What Is Placental abruption? Risks, Causes, Symptoms and Treatment

Overview
The placenta is your baby’s support system in the womb. If your placenta doesn’t work properly, your baby is at risk of health problems. Placental abruption is when your placenta comes away from the wall of your womb.

The placenta processes your baby’s nutrients, waste and oxygen by bridging your baby’s blood circulation with that of your own. It sits inside the womb alongside your baby, and is attached to the wall of the womb. It is linked to the baby by umbilical cord, which is attached to the baby’s abdomen.

Placental abruption (discussed here) and low-lying placenta are conditions linked to the placenta that can cause premature birth.

Placental abruption is a serious condition in which the placenta starts to come away from the inside of the womb wall before the baby has delivered. This is an emergency because it means that the support system for the baby is failing.

Studies show that placental abruption affects up to 1% of pregnancies (though it is suspected that the actual figure may be higher as it may not always be diagnosed). In this condition some or all of the placenta separates from the wall of the womb before the baby is delivered. This can be caused by an impact such as a car crash, or may be related to a condition such as pre-eclampsia or fetal growth restriction, also know n as Intrauterine growth restriction or IUGR.

When placenta abruption happens the placenta is damaged and the baby may not be supported to develop properly.

Placental abruption (abruptio placentae) is an uncommon yet serious complication of pregnancy.

The placenta develops in the uterus during pregnancy. It attaches to the wall of the uterus and supplies the baby with nutrients and oxygen. Placental abruption occurs when the placenta partially or completely separates from the inner wall of the uterus before delivery. This can decrease or block the baby’s supply of oxygen and nutrients and cause heavy bleeding in the mother.

Placental abruption often happens suddenly. Left untreated, it endangers both the mother and baby.

Symptoms
Placental abruption is most likely to occur in the last trimester of pregnancy, especially in the last few weeks before birth. Signs and symptoms of placental abruption include:

Vaginal bleeding
Abdominal pain
Back pain
Uterine tenderness
Uterine contractions, often coming one right after another
Firmness in the uterus or abdomen
Abdominal pain and back pain often begin suddenly. The amount of vaginal bleeding can vary greatly, and doesn’t necessarily correspond to how much of the placenta has separated from the uterus. It’s possible for the blood to become trapped inside the uterus, so even with a severe placental abruption, there might be no visible bleeding.

In some cases, placental abruption develops slowly (chronic abruption), which can cause light, intermittent vaginal bleeding. Your baby might not grow as quickly as expected, and you might have low amniotic fluid (oligohydramnios) or other complications.

causes
Most of the time, doctors don’t know the cause. But drinking alcohol or using cocaine while you’re pregnant can increase your risk. Other things that can play a role include:

Placental abruptions in previous pregnancies. If you’ve had it before, you’ve got about a 10% chance of it happening again.
Smoking. One study showed that women who smoked before getting pregnant raised their chances of placental abruption by 40% for each year they smoked.
High blood pressure . Whether your blood pressure was high before or after you got pregnant, work with your doctor to manage it.
Problems with your amniotic sac. This sac cushions your baby inside your uterus. It’s filled with fluid. If something breaks it or makes it leak before you’re ready to give birth, the possibility of placental abruption increases.
Getting pregnant later in life. Your chances of having a placental abruption are higher if you’re 35 or older. In most cases, the mother is over 40.
Carrying more than one baby. Sometimes, delivering the first baby can make the placenta separate before the next baby is ready to be born.
Abdominal trauma. This could happen if you fall and hit your belly. It could also happen in a traffic accident if your abdomenis injured, so always remember to buckle up.
You can’t prevent placental abruption, but there are some things you can avoid, such as tobacco and alcohol, to reduce your odds.

You should tell your doctor if you’ve had placental abruption before. She’ll monitor you closely. She also may suggest other ways you can prevent it from happening again.

Smoke
Use cocaine during pregnancy
Are over the age of 35
Have preeclampsiaor hypertension
Are pregnant with twins or triplets
Have had a previous placental abruption
Experience trauma to the abdomen
Have abnormalities in the uterus
Healthinfi
What Is Placental abruption? Risks, Causes, Symptoms and Treatment

When should I call my healthcare provider?
You should call your health care provider immediately if you experience bleeding in your third trimester. Only your health care provider can make a proper diagnosis for the cause of late-term bleeding. The outcome of a placental abruption diagnosis is improved with fast and accurate treatment.

