4/2/2017 AbruptioPlacentae:Background,Etiology,Epidemiology

AbruptioPlacentae
Updated:Nov23,2016
Author:ShadHDeering,MDChiefEditor:CarlVSmith,MDmore...

OVERVIEW

Background
Abruptioplacentaeisdefinedastheprematureseparationoftheplacentafromtheuterus.Patients
withabruptioplacentae,alsocalledplacentalabruption,typicallypresentwithbleeding,uterine
contractions,andfetaldistress.Asignificantcauseofthirdtrimesterbleedingassociatedwithfetal
andmaternalmorbidityandmortality,placentalabruptionmustbeconsideredwheneverbleedingis
encounteredinthesecondhalfofpregnancy.[1]Placentalabruptionisdemonstratedintheimage
below.(SeeClinical.)

Placentalabruptionseenafterdelivery.
ViewMediaGallery

Complications
Hemorrhageintothedeciduabasalisoccursastheplacentaseparatesfromtheuterus.Vaginal
bleedingusuallyfollows,althoughthepresenceofaconcealedhemorrhageinwhichthebloodpools
behindtheplacentaispossible.(SeeWorkup.)

Hematomaformationfurtherseparatestheplacentafromtheuterinewall,causingcompressionof
thesestructuresandcompromiseofbloodsupplytothefetus.Retroplacentalbloodmaypenetrate
throughthethicknessoftheuterinewallintotheperitonealcavity,aphenomenonknownas
Couvelaireuterus.Themyometriuminthisareabecomesweakenedandmayrupturewithincreased
intrauterinepressureduringcontractions.Amyometriumruptureimmediatelyleadstoalife
threateningobstetricemergency.(SeeTreatment.)

Classificationofplacentalabruption
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Classificationofplacentalabruptionisbasedonextentofseparation(ie,partialvscomplete)and
locationofseparation(ie,marginalvscentral).(SeeClinical.)Clinicalclassificationisasfollows:

Class0Asymptomatic
Class1Mild(representsapproximately48%ofallcases)
Class2Moderate(representsapproximately27%ofallcases)
Class3Severe(representsapproximately24%ofallcases)

Adiagnosisofclass0ismaderetrospectivelybyfindinganorganizedbloodclotoradepressedarea
onadeliveredplacenta.

Class1characteristicsincludethefollowing:

Novaginalbleedingtomildvaginalbleeding
Slightlytenderuterus
NormalmaternalBPandheartrate
Nocoagulopathy
Nofetaldistress

Class2characteristicsincludethefollowing:

Novaginalbleedingtomoderatevaginalbleeding
Moderatetosevereuterinetendernesswithpossibletetaniccontractions
MaternaltachycardiawithorthostaticchangesinBPandheartrate
Fetaldistress
Hypofibrinogenemia(ie,50250mg/dL)

Class3characteristicsincludethefollowing:

Novaginalbleedingtoheavyvaginalbleeding
Verypainfultetanicuterus
Maternalshock
Hypofibrinogenemia(ie,<150mg/dL)
Coagulopathy
Fetaldeath

GotoEmergentManagementofAbruptioPlacentaeforcompleteinformationonthistopic.

Etiology
Theprimarycauseofplacentalabruptionisusuallyunknown,butmultipleriskfactorshavebeen
identified.[2,3]However,onlyafeweventshavebeencloselylinkedtothiscondition.

Riskfactorsinabruptioplacentaeincludethefollowing:

MaternalhypertensionMostcommoncauseofabruption,occurringinapproximately44%ofall
cases
Maternaltrauma(eg,motorvehiclecollision[MVC],assaults,falls)Causes1.59.4%ofall
cases
Cigarettesmoking
Alcoholconsumption
Cocaineuse
Shortumbilicalcord
Suddendecompressionoftheuterus(eg,prematureruptureofmembranes,deliveryoffirsttwin)
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Retroplacentalfibromyoma
Retroplacentalbleedingfromneedlepuncture(ie,postamniocentesis)
Idiopathic(probableabnormalitiesofuterinebloodvesselsanddecidua)[4]
Previousplacentalabruption
Chorioamnionitis[5]
Prolongedruptureofmembranes(24horlonger)
Maternalage35yearsorolder
Maternalageyoungerthan20years
Malefetalsex
Lowsocioeconomicstatus
Elevatedsecondtrimestermaternalserumalphafetoprotein(associatedwithuptoa10fold
increasedriskofabruption)
Subchorionichematoma[6]

Cigarettesmoking/tobaccoabuse

Cigarettesmokingincreasesapatient'soverallriskofplacentalabruption.[7]

Aprospectivecohortstudyshowedtheriskofabruptiontobeincreasedby40%foreachyearof
smokingpriortopregnancy.

