Definition

Plasenta abruption is separation from

its implantation site before delivery and

in Great Britain, accidental hemorrhage.
The Latin term abruptio placentae
means rending asunder of the
placenta and denotes a sudden
accident, which is a clinical
characteristic of most cases. The
cumbersome term premature
separation of the normally implanted
placenta is most descriptive.

 The bleeding of placental abruption typically

insinuates itself between the membranes and

uterus, ultimately escaping through the cervix,
causing external hemorrhage.
Less often, the blood does not escape
externally but is retained between the detached
placenta and the uterus, leading to concealed
hemorrhage
Placental abruption may be total or partial.
Concealed hemorrhage carries much greater
maternal and fetal hazards. This is not only
because of possible consumptive coagulopathy,
but also because the extent of the hemorrhage
is not readily appreciated, and the diagnosis
typically is delayed

Concealed
hemorrhage
Placenta
Complete
Abruption
External
hemorrhage

Partial
placenta
Previa
External
hemorrhage

Hemorrhage from extensive placental abruption.

External hemorrhage: the placenta has detached peripherally, and
the membranes between the placenta and cervical canal are
detached from the underlying decidua. This allows blood egress
through the vagina.
Concealed hemorrhage: the periphery of the placenta and the
membranes are still adhered and blood remains within the uterus.
Partial placenta previa: there is placental separation and external
hemorrhage.

Epidemiology
Abruption severity often depends on

how quickly the woman is seen

following symptom onset. With delay,
the likelihood of extensive separation
causing fetal death is increased
remarkably.
The frequency with which placental
abruption is diagnosed varies because
of different criteria, but reported
frequency averages 1 in 200 deliveries.

Epidemiology
National Center for Health Statistics ~

incidence in singleton births of 1 in 160.

Birth certificate data for the US for 2003
~ incidence of placenta abruption was
found to be 1 in 190 deliveries.
Parkland Hospital from 1988 - 2006 ~
incidence of placenta abruption in more
than 280,000 deliveries has been
approximately 1 in 290.

Epidemiology
Both incidence and severity have

decreased over time

As the number of high parity women
giving birth decreased and as
availability of prenatal care and
emergency transportation improved,
the frequency of abruption causing
fetal death dropped to approximately 1
in 830 delivery from 1974-1989.
Between 1996-2003, it decreased
further to approximately 1 in 1600.

Perinatal Morbidity and

Mortality
(Salihu and colleagues) in the US between

1995-1998 ~ the perinatal mortality rate

associated with placental abruption was
119 per 1000 births compared with 8 per
1000 for those without this complication.
The high perinatal mortality rate ~
increased incidence of preterm delivery and
fetal-growth restriction.
There are also increased serious adverse
sequele in infants who survive (neurological
deficits).

Etiology
Many cases continue to be idiopathic, but placental
abruptio is associated with maternal hypertension,
advanced maternal age, multiparity, cocaine use,
tobacco use, chorioamnionitis, and trauma.
1. Patients with chronic hypertension, superimposed
pre-eclampsia, or severe pre-eclampsia have a
fivefold increased risk of severe abruption compared
to normotensive counterparts. Moreover,
antihypertensive medications have not been shown
to reduce the risk of abruption in patients with
chronic hypertension
2. In patients who smoke, the risk of a stillbirth resulting
from placental abruption is increased 2.5-fold and
increases 40% for each pack per day smoked

Etiology
4. Rarely, rapid contraction of an overdistended
uterus may lead to abruption, such as with
rupture of membranes with polyhydramnios,
or delivery of an infant in a multiple
gestation.
5. Abruptions also occur more frequently when
the placenta implants over a uterine
anomaly or myoma.
6. Inherited thrombophilias, such as
hyperhomocysteinemia, Factor V Leiden and
prothrombin 20210 mutations are associated
with an increased risk of abruption

Clinical Manifestation
The amount of external bleeding varies

from none to massive hemorrhage. The

amount of bleeding, however, does not
correlate well with the severity of the
abruption
The presence of blood in the basalis
stimulates uterine contractions, which
results in abdominal pain.
Fetal and maternal mortality rates vary,
depending on the location and size of the
hemorrhage.

Pathophisiology
Placental abruption is initiated by hemorrhage

into the decidua basalis. The decidua then

splits, leaving a thin layer adhered to the
myometrium. Consequently, the process in its
earliest stages consists of the development of a
decidual hematoma that leads to separation,
compression, and ultimate destruction of the
placenta adjacent to it.
There is histological evidence of inflammation
more commonly in cases of placental abruption
than in normal controls. inflammationinfection
may be a contributor to causal pathways.

 In its early stage, there may be no clinical

symptoms, and the separation is

discovered upon examination of the
freshly delivered placenta.
In these cases, there is a circumscribed
depression on the placentas maternal
surface. It usually measures a few
centimeters in diameter and is covered by
dark, clotted blood.
Because several minutes are required for
these anatomical changes to materialize,
a very recently separated placenta may
appear to be totally normal at delivery.

 Substantive-sized dark clot is well formed, it has

depressed the placental bulk, and it likely is several hours

old. In some instances, a decidual spiral artery ruptures
to cause a retroplacental hematoma, which as it expands,
disrupts more vessels to separate more placenta.
The area of separation rapidly becomes more extensive
and reaches the margin of the placenta. Because the
uterus is still distended by the products of conception, it
is unable to contract sufficiently to compress the torn
vessels that supply the placental site. The escaping blood
may dissect the membranes from the uterine wall and
eventually appear externally or may be completely
retained within the uterus2

Diagnosis
Clinical ~ vaginal bleeding, uterine tenderness

or back pain, fetal distress (CTG) , uterine

contractions and persistent uterine hypertonus.
Pain from abruption may mimic normal labor or
it may be painless, especially with posterior
placenta. At times, the cause of vaginal
bleeding remains obscure even after delivery.
Sonography : sonography infrequenly confirms
the diagnosis of placental abruption at least
acutely, because the placenta and fresh clot
have similar sonographic appearance.
(Negative findings with sonographic
examination do not exclude placental
abruption)

Diagnosis
Neither laboratory tests nor diagnostic

methods are available to detect lesser

degrees of placental separation accurately.
It often becomes necessary to exclude
placenta previa and other causes of bleeding
by clinical and sonographic evaluation.
Clinically, painful uterine bleeding signifies
placental abruption, whereas painless
uterine bleeding is indicative of placenta
previa.

Diagnosis(after
delivery)
Retroplacenta hematome
Couvelaire uterus from

total placental abruption

after cesarean delivery.
Blood markedly infiltrates
the myometrium to reach
the serosa, especially at
the cornua. It gives the
myometrium a bluishpurple tone as shown

Management
Based on maternal and fetal condition, gestational

age and severity

Fluid Rescucitation and Blood transfusion
hypovolemic shock and consumptive coagulopathy
Continuous monitoring of fetal heart rate and
maternal laboratory assessment
Preterm pregnancy
Expectant management in preterm pregnancy and

Tocolysis Close observation of fetal condition

Fetal corticosteroid prepare termination

Term or near term pregnancy

Termination:
Sectio Caesarian preferred in emergency setting
Oxytocin for vaginal delivery

Prognosis
Neonatal outcome:
10 times risk of perinatal death
Greater risks for adverse long-term

neurobehavioral outcomes
Risk for periventricular leukomalacia and
sudden infant death syndrome