Placental abruption
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
all patients
stabilisation of mother
Goals are to prevent hypovolaemia, anaemia, and DIC. The need for blood and fluid replacement can be determined by estimated blood loss and by vital signs (BP, pulse, and urine output). Hb levels should be kept above 100g/L (10 g/dL) and Hct above 30%. Urine output should be at least 30 mL/hour.
In acute severe haemorrhage the use of antifibrinolytics (such as tranexamic acid) can be considered as they have been shown to have a survival benefit if given early (within 3 hours).[59]Gayet-Ageron A, Prieto-Merino D, Ker K, et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet. 2018 Jan 13;391(10116):125-32. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32455-8/abstract http://www.ncbi.nlm.nih.gov/pubmed/29126600?tool=bestpractice.com Transfusions should be given as needed. It is important to be proactive in giving blood. Fresh frozen plasma should be given early if there is any sign of DIC, because this will replace clotting factors. It is essential to replace volume, blood, and blood products aggressively.
monitoring of mother and fetus
Treatment recommended for ALL patients in selected patient group
The fetal heart rate should be monitored continuously, at least initially. Abnormalities in the tracing that suggest an abruption include late decelerations, loss of variability, variable decelerations, a sinusoidal fetal heart rate tracing, and fetal bradycardia, defined as a persistent fetal heart rate below 110 beats per minute.[18]Tikkanen M, Nuutila M, Hiilesmaa V, et al. Clinical presentation and risk factors of placental abruption. Acta Obstet Gynecol Scand. 2006;85(6):700-5. http://www.ncbi.nlm.nih.gov/pubmed/16752262?tool=bestpractice.com [49]Usui R, Matsubara S, Ohkuchi A, et al. Fetal heart rate pattern reflecting the severity of placental abruption. Arch Gynecol Obstet. 2008 Mar;277(3):249-53. http://www.ncbi.nlm.nih.gov/pubmed/17896112?tool=bestpractice.com Depending on how stable the mother and fetus are, and the gestational age at presentation, the monitoring may later be done intermittently on a case-by-case basis.
The mother's haemodynamic status should be monitored by monitoring BP, pulse, volume intake, and urine output. The need for blood and fluid replacement can be determined by estimated blood loss, by vital signs (BP, pulse, and urine output). Hb levels should be kept above 100 g/L (10 g/dL) and Hct above 30%. Urine output should be at least 30 mL/hour.
anti-D immunoglobulin
Treatment recommended for ALL patients in selected patient group
Anti-D immunoglobulin should be given to Rh-negative women.
Primary options
anti-D immunoglobulin: consult product literature for guidance on dose
monitoring of fetus ± delivery
Additional treatment recommended for SOME patients in selected patient group
Trauma is associated with an increased risk for abruption, even in the absence of direct uterine trauma.[25]Lane PL. Traumatic fetal deaths. J Emerg Med. 1989 Sep-Oct;7(5):433-35. http://www.ncbi.nlm.nih.gov/pubmed/2607102?tool=bestpractice.com [26]Schiff MA, Holt VL. Pregnancy outcomes following hospitalization for motor vehicle crashes in Washington State from 1989 to 2001. Am J Epidemiol. 2005 Mar 15;161(6):503-10. https://aje.oxfordjournals.org/cgi/reprint/161/6/503 http://www.ncbi.nlm.nih.gov/pubmed/15746466?tool=bestpractice.com [27]El-Kady D, Gilbert WM, Anderson J, et al. Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population. Am J Obstet Gynecol. 2004 Jun;190(6):1661-8. http://www.ncbi.nlm.nih.gov/pubmed/15284764?tool=bestpractice.com Shearing forces associated with sudden movement may cause placental separation. This separation may become clinically evident only several hours or days after the trauma. In particular, domestic violence and motor vehicle accidents may be associated with abruption.