Inadditiontotheincreasedriskofabruptioncausedbytobaccoabuse,theperinatalmortalityrateof
infantsborntowomenwhosmokeandhaveanabruptionisincreased.[8,9]

Cocaine(powderorcrack)abuse

Thehypertensionandincreasedlevelsofcatecholaminescausedbycocaineabusearethoughttobe
responsibleforavasospasmintheuterinebloodvesselsthatcausesplacentalseparationand
abruption.However,thishypothesishasnotbeendefinitivelyproven.

Therateofabruptioninpatientswhoabusecocainehasbeenreportedtobeapproximately1335%
andmaybedosedependent.[10]

Trauma
Abdominaltraumaisamajorriskfactorforplacentalabruption.

Motorvehicleaccidentsoftencauseabdominaltrauma.Thelowerseatbeltshouldextendacrossthe
pelvis,notacrossthemidabdomen,wherethefetusislocated.

Traumamayalsobeduetodomesticabuseorassault,bothofwhichareunderreported.

Thrombophilia

Whileitwaspreviouslythoughtthatpatientswhoexperiencedearlyorsevereabruptionswereat
increasedriskofhavingaspecificthrombophilia,thisisnolongerthoughttobethecaseand
screeningofpatientswithanabruptionisnolongerrecommended.

Epidemiology

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ThefrequencyofabruptioplacentaeintheUnitedStatesisapproximately1%,andasevereabruption
leadingtofetaldeathoccursin0.12%ofpregnancies(1:830).

Abruptioplacentaealsooccursinabout1%ofallpregnanciesthroughouttheworld.

Racepredilection
PlacentalabruptionismorecommoninAfricanAmericanwomenthaninwhiteorLatinAmerican
women.However,whetherthisistheresultofsocioeconomic,genetic,orcombinedfactorsremains
unclear.

Agepredilection

Anincreasedriskofplacentalabruptionhasbeendemonstratedinpatientsyoungerthan20years
andthoseolderthan35years.

Prognosis
Ifthebleedingcontinues,fetalandmaternaldistressmaydevelop.Fetalandmaternaldeathmay
occurifappropriateinterventionsarenotundertaken.

Theseverityoffetaldistresscorrelateswiththedegreeofplacentalseparation.Innearcompleteor
completeabruption,fetaldeathisinevitableunlessanimmediatecesariandeliveryisperformed.[11]

Ifanabruptionoccurs,theriskofperinatalmortalityisreportedas119per1,000peopleintheUnited
States,butthiscandependontheextentoftheabruptionandthegestationalageofthefetus.[12,13]
Thisrateishigherinpatientswithasignificantsmokinghistory.

Currently,placentalabruptionisresponsibleforapproximately6%ofmaternaldeaths.

Morbidityassociatedwithabruptioplacentae
Fetalmorbidityiscausedbytheinsultoftheabruptionitselfandbyissuesrelatedtoprematuritywhen
earlydeliveryisrequiredtoalleviatematernalorfetaldistress.

Maternalmorbiditymayincludethefollowing:

Transfusionrelatedmorbidity
Classiccesareandeliverywithneedforrepeatcesareandeliveries
Hysterectomy[14]

Maternalandfetalcomplicationsincludeissuesrelatedto(1)cesareandelivery,(2)
hemorrhage/coagulopathy,and(3)prematurity.

Cesareandelivery

Cesareandeliveryisoftennecessaryifthepatientisfarfromherdeliverydateorifsignificantfetal
compromisedevelops.Ifsignificantplacentalseparationispresent,thefetalheartratetracing
typicallyshowsevidenceoffetaldecelerationsandevenpersistentfetalbradycardia.

Acesareandeliverymaybecomplicatedbyinfection,additionalhemorrhage,theneedfortransfusion
ofbloodproducts,injuryofthematernalbowelorbladder,and/orhysterectomyforuncontrollable
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hemorrhage.Inrarecases,deathoccurs.

Hemorrhage/coagulopathy
Disseminatedintravascularcoagulation(DIC)mayoccurasasequelaofplacentalabruption.Patients
withaplacentalabruptionareathigherriskofdevelopingacoagulopathicstatethanthosewith
placentaprevia.Thecoagulopathymustbecorrectedtoensureadequatehemostasisinthecaseofa
cesareandelivery.