Risk factors
Risk factors for abruptio placentae include the following:

Older maternal age
Hypertension (pregnancy-induced or chronic)
Placental ischemia (ischemic placental disease) manifesting as intrauterine growth restriction
Polyhydramnios
Intra-amniotic infection (chorioamnionitis)
Vasculitis
Other vascular disorders
Prior abruptio placentae
Abdominal trauma
Acquired maternal thrombotic disorders
Tobacco use
Premature rupture of membranes
Cocaine use (risk of up to 10%)
Complications
Placental abruption can cause life-threatening problems for both mother and baby.

For the mother, placental abruption can lead to:

Shock due to blood loss

Blood clotting problems (disseminated intravascular coagulation)

The need for a blood transfusion

Failure of the kidneys or other organs resulting from significant blood loss

Rarely, when uterine bleeding cannot be controlled, hysterectomy may be necessary

For the baby, placental abruption can lead to:

Restricted growth from not getting enough nutrients

Not getting enough oxygen

Premature birth

Stillbirth

Prevention
You can’t prevent placental abruption, but you can decrease certain risk factors. For example, don’t smoke or use illegal drugs, such as cocaine. If you have high blood pressure, work with your health care provider to monitor the condition.

Always wear your seatbelt when in a motor vehicle. If you’ve had abdominal trauma — from an auto accident, fall or other injury — seek immediate medical help.

If you’ve had a placental abruption, and you’re planning another pregnancy, talk to your health care provider before you conceive to see if there are ways to reduce the risk of another abruption.

Diagnosis
Clinical evaluation, sometimes plus laboratory and ultrasonographic findings

The diagnosis of abruptio placentae is suspected if any of the following occur after the 1st trimester:

Vaginal bleeding (painful or painless)

Uterine pain and tenderness

Fetal distress or death

Hemorrhagic shock

DIC

Tenderness or shock disproportionate to the degree of vaginal bleeding

Abruptio placentae should also be considered in women who have had abdominal trauma. If bleeding occurs during middle or late pregnancy, placenta previa, which has similar symptoms, must be ruled out before pelvic examination is done; if placenta previa is present, examination may increase bleeding.

Evaluation for abruptio placentae includes the following:

Fetal heart monitoring

CBC

Blood and Rh typing

PT/PTT

Serum fibrinogen and fibrin-split products (the most sensitive indicator)

Transabdominal or pelvic ultrasonography

Kleihauer-Betke test if the patient has Rh-negative blood—to calculate the dose of Rh0(D) immune globulin needed

Fetal heart monitoring may detect a nonreassuring pattern or fetal death.

Transvaginal ultrasonography is necessary if placenta previa is suspected based on transabdominal ultrasonography. However, findings with either type of ultrasonography may be normal in abruptio placentae.

Placental abruption is something that can happen suddenly during pregnancy. It can be dangerous for you and your baby. Fortunately, it’s not common.

Your placenta develops in your uterus while you’re pregnant. It sends nutrients and oxygen from you to your baby, and it helps get rid of waste that builds up in your baby’s blood. It’s attached to the wall of your uterus, and your baby is attached to that by her umbilical cord. If you have placental abruption, the placenta separates from your uterus too soon, before your baby is ready to be born.

Healthinfi
What Is Placental abruption? Risks, Causes, Symptoms and Treatment

What Are the Dangers of Placental Abruption?
If only a small part of the placenta separates, it may not cause many problems. But if a big part or all of it detaches from your uterus, it can cause serious harm to you and your baby. For you, this could mean:

Major bloodloss that can cause you to go into shock or need a blood transfusion
Problems with blood clotting
Kidney failureor failure of other organs
Death — for you or your baby
If you have a near or complete abruption, you’ll need to have a C-section right away.

Etiology
The primary cause of placental abruption is usually unknown, but multiple risk factors have been identified. However, only a few events have been closely linked to this condition.

Risk factors in abruptio placentae include the following:
Maternal hypertension – Most common cause of abruption, occurring in approximately 44% of all cases
Maternal trauma (eg, motor vehicle collision [MVC], assaults, falls) – Causes 1.5-9.4% of all cases
Cigarette smoking
Alcohol consumption
Cocaine use
Short umbilical cord
Sudden decompression of the uterus (eg, premature rupture of membranes, delivery of first twin)
Retroplacental fibromyoma
Retroplacental bleeding from needle puncture (ie, postamniocentesis)
Idiopathic (probable abnormalities of uterine blood vessels and decidua) [4]
Previous placental abruption
Chorioamnionitis
Prolonged rupture of membranes (24 h or longer)
Maternal age 35 years or older
Maternal age younger than 20 years
Male fetal sex
Low socioeconomic status
Elevated second trimester maternal serum alpha-fetoprotein (associated with up to a 10-fold increased risk of abruption)
Subchorionic hematoma
Cigarette smoking/tobacco abuse
Cigarette smoking increases a patient’s overall risk of placental abruption.

