Placental Abruption

Premature separation of a normally sited placenta from the uterine wall before delivery, causing bleeding into the decidua basalis.

Risk factors include hypertension and pre-eclampsia (the strongest association), previous abruption, trauma, smoking and cocaine use, multiple pregnancy, polyhydramnios with rapid decompression (as with membrane rupture), and preterm premature rupture of membranes.

Classically painful vaginal bleeding with a tense, tender, "woody hard" uterus, in contrast to the painless bleeding of placenta praevia.

Bleeding may be revealed (visible vaginally) or concealed (retroperitoneal, behind the placenta, with disproportionately severe systemic signs relative to visible blood loss).

Fetal distress or fetal death may be the presenting feature in severe abruption.

Uterine contractions are frequently present, and preterm labor commonly follows.

Primarily clinical, based on the pain, tenderness, and bleeding pattern; ultrasound is poor at reliably detecting abruption (retroplacental clot is visualized in only a minority of cases) but is used to assess fetal wellbeing and exclude placenta praevia as an alternative cause of bleeding.

Cardiotocography assesses fetal status.

Coagulation profile is essential, given the risk of DIC, particularly with concealed abruption or fetal death, from release of thromboplastin into the maternal circulation.

FBC, group and crossmatch, Kleihauer test (quantifies fetomaternal hemorrhage, guiding anti-D dosing).

Managed as an obstetric emergency: senior obstetric and anesthetic involvement, ABC assessment, two large-bore IV access, aggressive fluid resuscitation, and crossmatched blood
Fetal status dictates urgency: a non-reassuring or absent fetal heart rate with maternal instability warrants immediate delivery, generally by emergency cesarean unless vaginal delivery is imminent
With a live fetus and reassuring CTG, continuous fetal monitoring and expedited delivery (mode depending on gestation, severity, and cervical status)
Intrauterine fetal death with abruption: vaginal delivery is generally preferred once the mother is stabilized, given the coagulopathy risk with cesarean in this setting, unless maternal condition mandates otherwise
Correct coagulopathy aggressively with fresh frozen plasma, cryoprecipitate, and platelets as guided by coagulation results and ongoing bleeding (see Postpartum Haemorrhage entry for detailed transfusion principles)
Anti-D prophylaxis for Rh negative women, dose guided by Kleihauer result where significant fetomaternal hemorrhage is suspected
Corticosteroids for fetal lung maturation if preterm and delivery is not immediately mandated

Referral: obstetric emergency requiring immediate senior obstetric, anesthetic, and neonatal involvement.

Uterine Rupture

Complete or partial disruption of the uterine wall during pregnancy or labor, a catastrophic obstetric emergency carrying high maternal and fetal mortality if not immediately recognized and managed.

The strongest risk factor is a previous cesarean section or other uterine surgery (myomectomy, previous rupture), particularly with a classical (vertical) uterine incision, which carries a substantially higher rupture risk than a lower segment transverse incision.

Other risk factors include obstructed labor (see that entry, a major cause in settings with limited cesarean access), injudicious oxytocin use, grand multiparity, and uterine over-distension (multiple pregnancy, polyhydramnios).

Sudden, severe abdominal pain, often described as tearing, sometimes with a brief cessation of contractions after previously strong labor
Sudden, sustained fetal bradycardia or other severe CTG abnormality is frequently the first and most reliable sign, particularly in a trial of labor after cesarean, and should prompt immediate consideration of rupture
Vaginal bleeding, though this may be minimal despite significant intra-abdominal hemorrhage
Loss of station of the presenting part (the fetal head, previously engaged, becomes palpable higher or is no longer palpable on vaginal examination) as the fetus extrudes into the abdominal cavity
Maternal tachycardia, hypotension, and signs of hypovolemic shock, which may be disproportionate to visible blood loss given concealed intraperitoneal hemorrhage
Scar tenderness in a woman with a previous cesarean section attempting vaginal birth

Primarily clinical, given the need for immediate action; imaging is not used to confirm the diagnosis in the acute setting, since any delay for imaging risks maternal and fetal death.

The combination of sudden fetal bradycardia, severe abdominal pain, and maternal hemodynamic compromise, particularly in a woman with a uterine scar or obstructed labor, should prompt immediate emergency laparotomy without waiting for further confirmatory testing.

Immediate emergency laparotomy is the definitive management, with delivery of the fetus and repair or, where repair is not feasible or bleeding is uncontrollable, hysterectomy
Call for senior help immediately: senior obstetrician, senior anesthetist, and theatre team activated as a maximum obstetric emergency
Aggressive maternal resuscitation as for any major hemorrhage: two large-bore IV access, crossmatched blood, activation of the massive transfusion protocol as needed (see Postpartum Haemorrhage entry for detailed transfusion principles)
Uterine repair is attempted where the rupture is amenable and future fertility is desired and feasible; hysterectomy is performed where repair is not possible or bleeding cannot otherwise be controlled
Neonatal resuscitation team present at delivery given the high risk of severe fetal hypoxia
Counseling regarding future pregnancy: subsequent pregnancies after uterine rupture are managed with planned cesarean delivery, typically before the onset of labor, given the substantially elevated recurrence risk with any subsequent labor

Referral: this is a maximum obstetric emergency requiring immediate senior obstetric, anesthetic, and theatre team activation.

Placental Abruption

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management