The Society of Obstetricians and Gynaecologists of Canada recommends that women involved in trauma should have fetal monitoring for a minimum of 4 hours.[60]Society of Obstetricians and Gynaecologists of Canada. Guidelines for the Management of a Pregnant Trauma Patient. Jun 2015 [internet publication]. https://www.jogc.com/article/S1701-2163(15)30232-2/fulltext If there are uterine contractions, abnormal fetal heart rate tracings, severe maternal trauma, vaginal bleeding, uterine tenderness, or rupture of the membranes, further evaluation and/or delivery are indicated as determined by gestational age and individual circumstances.[60]Society of Obstetricians and Gynaecologists of Canada. Guidelines for the Management of a Pregnant Trauma Patient. Jun 2015 [internet publication]. https://www.jogc.com/article/S1701-2163(15)30232-2/fulltext
live fetus: >34 weeks
vaginal delivery
If the mother is in a stable condition and the fetal heart tracing is reassuring, then vaginal delivery can be attempted.
amniotomy + oxytocin induction
Additional treatment recommended for SOME patients in selected patient group
Often the mother is having vigorous contractions, but if the mother is not in active labour, amniotomy and oxytocin induction usually results in delivery.
Primary options
oxytocin: 0.5 to 1 milliunits/minute intravenous infusion initially, increase in 1-2 milliunits/minute increments gradually according to response every 15-60 minutes, maximum 10 milliunits/minute
blood coagulation products
Additional treatment recommended for SOME patients in selected patient group
These should be readily available and replaced aggressively if needed.
post-placental delivery utero-tonic agent
Additional treatment recommended for SOME patients in selected patient group
Uterus may not contract adequately, and therefore haemorrhage may be difficult to control. Utero-tonic agents such as oxytocin, methylergometrine, and prostaglandin analogues may be given.
Primary options
oxytocin: 10 units intramuscularly as a single dose
Secondary options
methylergometrine: 0.2 mg intravenously/intramuscularly after delivery of shoulder and then every 2-4 hours when required
OR
misoprostol: 800-1000 micrograms rectally/vaginally as a single dose
OR
carboprost tromethamine: 250 micrograms intramuscularly as a single dose, additional doses may be given every 15-90 minutes when required, maximum 2 mg/total dose
post-delivery haemostatic interventions
Additional treatment recommended for SOME patients in selected patient group
In severe cases, where bleeding is unresponsive to delivery and to administration of utero-tonic agents, surgical ligation of the uterine arteries or the hypogastric arteries may be life-saving.
Selective embolisation of these vessels may also lead to cessation of this life-threatening haemorrhage.
In cases that fail to respond to these conservative methods, hysterectomy may be necessary. Coagulation derangement should be actively corrected while these procedures are taking place.
urgent caesarean delivery
If maternal condition is worsening with severe haemorrhage, caesarean delivery may be indicated. Unnecessary delay should be avoided. A study demonstrated that neonates born to women with placental abruption and bradycardia had better perinatal outcomes if the decision-delivery interval for caesarean delivery was <20 minutes.[62]Kayani SI, Walkinshaw SA, Preston C. Pregnancy outcome in severe placental abruption. BJOG. 2003 Jul;110(7):679-83. http://www.ncbi.nlm.nih.gov/pubmed/12842059?tool=bestpractice.com
pre/intra-operative blood coagulation products
Additional treatment recommended for SOME patients in selected patient group
Blood and blood products should be replaced before and during the surgery if needed.
post-placental delivery utero-tonic agent
Additional treatment recommended for SOME patients in selected patient group
Uterus may not contract adequately in these cases, and therefore haemorrhage may be difficult to control. Utero-tonic agents such as oxytocin, methylergometrine, and prostaglandin analogues may be given.
Primary options
oxytocin: 10 units intramuscularly as a single dose
Secondary options
methylergometrine: 0.2 mg intravenously/intramuscularly after delivery of shoulder and then every 2-4 hours when required
OR
misoprostol: 800-1000 micrograms rectally/vaginally as a single dose
OR
carboprost tromethamine: 250 micrograms intramuscularly as a single dose, additional doses may be given every 15-90 minutes when required, maximum 2 mg/total dose
post-delivery haemostatic interventions
Additional treatment recommended for SOME patients in selected patient group
In severe cases, where bleeding is unresponsive to delivery and to administration of utero-tonic agents, surgical ligation of the uterine arteries or the hypogastric arteries may be life-saving.
