Placental Abruption

Concealed hemorrhage is the trap - No blood on the pad does not mean no bleeding. Tachycardia or hypotension may be the only external sign of blood collecting behind the placenta. Trend the vital signs and the running blood loss rather than what you see in the drapes.

Get the coagulation picture early - CBC, fibrinogen, PT/aPTT, and type and Rh. These do not diagnose abruption; they give you the baseline to trend, and they are what decides whether neuraxial is on the table at all. Abruption is one of the classic obstetric triggers of disseminated intravascular coagulation (DIC), so treat a falling fibrinogen or platelet count as the story changing.

Fetal monitoring sets the clock - Continuous electronic fetal monitoring for prolonged bradycardia, decreased variability, and late decelerations. A biophysical profile score of 6 or below indicates a compromised fetus. Those findings, not the volume of visible bleeding, are what convert this into a crash cesarean.

Set up before incision - A class 2 or 3 abruption means complete or central separation with mother and fetus at risk. Large-bore access, blood products in the room, and vasopressors drawn up before you start. Replace volume and factors during the case, not after it.

Expect postpartum atony - Abruption is a recognized cause of ineffective uterine contraction. Blood extravasated into the myometrium turns the serosa purple — the Couvelaire uterus — and that uterus does not clamp down. Keep uterotonics running past delivery of the placenta.

Watch the downstream organs - Abruption carries a maternal risk of transfusion, hysterectomy, DIC, renal failure, and Sheehan syndrome (postpartum pituitary necrosis). Follow urine output intraoperatively and hand off postpartum hypotension or failure to lactate as something to be chased, not dismissed.

Quantify fetomaternal hemorrhage - A Kleihauer-Betke test does not diagnose abruption but quantifies fetal cells crossing into the maternal circulation, which matters for the RhD-negative mother. Have the Rh status before delivery, not after.

Skip the tocolytic - Tocolytics have been suggested for intrapartum resuscitation of a category III tracing, but in suspected abruption they can worsen maternal hemodynamic instability and increase postpartum bleeding.

Placental abruption is separation of the placenta from the uterine lining before the second stage of labor is complete. Maternal vessels tear away from the placenta and blood collects between the uterine wall and the maternal placental surface, prying the two apart and interrupting fetal oxygen and nutrient exchange. The uterus is elastic and the placenta is not, so anything that stretches the uterus suddenly shears that vascular bed — polyhydramnios, multiple gestation, sudden uterine decompression, a short cord.

Other associations are hypertension, preeclampsia, cocaine use, smoking, maternal age over 35, prior abruption, and abdominal trauma. Most abruptions occur before 37 weeks. Bleeding may be concealed: the absence of vaginal bleeding does not exclude the diagnosis.