Placental Abruption

Key considerations: Concealed abruption (no visible bleeding), DIC from massive abruption, Fetal distress and demise

Cannot miss

history: Trauma, cocaine use, hypertension, vaginal bleeding, pain, fetal movement, gestational age; exam: Uterine tenderness and tone (board-like rigidity), fetal heart tones, vaginal bleeding assessment; labs: CBC, coagulation studies (fibrinogen most sensitive early marker); Type and crossmatch, Kleihauer-Betke test, urine toxicology; imaging: External fetal monitoring (Category II/III tracing); Ultrasound (only 50% sensitive — negative does NOT rule out); bedside: Continuous fetal monitoring, serial fibrinogen levels

immediate: Large bore IV access x2, continuous fetal monitoring; OB emergency consult immediately; Severe or fetal distress: immediate cesarean delivery; general: Mild with reassuring fetal status: expectant management, betamethasone if <34 weeks; DIC treatment: FFP, cryoprecipitate (target fibrinogen >200), platelets, MTP if massive hemorrhage; Rh-negative mothers: RhIg administration

admit: All suspected abruptions — L&D with continuous monitoring; discharge: Never with suspected abruption; consults: OB/GYN emergently, anesthesia for OR readiness, neonatology if preterm

In pregnancy, normal fibrinogen is 400-600 mg/dL — a level of 250 indicates significant consumption and impending DIC
Ultrasound is only 50% sensitive for abruption — clinical diagnosis in the setting of vaginal bleeding, pain, and uterine tenderness
Concealed abruption (retroplacental clot without external bleeding) can be catastrophic — amount of visible bleeding does not correlate with severity