Prematurity

Deliveryisrequiredincasesofsevereabruptionorwhensignificantfetalormaternaldistressoccurs,
eveninthesettingofprofoundprematurity.Insomecases,immediatedeliveryistheonlyoption,even
beforetheadministrationofcorticosteroidtherapyintheseprematureinfants.Allotherproblemsand
complicationsassociatedwithaprematureinfantarealsopossible.

Recurrence
Theriskofrecurrenceofabruptioplacentaeisreportedly412%.Ifthepatienthasabruptioplacentae
in2consecutivepregnancies,theriskofrecurrencerisesto25%.

Iftheabruptionissevereandresultsinthedeathofthefetus,theriskofarecurrentabruptionand
fetaldemiseis7%.

Maternalcardiovascularmortality

AstudybyParienteetalindicatedthatwomenwhohaveplacentalabruptionareatincreasedlong
termriskforcardiovascularmortality.Thestudyexaminedthecardiovascularmortalityrateafter653
deliveriesinpatientswithplacentalabruption,withfollowupoccurringovermorethan10years.
Althoughtheinvestigatorsdidnotfindasignificantconnectionbetweenplacentalabruptionandlater,
longtermhospitalizationforcardiovasculardisease,theyfounda13%cardiovascularmortalityratein
thewomenwhohadsufferedplacentalabruption,comparedwitha2.5%rateinwomenwhohadnot.
[15]

PatientEducation
Educatepatientsaboutreversibleriskfactors,especiallysmoking,beforefurtherpregnancies.

Questionthepatientregardingpossibletraumafromabuse.

ClinicalPresentation

References

1.MeguerdichianD.Complicationsinlatepregnancy.EmergMedClinNorthAm.2012Nov.
30(4):91936.[Medline].

2.AbuHeijaA,alChalabiH,elIloubaniN.Abruptioplacentae:riskfactorsandperinataloutcome.
JObstetGynaecolRes.1998Apr.24(2):1414.[Medline].

3.OyeleseY,AnanthCV.Placentalabruption.ObstetGynecol.2006Oct.108(4):100516.

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4.AnanthCV,OyeleseY,YeoL,PradhanA,VintzileosAM.PlacentalabruptionintheUnited
States,1979through2001:temporaltrendsandpotentialdeterminants.AmJObstetGynecol.
2005Jan.192(1):1918.[Medline].

5.RanaA,SawhneyH,GopalanS.Abruptioplacentaeandchorioamnionitismicrobiologicaland
histologiccorrelation.ActaObstetGynecolScand.1999May.78(5):3636.[Medline].

6.TuuliMG,NormanSM,OdiboAO,MaconesGA,CahillAG.Perinataloutcomesinwomenwith
subchorionichematoma:asystematicreviewandmetaanalysis.ObstetGynecol.2011May.
117(5):120512.[Medline].

7.AnanthCV,SmulianJC,VintzileosAM.Incidenceofplacentalabruptioninrelationtocigarette
smokingandhypertensivedisordersduringpregnancy:ametaanalysisofobservationalstudies.
ObstetGynecol.1999Apr.93(4):6228.[Medline].

8.AnanthCV,SavitzDA,LutherER.Maternalcigarettesmokingasariskfactorforplacental
abruption,placentaprevia,anduterinebleedinginpregnancy.AmJEpidemiol.1996Nov1.
144(9):8819.[Medline].

9.AnanthCV,SavitzDA,BowesWAJr,LutherER.Influenceofhypertensivedisordersand
cigarettesmokingonplacentalabruptionanduterinebleedingduringpregnancy.BrJObstet
Gynaecol.1997May.104(5):5728.[Medline].

10.HoskinsIA,FriedmanDM,FriedenFJ.Relationshipbetweenantepartumcocaineabuse,
abnormalumbilicalarteryDopplervelocimetry,andplacentalabruption.ObstetGynecol.1991
Aug.78(2):27982.[Medline].

11.TikkanenM,NuutilaM,HiilesmaaV,PaavonenJ,YlikorkalaO.Clinicalpresentationandrisk
factorsofplacentalabruption.ActaObstetGynecolScand.2006.85(6):7005.[Medline].

12.AnanthCV,WilcoxAJ.PlacentalabruptionandperinatalmortalityintheUnitedStates.AmJ
Epidemiol.2001Feb15.153(4):3327.[Medline].

