Approach

The treatment depends on the gestational age and on the condition of the mother and fetus. If there is fetal demise, the goal is to minimise morbidity to the mother. In cases of a live fetus at term, prompt delivery is indicated. If there is evidence of fetal compromise, delivery by caesarean section is usually indicated. In gestations at 34 weeks or less, conservative management may be attempted if both the mother and the fetus are stable.

Initial management

For all women with placental abruption, initial treatment should consist of stabilisation and monitoring of the fetus and the mother. This includes:

  • Intravenous access with wide-bore cannulas.

  • FBC for evidence of anaemia. Haematocrit and haemoglobin (Hb) levels may be low.

  • Coagulation profile looking for evidence of impaired coagulation. Low fibrinogen levels and a prolonged PT are suggestive of impaired coagulation due to disseminated intravascular coagulation (DIC).

  • Monitoring of the mother's haemodynamic status by monitoring BP, pulse, volume intake, and urine output.

  • Continuous fetal monitoring.

  • Anti-D immunoglobulin in Rh-negative women.

  • Fluid, antifibrinolytics, blood, or blood-product replacement, as indicated.

  • Sonographic examination for placental location and for evidence of abruption. Placenta praevia found on sonography makes placental abruption unlikely.

The goals are to prevent hypovolaemia, anaemia, and DIC. Blood and fluid replacement needs can be determined by estimated blood loss, and by vital signs (BP, pulse, and urine output). The goal should be to keep the Hb level above 100 g/L (10 g/dL) and Hct above 30%. Urine output should be at least 30 mL/hour.

In acute severe haemorrhage the use of antifibrinolytics (such as tranexamic acid) can be considered as they have been shown to have a survival benefit if given early (within 3 hours).[59] Transfusions should be given as needed. It is important to be proactive in giving blood. Fresh frozen plasma should be given early if there is any sign of DIC, because this will replace clotting factors. It is essential to replace volume, blood, and blood products aggressively. 

Not infrequently, a woman who was involved in trauma, such as a motor vehicle accident, will be evaluated for abruption. However, abruption may occur in the absence of direct abdominal trauma. In addition, abruption may become clinically apparent only several hours or days after the trauma. The Society of Obstetricians and Gynaecologists of Canada recommends that women involved in trauma should have fetal monitoring for a minimum of 4 hours.[60] If there are uterine contractions, abnormal fetal heart rate tracings, severe maternal trauma, vaginal bleeding, uterine tenderness, or rupture of the membranes, further evaluation and/or delivery are indicated as determined by gestational age and individual circumstances.[60] There are no clinical trials to guide timing of delivery for women with preterm abruption. Expert opinion suggests that delivery for stable women with a high index of suspicion for a placental abruption should be in the late preterm or early term period.[61]

Live fetus: >34 weeks' gestation

The aim in these circumstances is expeditious delivery. If the mother is in a stable condition and the fetal heart tracing is reassuring, then vaginal delivery can be attempted.[61] Often the mother is having vigorous contractions, but if the mother is not in active labour, amniotomy and oxytocin induction usually results in delivery. Blood coagulation products should be readily available and replaced aggressively if needed.

If the maternal condition is worsening with severe haemorrhage, urgent caesarean delivery may be indicated (although rarely). Unnecessary delay should be avoided. A study demonstrated that neonates born to women with placental abruption and bradycardia had better perinatal outcomes if the decision-delivery interval for caesarean delivery was <20 minutes.[62] It is important that both blood and blood products are replaced before and during the surgery.

In cases of placental abruption, after delivery, the uterus may not contract adequately, and therefore haemorrhage may be difficult to control. Utero-tonic agents such as oxytocin, methylergometrine, and prostaglandin analogues may be given. In severe cases, where bleeding is unresponsive to delivery and to administration of utero-tonic agents, surgical ligation of the uterine arteries or the hypogastric arteries may be life-saving. In centres with an adequately skilled interventional radiologist, selective embolisation of these vessels may lead to cessation of this life-threatening haemorrhage. In cases that fail to respond to these conservative methods, hysterectomy may be necessary. Coagulation derangement should be actively corrected while these procedures are taking place.

Live fetus: ≤34 weeks' gestation

If delivery is planned or expected before 34 weeks' gestation, intravenous magnesium sulfate (for neuroprotection of the baby) and antenatal corticosteroids (to mature fetal lungs) are recommended.[63][64]​​ Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria, treatment regimens, and concurrent tocolysis.[64]​ There is no evidence that magnesium sulfate has any value as a tocolytic agent, and its use should only be for neuroprotection in appropriate groups of women.[65]

If the fetus and mother are both stable and there is no evidence of maternal coagulopathy, hypotension, or severe ongoing blood loss, conservative management with the aim of delivering a more mature fetus is the main goal of therapy.

Tocolytics may be used with extreme caution in cases where there are uterine contractions in pregnancies >24 weeks. This is controversial, but small studies have confirmed that careful use of tocolytics may be safe in these circumstances.[66][67][68]​​ The FDA has warned against the off-label use of injectable terbutaline for the long-term (i.e., >72 hours) treatment or prevention of preterm labour, due to an increased risk of maternal cardiovascular adverse effects. Oral terbutaline is now contraindicated for this indication. Therefore, terbutaline should not be used for this indication in pregnant women with suspected abruption.

The status of both fetus and mother require close monitoring. This includes a combination of regular sonograms, fetal heart rate monitoring, and biophysical profiles. The particular monitoring programme must be individualised on a case-by-case basis. The mother may occasionally be managed as an outpatient but should be instructed to report immediately should she experience bleeding, severe abdominal pain, contractions, or reduced fetal movements.

There is an increased risk of stillbirth so it is recommended that delivery by 37 to 38 weeks is considered.

If the fetus or mother is not stable, delivery should take place promptly, with concurrent stabilisation of the fetus and mother. This is usually by caesarean, unless delivery is imminent and can be achieved safely. It is important that both blood and blood products are replaced before and during the surgery.

Utero-tonic agents or haemostatic interventions may be given post-placental delivery to control haemorrhage.

Fetal demise

The approach to management is similar to that when the fetus is alive (i.e., expeditious delivery, preferably by the vaginal route). If the mother is not in active labour, she can be induced by amniotomy and oxytocin. Women who have had an abruption sufficient to cause fetal demise are highly likely to have DIC.

If the maternal condition is worsening with severe haemorrhage, caesarean delivery may be indicated (although rarely). It is important that both blood and blood products are replaced before and during the surgery.

The uterus may not contract adequately in these cases, and therefore haemorrhage may be difficult to control. Utero-tonic agents or haemostatic interventions may be given post-placental delivery to control haemorrhage.

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