RISK FACTORS: Prior abruption (increases risk 10-fold), Smoking, Severe small for gestational age birth, Alcohol abuse, Hypertension: pregnancy-induced and chronic, Uterine anomalies, Advanced maternal age, Increased risk if hypertensive and parity>3
Drugs that may alter lab results:
β’ Those affecting clotting parameters
β’ RHoD immune globulin less than 12 weeks prior may affect antibody test
Disorders that may alter lab results:
β’ Fibrinogen levels climb to 350-550 mg/dl (3.5-5.5 g/L) in third trimester and must fall to 100-150 mg/dl (1.0-1.5 g/L) before PTT will rise
β’ Fibrin split or degradation products are elevated in pregnancy and are not very helpful in assessing disseminated intravascular coagulation (DIC)
Medical Care: Inpatient admission is required if abruptio placentae is considered likely.
Procedures
Obtain intravenous access using 2 large-bore intravenous lines.
Institute crystalloid fluid resuscitation for the patient.
Type and crossmatch blood.
Begin a transfusion if the patient is hemodynamically unstable after fluid resuscitation.
Correct coagulopathy, if present.
Administer Rh immune globulin if the patient is Rh-negative.
Vaginal delivery
This is the preferred method of delivery for a fetus that has died secondary to placental abruption.
The ability of the patient to undergo vaginal delivery depends on her remaining hemodynamically stable.
Delivery is usually rapid in these patients secondary to increased uterine tone and contractions.
SURGICAL CARE :
Cesarean delivery :
Cesarean delivery is often necessary for both fetal and maternal stabilization.
While cesarean delivery facilitates rapid delivery and direct access to the uterus and its vasculature, it can be complicated by the patient's coagulation status. Because of this, a vertical skin incision, which has been associated with less blood loss, is often used when the patient appears to have DIC.
The type of uterine incision is dictated by the gestational age of the fetus, with a vertical or classic uterine incision often being necessary in the preterm patient.
If hemorrhage cannot be controlled after delivery, a cesarean hysterectomy may be required to save the patient's life.
Before proceeding to hysterectomy, other procedures, including correction of coagulopathy, ligation of the uterine artery, administration of uterotonics (if atony is present), packing of the uterus, and other techniques to control hemorrhage, may be attempted.
ICU: If the patient is hemodynamically unstable, either before or after delivery, invasive monitoring in an ICU may be required.
ACTIVITY : Preterm patients diagnosed with a chronic abruption may be started on a modified bedrest regimen and monitored closely for any signs of maternal or fetal distress that could necessitate delivery.
DRUG TREATMENT : Tocolysis is considered controversial in the management of placental abruption and is considered only in patients (1) who are hemodynamically stable, (2) in whom no evidence of fetal jeopardy exists, and (3) in whom a preterm fetus may benefit from corticosteroids or delay of delivery.
Even in patients meeting these criteria, consultation with an MFM specialist is important. Tocolysis must be undertaken with caution because maternal or fetal distress can develop rapidly. In general, magnesium sulfate is used for tocolysis and beta-sympathomimetic agents are avoided, as the latter may cause significant undesirable cardiovascular effects, such as tachycardia, which may mask clinical signs of blood loss in these patients.
Drug Category:
Tocolytics -- May allow for effective administration of glucocorticoids to the preterm fetus to accelerate fetal lung maturation. In chronic abruption, may also help delay delivery to a gestational age when complications of prematurity are less severe.
- MAGNESIUM SULPHATE
POSSIBLE COMPLICATIONS
β’ Infection transfusion risks: Hepatitis, cytomegalovirus infection, HIV and others
β’ Sensitization from blood product transfusion
β’ Increased pelvic blood fl ow of pregnancy may enhance blood loss
β’ Amniotic fl uid embolism is rare but may present with DIC and severe respiratory distress
β’ Increased risk of fetal-maternal transfusion with trauma of anterior placenta location