13.TikkanenM,LuukkaalaT,GisslerM,etal.Decreasingperinatalmortalityinplacentalabruption.
ActaObstetGynecolScand.2013Mar.92(3):298305.[Medline].

14.RaymondEG,MillsJL.Placentalabruption.Maternalriskfactorsandassociatedfetal
conditions.ActaObstetGynecolScand.1993Nov.72(8):6339.[Medline].

15.ParienteG,ShohamVardiI,KessousR,etal.Placentalabruptionasasignificantriskfactorfor
longtermcardiovascularmortalityinafollowupperiodofmorethanadecade.PaediatrPerinat
Epidemiol.2014Jan.28(1):328.[Medline].

16.ClarkSL.Placentaepreviaandabruptioplacentae.CreasyRK,ResnikR,eds.MaternalFetal
Medicine.5thed.Philadelphia,Pa:WBSaunders2004.715.

17.GlantzC,PurnellL.Clinicalutilityofsonographyinthediagnosisandtreatmentofplacental
abruption.JUltrasoundMed.2002Aug.21(8):83740.[Medline].

18.KramerMS,UsherRH,PollackR.Etiologicdeterminantsofabruptioplacentae.ObstetGynecol.
1997Feb.89(2):2216.[Medline].

19.ACOGCommitteeOpinion.AntenatalCorticosteroidTherapyforFetalMaturation.ACOG.
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November23,2016.
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MediaGallery

Placentalabruptionseenafterdelivery.
Fetaltracingwithplacentalabruption.Decreasedshorttermvariability,increasedbaseline
uterinetone,uterinehyperstimulation,andworseningvariabledecelerations.

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ContributorInformationandDisclosures

Author

ShadHDeering,MDMedicalDirector,AndersenSimulationCenter,MadiganArmyMedicalCenter

ShadHDeering,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeof
ObstetriciansandGynecologists,AssociationofProfessorsofGynecologyandObstetrics,Societyfor
MaternalFetalMedicine

Disclosure:Nothingtodisclose.

SpecialtyEditorBoard

FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedical
CenterCollegeofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.

JohnGPierce,Jr,MDAssociateProfessor,DepartmentsofObstetrics/GynecologyandInternal
Medicine,MedicalCollegeofVirginiaatVirginiaCommonwealthUniversity

JohnGPierce,Jr,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeof
ObstetriciansandGynecologists,AssociationofProfessorsofGynecologyandObstetrics,Christian
MedicalandDentalAssociations,MedicalSocietyofVirginia,SocietyofLaparoendoscopicSurgeons

Disclosure:Nothingtodisclose.

ChiefEditor

CarlVSmith,MDTheDistinguishedChrisJandMarieAOlsonChairofObstetricsandGynecology,
Professor,DepartmentofObstetricsandGynecology,SeniorAssociateDeanforClinicalAffairs,
UniversityofNebraskaMedicalCenter

CarlVSmith,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofObstetricians
andGynecologists,AmericanInstituteofUltrasoundinMedicine,AssociationofProfessorsof
GynecologyandObstetrics,CentralAssociationofObstetriciansandGynecologists,Societyfor
MaternalFetalMedicine,CouncilofUniversityChairsofObstetricsandGynecology,Nebraska
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4/2/2017 AbruptioPlacentae:Background,Etiology,Epidemiology

MedicalAssociation

Disclosure:Nothingtodisclose.

AdditionalContributors

BruceAMeyer,MD,MBAExecutiveVicePresidentforHealthSystemAffairs,ExecutiveDirector,
FacultyPracticePlan,Professor,DepartmentofObstetricsandGynecology,UniversityofTexas
SouthwesternMedicalSchool

BruceAMeyer,MD,MBAisamemberofthefollowingmedicalsocieties:MedicalGroupManagement
Association,AmericanCollegeofObstetriciansandGynecologists,AmericanAssociationfor
PhysicianLeadership,AmericanInstituteofUltrasoundinMedicine,AssociationofProfessorsof
GynecologyandObstetrics,MassachusettsMedicalSociety,SocietyforMaternalFetalMedicine

Disclosure:Nothingtodisclose.

Acknowledgements

TheauthorsandeditorsofMedscapeReferencegratefullyacknowledgethecontributionsofprevious
authorAndrewSatin,MD,tothedevelopmentandwritingofthesourcearticle.

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