm prematurely ruptured membranes
o risk of abruption with PROM id further increased with comorbid infection (inflammation +
infection + preterm deliverymay be primary causes leadin to abruption
 o 8-fold higher abruption risk in pregnancies >=34 weeks if hydramnios was a comorbid
 Abrupt uterine decompression during membrane rupture may be an inciting factor
- Prior abruption
o High recurrence rate
o Prior 2 severe abruptions, risk for a third was increased 50-fold
o Because term abruptions tend to recur, recommended labor induction at 37 weeks
- Other assoc
o Cigarette smoking- 2fold risk
 5fold if smoker had chronic HTN, severe preeclampsia or both
 Antepartum vit C and E were reported to be protective for abruption in smoekrs
o Cocaine abuse
o Uterine leiomyoma esp if located near the mucosal surface behind the placental implantation site
o Isolated single umbilical artery
 3.4fold increased risk
 Twins from infertility treatment also carry greater risk
 Subclinical hypothyroidism or high levels of antithyroid Abs- 2-3fold risk

DIAGNOSTICS
- Primarily clinical
- Only 2-25% of abruptions are diagnosed by ultrasound (evidenced by retroplacental clot)
- UTZ
o Routinely performed to r/o previa in cases of suspected abruption
o (-) findings do NOT exclude placental abruption
- May be confirmed by inspection of placenta at delivery
- Presence of retroplacental clot with overlying placental destruction confirms diagnosis

POGS: Abruptio placenta should be diagnosed clinically, as there are no sensitive or reliable diagnostic tests
available

Ultrasound
Ultrasound is almost always the first (and usually the only) imaging modality used
to evaluate placental abruption, but an index of suspicion should be maintained
for the diagnosis since ultrasound is relatively insensitive for the diagnosis 9. This
is partly because a retroplacental hematoma may be identified only in 2-25% of
all abruptions.

The sonographic signs of placental abruption include:

 retroplacental hematoma (often poorly echogenic)

 intraplacental anechoic areas
 separation and rounding of the placental edge
 thickening of the placenta: often to over 5.5 cm
 thickening of the retroplacental myometrium: usually should be 1-2 cm unless
there is a focal myometrial contraction
 disruption in retroplacental circulation
 intra-amniotic echoes due to intra-amniotic hemorrhage
 blood in the fetal stomach
 intermembranous clot in twins
The echogenicity of hematomas depends upon their age. Acute hematomas
imaged at the time of symptoms tend to be hyperechoic or isoechoic compared
to the adjacent placenta. As the hematoma is commonly isoechoic to the
placenta, it may be mistaken for focal thickening of the placenta. A 'normal'
ultrasound does not exclude a placental abruption-particularly as the blood
may have escaped through the vagina in the case of external hemorrhage

In other cases, the retroplacental hematoma may be hypoechoic or of

heterogeneous echogenicity.

Reasons for the poor sonographic detection of abruption are as follows: (a) the echotexture of acute
hemorrhage is very similar to that of the adjacent placenta and, therefore, very diffi cult to detect ( 7 );
(b) the sign of an abnormally thick and heterogeneous placenta is rare, being present only in large acute
clots ( 8 ); and (c) many subacute clots may not be visualized because blood dissects out from beneath
the pla

MRI
MR imaging can accurately detect placental abruption and should be considered
after negative US findings in the presence of late pregnancy bleeding if the
diagnosis of abruption would change management.

Hemorrhage due to abruption appears as an area of medium to high signal

intensity on T1 and high signal intensity on a T2 weighted image, located
between the placenta and uterine wall.

Additional clinical findings:

- Hypovolemic shock
- Consumptive coagulopathy- activation of intravascular coagulation with varying degrees of
defibrination

MANAGEMENT

The diagnosis of abruptio placentae is primarily clinical, but findings particularly from imaging and
postpartum pathologic studies can be used to support the clinical diagnosis. Women with an acute abruption
classically present with the abrupt onset of mild to moderate vaginal bleeding and abdominal and/or back
pain, accompanied by uterine contractions. The uterus has increased tone/rigidity and may be tender both
during and between contractions. In patients with classic symptoms, fetal heart rate abnormalities or
intrauterine fetal demise and/or maternal disseminated intravascular coagulation (DIC) strongly support the
clinical diagnosis and indicate extensive placental separation.
Ultrasound examination is useful for identifying a retroplacental hematoma and for excluding other
disorders associated with vaginal bleeding and abdominal pain (see 'Differential diagnosis' below). A
retroplacental hematoma is the classic ultrasound finding and strongly supports the clinical diagnosis, but is
absent in many patients with abruption.
because abruption can present clinically in a similar fashion to
placenta previa with vaginal bleeding, ultrasonography is routinely performed
to rule out previa in cases of suspected abruption. Importantly, negative
findings on ultrasound examination do NOT exclude placental abruption.
Magnetic resonance imaging can detect abruptions missed by ultrasound examination, but increased
diagnostic certainty is unlikely to change management or be cost-effective
The diagnosis of abruption may be confirmed by inspection of the placenta at
delivery. The presence of a retroplacental clot with overlying placental
destruction confirms the diagnosis.
Kleihauer-Betke (KB) test