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 include the following:
Complications include the following:
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.
Diagnosis is suggested if any of the following occur during late pregnancy:
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 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.
Prompt cesarean delivery is usually indicated if any of the following is present, particularly if vaginal delivery is contraindicated:
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:
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.
Last full review/revision January 2014 by Antonette T. Dulay, MD
Content last modified January 2014