Overview
Practice Essentials
Abruptio placentae is defined as the premature separation of the placenta from the uterus. Patients with abruptio placentae, also called placental abruption, typically present with bleeding, uterine contractions, and fetal distress. A significant cause of third-trimester bleeding associated with fetal and maternal morbidity and mortality, placental abruption must be considered whenever bleeding is encountered in the second half of pregnancy.{ref121-INVALID REFERENCE} Placental abruption is demonstrated in the image below. (See Clinical.)
Complications
Hemorrhage into the decidua basalis occurs as the placenta separates from the uterus. Vaginal bleeding usually follows, although the presence of a concealed hemorrhage in which the blood pools behind the placenta is possible. (See Workup.)
Hematoma formation further separates the placenta from the uterine wall, causing compression of these structures and compromise of blood supply to the fetus. Retroplacental blood may penetrate through the thickness of the uterine wall into the peritoneal cavity, a phenomenon known as Couvelaire uterus. The myometrium in this area becomes weakened and may rupture with increased intrauterine pressure during contractions. A myometrium rupture immediately leads to a life-threatening obstetric emergency. (See Treatment.)
Classification of placental abruption
Classification of placental abruption is based on extent of separation (ie, partial vs complete) and location of separation (ie, marginal vs central). (See Clinical.) Clinical classification is as follows:
Class 0 - Asymptomatic
Class 1 - Mild (represents approximately 48% of all cases)
Class 2 - Moderate (represents approximately 27% of all cases)
Class 3 - Severe (represents approximately 24% of all cases)
A diagnosis of class 0 is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.
Class 1 characteristics include the following:
No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress
Class 2 characteristics include the following:
No vaginal bleeding to moderate vaginal bleeding
Moderate to severe uterine tenderness with possible tetanic contractions
Maternal tachycardia with orthostatic changes in BP and heart rate
Fetal distress
Hypofibrinogenemia (ie, 50-250 mg/dL)
Class 3 characteristics include the following:
No vaginal bleeding to heavy vaginal bleeding
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, < 150 mg/dL)
Coagulopathy
Fetal death
Go to Emergent Management of Abruptio Placentae for complete information on this topic.
Etiology
The primary cause of placental abruption is usually unknown, but multiple risk factors have been identified. [1, 2, 3] However, only a few events have been closely linked to this condition.
Risk factors in abruptio placentae include the following:
Maternal hypertension - Most common cause of abruption, occurring in approximately 44% of all cases
Maternal trauma (eg, motor vehicle collision [MVC], assaults, falls) - Causes 1.5-9.4% of all cases
Cigarette smoking
Alcohol consumption
Cocaine use
Short umbilical cord
Sudden decompression of the uterus (eg, premature rupture of membranes, delivery of first twin)
Retroplacental fibromyoma
Retroplacental bleeding from needle puncture (ie, postamniocentesis)
Idiopathic (probable abnormalities of uterine blood vessels and decidua) [4]
Previous placental abruption
Chorioamnionitis [5]
Prolonged rupture of membranes (24 h or longer)
Maternal age 35 years or older
Maternal age younger than 20 years
Male fetal sex
Low socioeconomic status
Elevated second trimester maternal serum alpha-fetoprotein (associated with up to a 10-fold increased risk of abruption)
Subchorionic hematoma [6]
Cigarette smoking/tobacco abuse
Cigarette smoking increases a patient's overall risk of placental abruption. [7]
A prospective cohort study showed the risk of abruption to be increased by 40% for each year of smoking prior to pregnancy.
In addition to the increased risk of abruption caused by tobacco abuse, the perinatal mortality rate of infants born to women who smoke and have an abruption is increased. [8, 9]
Cocaine (powder or crack) abuse
The hypertension and increased levels of catecholamines caused by cocaine abuse are thought to be responsible for a vasospasm in the uterine blood vessels that causes placental separation and abruption. However, this hypothesis has not been definitively proven.
The rate of abruption in patients who abuse cocaine has been reported to be approximately 13-35% and may be dose-dependent. [10]
Trauma
Abdominal trauma is a major risk factor for placental abruption.
Motor vehicle accidents often cause abdominal trauma. The lower seat belt should extend across the pelvis, not across the midabdomen, where the fetus is located.
Trauma may also be due to domestic abuse or assault, both of which are underreported.
Thrombophilia
While it was previously thought that patients who experienced early or severe abruptions were at increased risk of having a specific thrombophilia, this is no longer thought to be the case and screening of patients with an abruption is no longer recommended.
