Placental abruption

Placental abruption

Placental abruption is per vaginal bleeding due to premature separation of a normally situated placenta after 28 weeks of gestation.

Clinical presentation

• Vaginal bleeding of dark-coloured blood or clots; sometimes bleeding may be concealed

• Moderate to severe abdominal pain, although pain may be absent in revealed placental abruption

• Enlarged and very tender uterus

• Fetal demise or fetal distress may be present

Management of placental abruption at the dispensary and health centre

• Apply Airway, Breathing, Circulation and Dehydration (ABCD) principles of resuscitation

• Insert a large-bore IV cannula and start rapid infusion of Ringer's lactate or normal saline

• Insert a urethral catheter

Referral

• Resuscitate and refer immediately to a hospital with an escort by a skilled health attendant

Management of placental abruption at the hospital

Investigations

• Ultrasound to assess fetal wellbeing, placental localization, and evidence of retroplacental clot

• Full blood count and blood cross-matching

• Renal function tests, liver function tests, and electrolytes

• Fibrinogen level (if available), D-dimer, PT, PTT, and INR

Note

• The diagnosis of placental abruption is mainly clinical

Maternal resuscitation

• Apply Airway, Breathing, Circulation and Dehydration (ABCD) principles of resuscitation

• Insert two large-bore IV lines and administer normal saline or Ringer's lactate

• Replace crystalloids at a ratio of 3 units of crystalloid for every 1 unit of blood loss

• Blood transfusion is usually necessary

• Provide oxygen supplementation at a flow rate of 6 L/min

• Insert a urinary catheter to monitor fluid input and output

• If disseminated intravascular coagulation (DIC) is present:

  • Give fresh frozen plasma at 1 unit/hour

  • Give 2–4 units of whole blood

• Monitor blood pressure, pulse rate, and bleeding hourly

• Repeat full blood count and clotting profile every 2 hours

Obstetrical management

• If the fetus is alive and viable, perform emergency caesarean section

• If the fetus is dead, vaginal delivery is preferable provided there is no contraindication to vaginal delivery (e.g., uterine scar)

• Perform artificial rupture of membranes

If labour does not start spontaneously:

• Induce labour with oxytocin infusion 5 IU in 500 mL normal saline, starting at 10 drops/minute and increasing the rate every 20 minutes until adequate contractions are achieved

• Perform active management of the third stage of labour and uterine massage

Indications for emergency caesarean section

• Worsening maternal condition

• Failure or non-progress of vaginal delivery

Prophylactic antibiotics

• Amoxicillin + clavulanic acid (FDC) (IV) 1.2 g stat

AND

• Metronidazole (IV) 500 mg stat.