Placental abruption Def Classification Etio Clinical features Manageme

Placental abruption Def Classification Etio Clinical features Management

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Placental abruption (abruptio placentae)

Definition

Premature partial or complete separation of a normally implanted placenta from the uterine wall after 20 weeks of gestation and before delivery of the fetus. Bleeding into the decidua basalis forms a retroplacental hematoma, which can worsen separation and compromise fetoplacental oxygen exchange. Textbook of Family Medicine, p. 497

Classification

1. By extent / clinical severity

Grade	Features
Grade 0	Asymptomatic. Diagnosis is made retrospectively by finding a small retroplacental clot at delivery.
Grade 1 - mild	Mild vaginal bleeding, uterine tenderness or irritability may occur; mother is stable; fetus not distressed; coagulation normal.
Grade 2 - moderate	Marked uterine tenderness and hypertonicity, bleeding may be concealed or revealed, maternal tachycardia, fetal distress may be present.
Grade 3 - severe	Severe pain with a rigid, tetanic uterus; major concealed/revealed hemorrhage, maternal shock, coagulopathy/DIC, and commonly fetal death.

2. By pattern of bleeding

Revealed (external) abruption: Blood escapes through the cervix as vaginal bleeding.
Concealed abruption: Blood remains behind the placenta, so apparent vaginal blood loss may be minimal despite severe maternal hemorrhage.
Mixed abruption: Both concealed and external bleeding occur.

Etiology / risk factors

Often no single cause is identified. Important associations are:

Hypertensive disorders of pregnancy, especially preeclampsia and chronic hypertension
Previous placental abruption - strongest predictor of recurrence
Abdominal trauma, including road traffic injury and intimate-partner violence
Smoking and cocaine use
Multiparity and extremes of maternal age
Premature rupture of membranes and chorioamnionitis
Polyhydramnios or sudden uterine decompression, for example after delivery of the first twin
Multiple gestation
Thrombophilia
Prior miscarriage, infertility, or uterine abnormalities
Iatrogenic causes such as amniocentesis, rarely

Hypertension, trauma, alcohol excess, cocaine use, tobacco exposure, and sudden uterine decompression are documented associations. Textbook of Family Medicine, p. 497 Previous abruption, cocaine, smoking, hypertensive disorders, trauma, PROM, and chorioamnionitis are also emphasized in Swanson's Family Medicine Review.

Clinical features

Maternal

Sudden-onset painful vaginal bleeding, usually dark blood
Abdominal pain or backache
Uterine tenderness
Uterine hypertonicity: firm, "board-like" or tetanic uterus
Frequent, low-amplitude contractions
Shock out of proportion to visible blood loss, particularly in concealed abruption
Features of DIC: bleeding from venepuncture sites, petechiae, low fibrinogen

Fetal

Non-reassuring fetal heart rate pattern
Fetal distress due to impaired placental perfusion
Reduced or absent fetal movements
Fetal death in extensive abruption

Important: absence of vaginal bleeding does not exclude abruption. Around 10%-20% may have occult/concealed bleeding. Ultrasound can detect a hematoma but has limited sensitivity, so a normal scan does not rule out abruption. ROSEN's Emergency Medicine, p. 3355

Management

Placental abruption is an obstetric emergency. Management depends on maternal stability, severity of hemorrhage/coagulopathy, fetal status, gestational age, and whether labor is progressing.

1. Immediate resuscitation and assessment

Call senior obstetric, anesthetic, neonatal, and blood-bank teams.
ABC approach: oxygen if needed, continuous monitoring of pulse, BP, oxygen saturation, and urine output.
Left lateral tilt to reduce aortocaval compression.
Insert two large-bore IV cannulas.
Give warmed IV crystalloid initially and activate massive hemorrhage protocol where required.
Arrange cross-matched blood and blood products early.
Continuous cardiotocography if fetus is viable.
Avoid a digital vaginal examination until placenta previa has been excluded. A gentle speculum examination may be used when appropriate.

2. Investigations

CBC with platelet count
Blood group, Rh status, type and cross-match
Coagulation profile: PT/INR, aPTT, fibrinogen, D-dimer/fibrin degradation products
Renal and liver function tests
Kleihauer-Betke test or equivalent assessment of fetomaternal hemorrhage, especially if Rh-negative
Ultrasound for placental location and alternative diagnoses, but do not delay treatment for imaging

A falling fibrinogen is an important warning of severe abruption and consumptive coagulopathy. ROSEN's Emergency Medicine, p. 3355

3. Correct hemorrhage and coagulopathy

Packed red cells for major blood loss.
Fresh frozen plasma, platelets, and cryoprecipitate/fibrinogen replacement guided by clinical state and laboratory values.
Monitor for DIC, acute kidney injury, and postpartum hemorrhage.
Give anti-D immunoglobulin to an unsensitized Rh-negative mother after assessment for fetomaternal hemorrhage. Textbook of Family Medicine, p. 497

4. Delivery decision

Immediate delivery is indicated if:

Maternal hemodynamic instability or ongoing significant bleeding
DIC or worsening coagulopathy
Non-reassuring fetal status in a viable fetus
Severe abruption at term
Fetal death with maternal condition deteriorating or bleeding continuing

Mode of delivery

Emergency cesarean section: Usually required when the fetus is alive and distressed, and vaginal birth is not imminent.
Vaginal delivery: Preferred or appropriate when:
- Fetus has died
- Mother is stable
- Labor is established or delivery is expected soon
- There is no contraindication to vaginal delivery

When fetal death has occurred, vaginal delivery generally avoids the added hemorrhagic risk of cesarean section unless there is another maternal indication for surgery.

5. Expectant management

May be considered only for a mild, stable, preterm abruption with:

No active significant bleeding
Reassuring fetal surveillance
No maternal coagulopathy
Facilities for close inpatient monitoring and immediate delivery if status changes

Give antenatal corticosteroids if preterm delivery is likely and time permits. Magnesium sulfate may be used for fetal neuroprotection at very preterm gestations, according to local protocol. Do not use tocolysis in significant abruption or active bleeding.

Complications

Maternal hemorrhagic shock
DIC
Acute renal failure
Couvelaire uterus
Postpartum hemorrhage, hysterectomy, and rarely maternal death
Fetal hypoxia, growth restriction, prematurity, and intrauterine fetal death

Recent-evidence note: a 2025 systematic review and meta-analysis on independent risk factors is available (PMID: 40140972). It supports risk-factor assessment but does not replace emergency management based on maternal and fetal condition.

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