Placental abruption

Definition:

Placental abruption is a condition where the placenta partially or completely detaches from the uterine wall before delivery. This detachment can lead to significant maternal and fetal complications due to the loss of placental blood supply and bleeding.

Epidemiology:

Occurs in about 1% of pregnancies but is a leading cause of maternal and fetal morbidity and mortality.
The condition can happen at any time after the 20th week of gestation, but it is most common in the third trimester.

Risk Factors:

Hypertension (chronic or gestational)
Trauma (e.g., motor vehicle accidents, falls)
Previous history of placental abruption
Cigarette smoking and cocaine use
Advanced maternal age
Multiparity (having given birth two or more times)
Premature rupture of membranes
Polyhydramnios (excessive amniotic fluid) or multiple gestations

Clinical Features

Signs and Symptoms:

Vaginal bleeding (though up to 20% of cases may have concealed bleeding)
Abdominal pain, which may be constant or intermittent
Uterine tenderness and rigidity
Fetal distress or decreased fetal movements
Back pain
Uterine contractions, often with increased frequency and intensity

Diagnosis:

Clinical diagnosis is primarily based on symptoms and physical examination.
Ultrasound can be used to assess placental position and exclude placenta praevia but may not always detect abruption.
Monitoring of fetal well-being and maternal status is critical, including fetal heart rate monitoring and assessment of maternal hemodynamic stability.

Management

Immediate Management:

Stabilization of the mother’s condition is the first priority, including managing shock and ensuring adequate blood and fluid replacement.
Fetal monitoring to assess the status of the baby and decide on the timing and mode of delivery.

Delivery:

Vaginal Delivery: If the fetus is in distress and the mother is stable, vaginal delivery may be attempted with close monitoring.
Cesarean Section: In cases of severe abruption, fetal distress, or maternal instability, an immediate cesarean section may be necessary.

Postpartum Care:

Continued monitoring of maternal hemodynamic status and management of bleeding.
Evaluation for coagulopathies, as disseminated intravascular coagulation (DIC) can be a complication of severe abruption.

Complications

Maternal: Hemorrhage, shock, coagulation disorders, renal failure, and in severe cases, hysterectomy.
Fetal: Prematurity, intrauterine growth restriction (IUGR), fetal distress, and stillbirth.

Prognosis

The prognosis depends on the severity of the abruption, gestational age at occurrence, and the speed and effectiveness of the management.
Early detection and prompt management are key to improving outcomes for both mother and baby.

Summary

Placental abruption is a critical condition that necessitates immediate medical attention to prevent severe complications for both the mother and the fetus. Medical students should understand the risk factors, clinical presentation, diagnostic approach, and management principles to effectively contribute to the care of patients with this condition. The ability to quickly recognize and appropriately respond to signs of placental abruption is crucial in obstetric care.