A prospective cohort study showed the risk of abruption to be increased by 40% for each year of smoking prior to pregnancy.
In addition to the increased risk of abruption caused by tobacco abuse, the perinatal mortality rate of infants born to women who smoke and have an abruption is increased.
Cocaine (powder or crack) abuse
The hypertension and increased levels of catecholamines caused by cocaine abuse are thought to be responsible for a vasospasm in the uterine blood vessels that causes placental separation and abruption. However, this hypothesis has not been definitively proven.

The rate of abruption in patients who abuse cocaine has been reported to be approximately 13-35% and may be dose-dependent.
Trauma
Abdominal trauma is a major risk factor for placental abruption.

Motor vehicle accidents often cause abdominal trauma. The lower seat belt should extend across the pelvis, not across the midabdomen, where the fetus is located.
Trauma may also be due to domestic abuse or assault, both of which are underreported.
Thrombophilia
While it was previously thought that patients who experienced early or severe abruptions were at increased risk of having a specific thrombophilia, this is no longer thought to be the case and screening of patients with an abruption is no longer recommended.

Epidemiology
The frequency of abruptio placentae in the United States is approximately 1%, and a severe abruption leading to fetal death occurs in 0.12% of pregnancies (1:830).

Abruptio placentae also occurs in about 1% of all pregnancies throughout the world.
Race predilection
Placental abruption is more common in African American women than in white or Latin American women. However, whether this is the result of socioeconomic, genetic, or combined factors remains unclear.

Age predilection
An increased risk of placental abruption has been demonstrated in patients younger than 20 years and those older than 35 years.

Treatment
Treatment depends on the severity of the separation, location of the separation and the age of the pregnancy. There can be a partial separation or a complete (also called a total) separation that occurs. There can also be different degrees of each of these which will impact the type of treatment recommended. In the case of a partial separation, bed rest and close monitoring may be prescribed if the pregnancy has not reached maturity. In some cases, transfusions and other emergency treatment may be needed as well.

In a case with a total or complete separation, delivery is often the safest course of action. If the fetus is stable, vaginal delivery may be an option. If the fetus is in distress or the mom is experiencing severe bleeding, then a cesarean delivery would be necessary. Unfortunately, there is no treatment that can stop the placenta from detaching and there is no way to reattach it.

Any type of placental abruption can lead to premature birth and low birth weight. In cases where severe placental abruption occurs, approximately 15% will end in fetal death.

Sometimes prompt delivery and aggressive supportive measures (eg, in a term pregnancy or for maternal or possible fetal instability)

Trial of hospitalization and modified activity if the pregnancy is not near term and if mother and fetus are stable

Prompt cesarean delivery is usually indicated if abruptio placentae plus any of the following is present, particularly if vaginal delivery is contraindicated:

Maternal hemodynamic instability

Nonreassuring fetal heart rate pattern

Term pregnancy (≥ 37 wk)

Once delivery is deemed necessary, vaginal delivery can be attempted if all of the following are present:

The mother is hemodynamically stable.

The fetal heart rate pattern is reassuring.

Vaginal delivery is not contraindicated (eg, by placenta previa or vasa previa).

Labor can be carefully induced or augmented (eg, using oxytocin and/or amniotomy). Preparations for postpartum hemorrhage should be made.

Hospitalization and modified activity (modified rest) are advised if all of the following are present:

Bleeding does not threaten the life of the mother or fetus.

The fetal heart rate pattern is reassuring.

The pregnancy is preterm (< 37 wk).

This approach ensures that mother and fetus can be closely monitored and, if needed, rapidly treated. (Modified activity involves refraining from any activity that increases intra-abdominal pressure for a long period of time—eg, women should stay off their feet most of the day.)

Corticosteroids should be considered (to accelerate fetal lung maturity) if gestational age is < 34 wk. Corticosteroids may be given if all of the following are present

The pregnancy is late preterm (34 to 36 wk).

The mother has not previously received any corticosteroids.

Risk of delivery in the late preterm period is high.

If bleeding resolves and maternal and fetal status remains stable, ambulation and usually hospital discharge are allowed. If bleeding continues or if status deteriorates, prompt cesarean delivery may be indicated.

Complications of abruptio placentae (eg, shock, DIC) are managed with aggressive replacement of blood and blood products.

What does placental abruption mean for me and my baby?
The effects and treatment of placental abruption depend on how severe it is. If you are under 34 weeks and only a small part of the placenta has broken away from the womb you will be monitored closely to make sure the baby is growing properly and to watch for signs of labour starting.

If there is a risk of your baby not growing properly then labour may be induced.

If the abruption is more severe, you are losing lots of blood and the baby is in distress or at risk of not growing properly you may need to have your labour induced or have an emergency caesarean.

