Placental Abruption (Abruptio Placentae)

Last updated: April 25, 2025

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Abruptio placentae

Abruptio placentae

Abruptio placentae is premature separation of the placenta from the uterus. Abruption is difficult to pick up through ultrasound, but it is still done to rule out placenta and vasa previa. The preferable mode of delivery in case of abruption is vaginal delivery, since caesarean delivery may be prevented by disseminated intravascular coagulopathy (DIC). If caesarean delivery is preferred it should be perfomed immediately before clottign factors are depleted.

Abruption is relatively uncommon, and is not easy to treat. Abruption accounts for 30% of cases of antepartum hemorrhage. It occrs in 1% of pregnancies and fetal mortality ranges from 20 – 40%.

Types of bleeding in abruption

Bleeding	Description
Concealed (20%)	Minimal per vaginal bleeding. This form is more dangerous
Revealed/Apparent(80%)	Bleeding is appreciated, usually with partial detachment of the placenta from the uterus.

Grading of placental abruption

Grade	Description
Grade 1	Retrospective diagnosis
Grade 2	Abruption and live fetus
Grade 3	Dead fetus
Grade 3A	No coagulopathy
Grade 3B	With coagulopathy

Risk factors
- Hypertension
- Pre-eclampsia
- Blunt force trauma to the abdomen (avulses the placenta)
- Cocaine use (causes vasoconstriction)
- Previous abruption
- Multiple pregnancy
- Previous caesarean delivery
- Thrombophilia
- Smoking
Signs and symptoms
- Painful late pregnancy bleeding
- Firm “woody-hard” and tender uterus
- Pain between contractions
- Signs of shock – tachycardia, hypotension, tachypnoea, confusion or drowsiness, loss of consciousness
- Fetal bradycardia
- Late decelerations
- Couvelier uterus (bluish, enlarged and hard uterus due to blood in the myometrium)
- Retroplacental blood clot and sloughing
Investigations
- Complete blood count
- Group and crossmatch
- Coagulation panel
- Renal funciton test and Electrolytes
- Liver function tests
- Ultrasound: to exclude placenta previa
Principles of Treatment of abruption
1. Resuscitaiton and Replace blood loss
2. Deliver without delay (preferrably vaginal)
3. Investigate for and prevent post-partum hemorrhage, DIC, and renal failure

Treatment of abruption

Scenario	Treatment
Preterm and stable (no active bleeding)	Admit for observation
Treatment if term and stable (no active bleeding)	Vaginal delivery
Severe abruption	Emergency caesarean delivery

Indications for Caesarean delivery in abruption
- Previous caesarean delivery
- Failure to progress despite AROM, Oxytocin and traction
- Bleeding to death with normal clotting factors
- Live foetus > 2kg with signs of distress
- Transverse lie (vaginal delivery is impossible!)
Management of Intraoperative bleeding
- Intrauterine balloon tamponade
- Hemostatic sutures (B-lynch, Hayman)
- Devascularization
- Hysterectomy (last resort)
Complications of abruptio placentae
- Disseminated Intravascular coagulation: abruption causes release of tissue factor
  - CBC with peripheral blood film show thrombocytopenia, schistocytes and helmet cells
  - PT and PTT: prolonged
  - D-dimer: High
  - Fibrinogen: low or normal
- Maternal renal failure
- Maternal shock
- Amniotic fluid embolism
- Fetal distress (due to uteroplacental insufficiency)
- Intrauterine growth restriction
- Stillbirth
- Preterm delivery
- Postpartum hemorrhage (especially with a couvelier uterus in concealed hemorrhage)
- Death
  - Maternal demise (0.5-5%)
  - Fetal demise (35-80%)

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

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Abruptio placentae

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