Abruptio Placentae
Painful antepartum bleeding + tender, “woody” uterus. A clinical diagnosis with major maternal and foetal risk — treat as an obstetric emergency.
Painful vaginal bleeding
Rigid / tender uterus
Shock may be out of proportion to visible bleeding
Placenta previa = painless bright red bleeding
Definition & Overview
Abruptio placentae is the premature separation of a normally implanted placenta from the uterine wall, usually in the second half of pregnancy. It occurs in roughly 1% of pregnancies and is a major cause of maternal haemorrhage, foetal compromise, and stillbirth.
Pathophysiology: haemorrhage into the decidua basalis →
formation of a retroplacental haematoma →
separation and compression of the placenta →
impaired utero-placental perfusion.
- Separation may be acute (sudden collapse, heavy bleeding), or gradual with progressive symptoms through late pregnancy.
- Bleeding can be:
- Revealed: obvious vaginal bleeding.
- Concealed: little or no vaginal loss but significant internal bleeding and a tense uterus.
Risk Factors
- Maternal hypertension and pre-eclampsia.
- Advanced maternal age and multiparity.
- Smoking and cocaine/illicit drug use.
- Thrombophilia and clotting disorders.
- Previous miscarriage or prior placental abruption.
- Abdominal trauma (e.g. MVC, IPV, falls).
- Sudden uterine decompression (e.g. rupture of membranes with polyhydramnios, multiple pregnancy).
Hypertension / pre-eclampsia
Smoking / cocaine
Abdominal trauma
Previous abruption
Clinical Features
- Bleeding:
- Vaginal bleeding, often dark coloured.
- May be minimal or absent if bleeding is concealed.
- Pain: sudden onset abdominal or back pain, often continuous and severe.
- Uterus:
- Uterine tenderness and irritability.
- Firm or “woody” uterus, frequent contractions.
- Maternal status:
- Signs of shock (tachycardia, hypotension, pallor) may be disproportionate to visible blood loss.
- DIC and oozing from venepuncture sites in severe cases.
- Foetus:
- Reduced movements.
- Foetal distress on CTG or absent foetal heart in severe cases.
Diagnosis
Key point: Abruptio placentae is primarily a
clinical diagnosis – do not delay management while waiting for imaging.
- Clinical: painful antepartum bleeding, uterine tenderness/rigidity, foetal distress or demise.
- Laboratory:
- FBC, coagulation profile (PT/INR, aPTT), fibrinogen, D-dimer, crossmatch.
- Look for anaemia and evolving DIC.
- Ultrasound:
- Can help exclude placenta previa and assess fetal status.
- Retroplacental clot may be seen, but sensitivity is limited – fresh blood and placenta can look similar.
Treat as abruption if clinical picture fits
Normal scan ≠ no abruption
Maternal & Foetal Risks
- Foetal complications:
- Foetal distress and hypoxia.
- Intrauterine death if separation is extensive or rapid.
- Maternal complications:
- Massive haemorrhage and hypovolaemic shock.
- Coagulopathy and disseminated intravascular coagulation (DIC).
- Fetomaternal transfusion.
- Amniotic fluid embolism (rare but catastrophic).
- Renal failure, multi-organ failure.
Differential Diagnoses
- Placenta previa:
- Painless, bright red vaginal bleeding.
- Soft, non-tender uterus.
- Confirmed by ultrasound – avoid digital vaginal exam if suspected.
- Other causes of abdominal pain without bleeding:
- Severe pre-eclampsia / HELLP.
- Pyelonephritis.
- Hepatic or gallbladder disease.
- Appendicitis, bowel pathology.
- Ovarian torsion or ruptured cyst.
ED Management & Disposition
Priorities: resuscitate the mother, stabilise haemodynamics, assess foetal status, and involve obstetrics early.
Definitive management is usually delivery.
Mild, stable
- Minor bleeding, maternal vitals stable, uterus mildly tender, reassuring foetal status.
- IV access, bloods (FBC, coagulation, crossmatch).
- Continuous or frequent foetal monitoring if viable gestation.
- Admit to obstetric unit for observation and further management.
Moderate concern
- Ongoing bleeding, uterine tenderness/irritability, maternal tachycardia, non-reassuring foetal status.
- Two large-bore IVs, crystalloid resuscitation, early blood products as required.
- Activate obstetric emergency team; CTG / ultrasound if available.
- Likely need for early delivery depending on gestation and foetal status.
Severe / life-threatening
- Shock, rigid “board-like” uterus, heavy revealed or concealed bleeding, DIC, foetal demise or severe distress.
- Full resuscitation:
- O2, airway support as needed.
- Massive transfusion protocol; treat DIC with blood products per lab and protocol.
- Immediate obstetric decision regarding urgent delivery (often emergency caesarean section).
- ICU / high-care post-delivery for maternal support.
- Monitoring: continuous BP, HR, SpO₂, urine output; serial labs for Hb, coagulation, fibrinogen.
- Analgesia: use cautiously; do not mask evolving abdominal findings.
- Multidisciplinary: obstetrician, anaesthetist, neonatologist, ICU, haematology as needed.
Team Approach
Late-pregnancy complications like abruptio placentae demand close collaboration between emergency medicine, obstetrics, anaesthesia, radiology, ICU, and neonatology.
- Call obstetrics early for any suspected abruption.
- Agree on a clear plan: monitoring vs urgent delivery.
- Ensure appropriate level of care for the mother post-event (high care / ICU when indicated).
Resuscitate mother → assess foetus
Treat as abruption on clinical grounds
Do not be reassured by a normal ultrasound