In addition to any problems that the baby may have from the placental abruption, there are health risks of being delivered early. These depend on how far into the pregnancy you are.

Classification of placental abruption
Classification of placental abruption is based on extent of separation (ie, partial vs complete) and location of separation (ie, marginal vs central). (See Clinical.) Clinical classification is as follows:

Class 0 – Asymptomatic
Class 1 – Mild (represents approximately 48% of all cases)
Class 2 – Moderate (represents approximately 27% of all cases)
Class 3 – Severe (represents approximately 24% of all cases)
A diagnosis of class 0 is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.

Class 1 characteristics include the following:

No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress
Class 2 characteristics include the following:

No vaginal bleeding to moderate vaginal bleeding
Moderate to severe uterine tenderness with possible tetanic contractions
Maternal tachycardia with orthostatic changes in BP and heart rate
Fetal distress
Hypofibrinogenemia (ie, 50-250 mg/dL)
Class 3 characteristics include the following:
No vaginal bleeding to heavy vaginal bleeding
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, < 150 mg/dL)
Coagulopathy
Fetal death
Go to Emergent Management of Abruptio Placentae for complete information on this topic.
Prognosis
If the bleeding continues, fetal and maternal distress may develop. Fetal and maternal death may occur if appropriate interventions are not undertaken.

The severity of fetal distress correlates with the degree of placental separation. In near-complete or complete abruption, fetal death is inevitable unless an immediate cesarian delivery is performed.
If an abruption occurs, the risk of perinatal mortality is reported as 119 per 1,000 people in the United States, but this can depend on the extent of the abruption and the gestational age of the fetus. This rate is higher in patients with a significant smoking history.
Currently, placental abruption is responsible for approximately 6% of maternal deaths.
Morbidity associated with abruptio placentae
Fetal morbidity is caused by the insult of the abruption itself and by issues related to prematurity when early delivery is required to alleviate maternal or fetal distress.

Maternal morbidity may include the following:
Transfusion-related morbidity
Classic cesarean delivery with need for repeat cesarean deliveries
Hysterectomy
Cesarean delivery
Cesarean delivery is often necessary if the patient is far from her delivery date or if significant fetal compromise develops. If significant placental separation is present, the fetal heart rate tracing typically shows evidence of fetal decelerations and even persistent fetal bradycardia.

A cesarean delivery may be complicated by infection, additional hemorrhage, the need for transfusion of blood products, injury of the maternal bowel or bladder, and/or hysterectomy for uncontrollable hemorrhage. In rare cases, death occurs.
Hemorrhage/coagulopathy
Disseminated intravascular coagulation (DIC) may occur as a sequela of placental abruption. Patients with a placental abruption are at higher risk of developing a coagulopathic state than those with placenta previa. The coagulopathy must be corrected to ensure adequate hemostasis in the case of a cesarean delivery.

Prematurity
Delivery is required in cases of severe abruption or when significant fetal or maternal distress occurs, even in the setting of profound prematurity. In some cases, immediate delivery is the only option, even before the administration of corticosteroid therapy in these premature infants. All other problems and complications associated with a premature infant are also possible.

Recurrence
The risk of recurrence of abruptio placentae is reportedly 4-12%. If the patient has abruptio placentae in 2 consecutive pregnancies, the risk of recurrence rises to 25%.

If the abruption is severe and results in the death of the fetus, the risk of a recurrent abruption and fetal demise is 7%.
Maternal cardiovascular mortality
A study by Pariente et al indicated that women who have placental abruption are at increased long-term risk for cardiovascular mortality. The study examined the cardiovascular mortality rate after 653 deliveries in patients with placental abruption, with follow-up occurring over more than 10 years. Although the investigators did not find a significant connection between placental abruption and later, long-term hospitalization for cardiovascular disease, they found a 13% cardiovascular mortality rate in the women who had suffered placental abruption, compared with a 2.5% rate in women who had not.

How is it treated?
The kind of treatment you need will depend on:

How severe the abruption is.

How it is affecting your baby.

How close your due date is.

If you have mild placenta abruptio and your baby is not in distress, you may not have to stay in the hospital.

You and your baby will be checked often throughout the rest of your pregnancy.

If you are in preterm labor and are far from your due date, you may be given medicine to stop labor.

If you have moderate to severe placenta abruptio, you will probably have to stay in the hospital so your baby’s health can be watched closely.

In most cases, the baby will need to be delivered quickly. This means you are likely to have a C-section (cesarean delivery).

If you have lost a lot of blood, you may need a blood transfusion.

If your baby is premature, he or she may be treated in a neonatal intensive care unit, or NICU. The NICU is geared to the needs of premature or ill newborns.