Epidemiology
The frequency of abruptio placentae in the United States is approximately 1%, and a severe abruption leading to fetal death occurs in 0.12% of pregnancies (1:830).
Abruptio placentae also occurs in about 1% of all pregnancies throughout the world.
Race predilection
Placental abruption is more common in African American women than in white or Latin American women. However, whether this is the result of socioeconomic, genetic, or combined factors remains unclear.
Age predilection
An increased risk of placental abruption has been demonstrated in patients younger than 20 years and those older than 35 years.
Prognosis
If the bleeding continues, fetal and maternal distress may develop. Fetal and maternal death may occur if appropriate interventions are not undertaken.
The severity of fetal distress correlates with the degree of placental separation. In near-complete or complete abruption, fetal death is inevitable unless an immediate cesarian delivery is performed. [11]
If an abruption occurs, the risk of perinatal mortality is reported as 119 per 1,000 people in the United States, but this can depend on the extent of the abruption and the gestational age of the fetus. [12, 13] This rate is higher in patients with a significant smoking history.
Currently, placental abruption is responsible for approximately 6% of maternal deaths.
Morbidity associated with abruptio placentae
Fetal morbidity is caused by the insult of the abruption itself and by issues related to prematurity when early delivery is required to alleviate maternal or fetal distress.
Maternal morbidity may include the following:
Transfusion-related morbidity
Classic cesarean delivery with need for repeat cesarean deliveries
Hysterectomy [14]
Maternal and fetal complications include issues related to (1) cesarean delivery, (2) hemorrhage/coagulopathy, and (3) prematurity.
Cesarean delivery
Cesarean delivery is often necessary if the patient is far from her delivery date or if significant fetal compromise develops. If significant placental separation is present, the fetal heart rate tracing typically shows evidence of fetal decelerations and even persistent fetal bradycardia.
A cesarean delivery may be complicated by infection, additional hemorrhage, the need for transfusion of blood products, injury of the maternal bowel or bladder, and/or hysterectomy for uncontrollable hemorrhage. In rare cases, death occurs.
Hemorrhage/coagulopathy
Disseminated intravascular coagulation (DIC) may occur as a sequela of placental abruption. Patients with a placental abruption are at higher risk of developing a coagulopathic state than those with placenta previa. The coagulopathy must be corrected to ensure adequate hemostasis in the case of a cesarean delivery.
Prematurity
Delivery is required in cases of severe abruption or when significant fetal or maternal distress occurs, even in the setting of profound prematurity. In some cases, immediate delivery is the only option, even before the administration of corticosteroid therapy in these premature infants. All other problems and complications associated with a premature infant are also possible.
Recurrence
The risk of recurrence of abruptio placentae is reportedly 4-12%. If the patient has abruptio placentae in 2 consecutive pregnancies, the risk of recurrence rises to 25%.
If the abruption is severe and results in the death of the fetus, the risk of a recurrent abruption and fetal demise is 7%.
Maternal cardiovascular mortality
A study by Pariente et al indicated that women who have placental abruption are at increased long-term risk for cardiovascular mortality. The study examined the cardiovascular mortality rate after 653 deliveries in patients with placental abruption, with follow-up occurring over more than 10 years. Although the investigators did not find a significant connection between placental abruption and later, long-term hospitalization for cardiovascular disease, they found a 13% cardiovascular mortality rate in the women who had suffered placental abruption, compared with a 2.5% rate in women who had not. [15]
Patient Education
Educate patients about reversible risk factors, especially smoking, before further pregnancies.
Question the patient regarding possible trauma from abuse.
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Placental abruption seen after delivery.
Fetal tracing with placental abruption. Decreased short-term variability, increased baseline uterine tone, uterine hyperstimulation, and worsening variable decelerations.
Author
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
John G Pierce, Jr, MD Associate Professor, Departments of Obstetrics/Gynecology and Internal Medicine, Medical College of Virginia at Virginia Commonwealth University
John G Pierce, Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Christian Medical and Dental Associations, Medical Society of Virginia, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Chief Editor
Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center
Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association
Disclosure: Nothing to disclose.
Additional Contributors
Bruce A Meyer, MD, MBA Executive Vice President for Health System Affairs, Executive Director, Faculty Practice Plan, Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School
Bruce A Meyer, MD, MBA is a member of the following medical societies: Medical Group Management Association, American College of Obstetricians and Gynecologists, American Association for Physician Leadership, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.
Acknowledgements
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Andrew Satin, MD, to the development and writing of the source article.