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Abruptio Placentae

by Antonette T. Dulay, MD

Abruptio placentae is premature separation of a normally implanted placenta from the uterus, usually after 20 wk gestation. It can be an obstetric emergency. Manifestations may include vaginal bleeding, uterine pain and tenderness, hemorrhagic shock, and disseminated intravascular coagulation. Diagnosis is clinical and sometimes by ultrasonography. Treatment is modified activity (eg, a trial of bed rest) for mild symptoms and prompt delivery for maternal or fetal instability or a near-term pregnancy.

Abruptio placentae occurs in 0.4 to 1.5% of all pregnancies; incidence peaks at 24 to 26 wk gestation.

Abruptio placentae may involve any degree of placental separation, from a few millimeters to complete detachment. Separation can be acute or chronic. Separation results in bleeding into the decidua basalis behind the placenta (retroplacentally). Most often, etiology is unknown.

Risk factors

Risk factors 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 include the following:

  • Maternal blood loss that may result in hemodynamic instability, with or without shock, and/or disseminated intravascular coagulation (DIC)

  • Fetal compromise (eg, fetal distress, death) or, if abruptio placentae is chronic (usually), growth restriction

  • Sometimes fetomaternal transfusion and alloimmunization (eg, due to Rh sensitization).

Symptoms and Signs

Acute abruptio placentae may result in bright or dark red blood exiting through the cervix (external hemorrhage). Blood may also remain behind the placenta (concealed hemorrhage). Severity of symptoms and signs depends on degree of separation and blood loss. As separation continues, the uterus may be painful, tender, and irritable to palpation. Hemorrhagic shock may occur, as may signs of DIC. Chronic abruptio placentae may cause continued or intermittent dark brown spotting.

Abruptio placentae may cause no or minimal symptoms and signs.


  • Combination of clinical, laboratory, and ultrasonographic findings

Diagnosis is suggested if any of the following occur during late pregnancy:

  • 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

The diagnosis should also be considered in women who have had abdominal trauma. If bleeding occurs during 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 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 Rh 0 (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.

Pearls & Pitfalls

  • Normal ultrasonographic findings do not rule out abruptio placentae.


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

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

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

  • Maternal hemodynamic instability

  • Nonreassuring fetal heart rate pattern

  • Near-term pregnancy (eg, > 36 wk)

Once delivery is deemed necessary, vaginal delivery can be attempted if the mother is hemodynamically stable, fetal heart rate pattern is reassuring, and 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 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 not near term.

This approach ensures that mother and fetus can be closely monitored and, if needed, rapidly treated. (Modified rest 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. 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 (eg, shock, DIC) are managed with aggressive replacement of blood and blood products.

Key Points

  • Bleeding in abruptio placentae may be external or concealed.

  • Sometimes abruptio placenta causes only minimal symptoms and signs.

  • Do not exclude the diagnosis because a test result (including ultrasonographic) is normal.

  • Consider prompt cesarean delivery if maternal of fetal stability is threatened or if pregnancy is near term.

  • Consider vaginal delivery if mother and fetus are stable and pregnancy is near term.

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