In centres with an adequately skilled interventional radiologist, selective embolisation of these vessels may lead to cessation of this life-threatening haemorrhage.
In cases that fail to respond to these conservative methods, hysterectomy may be necessary. Coagulation derangement should be corrected while these procedures are taking place.
live fetus: ≤34 weeks
conservative management
If the fetus and mother are both stable and there is no evidence of maternal coagulopathy, hypotension, or severe ongoing blood loss, conservative management with the aim of delivering a more mature fetus is the main goal of therapy.
The status of both fetus and mother require close monitoring. This includes a combination of regular sonograms, fetal heart rate monitoring, and biophysical profiles. The particular monitoring programme must be individualised on a case-by-case basis.
The mother may occasionally be managed as an outpatient but should be instructed to report immediately should she experience bleeding, severe abdominal pain, contractions, or reduced fetal movements.
consideration of delivery by 37 to 38 weeks
Treatment recommended for ALL patients in selected patient group
There is an increased risk of stillbirth so it is recommended that delivery by 37 to 38 weeks is considered.
magnesium sulfate
Treatment recommended for ALL patients in selected patient group
If delivery is planned or expected before 34 weeks' gestation, intravenous magnesium sulfate is recommended for neuroprotection of the baby.[64]American College of Obstetricians and Gynecologists. Committee opinion no. 455: magnesium sulfate before anticipated preterm birth for neuroprotection. Mar 2010 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2010/03/magnesium-sulfate-before-anticipated-preterm-birth-for-neuroprotection Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria, treatment regimens, and concurrent tocolysis.[64]American College of Obstetricians and Gynecologists. Committee opinion no. 455: magnesium sulfate before anticipated preterm birth for neuroprotection. Mar 2010 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2010/03/magnesium-sulfate-before-anticipated-preterm-birth-for-neuroprotection There is no evidence that magnesium sulfate has any value as a tocolytic agent, and its use should only be for neuroprotection in appropriate groups of women.[65]Crowther CA, Brown J, McKinlay CJ, et al. Magnesium sulphate for preventing preterm birth in threatened preterm labour. Cochrane Database Syst Rev. 2014 Aug 15;2014(8):CD001060. http://www.ncbi.nlm.nih.gov/pubmed/25126773?tool=bestpractice.com
The US Food and Drug Administration (FDA) recommends against using magnesium sulfate injection for more than 5 to 7 days to stop preterm labour in pregnant women (an off-label use), as it may lead to low calcium levels and bone problems in the fetus or baby. The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) also recommends against any use of magnesium sulfate in pregnancy for more than 5 to 7 days. If prolonged or repeated use occurs during pregnancy (e.g., multiple courses or use for >24 hours), consider monitoring of neonates for abnormal calcium and magnesium levels and skeletal adverse effects.[69]US Food and Drug Administration. FDA drug safety communication: FDA recommends against prolonged use of magnesium sulfate to stop pre-term labor due to bone changes in exposed babies. May 2013 [internet publication]. https://www.fda.gov/Drugs/DrugSafety/ucm353333.htm [70]Medicines and Healthcare products Regulatory Agency. Magnesium sulfate: risk of skeletal adverse effects in the neonate following prolonged or repeated use in pregnancy. 2019 May;12(10):3. https://www.gov.uk/drug-safety-update/magnesium-sulfate-risk-of-skeletal-adverse-effects-in-the-neonate-following-prolonged-or-repeated-use-in-pregnancy#previous-safety-concerns-about-prolonged-use-of-magnesium-sulfate-in-pregnancy
Primary options
magnesium sulfate: consult specialist for guidance on dose
More magnesium sulfateDose depends on the indication, route of administration, and local guidelines. Consult your local drug formulary or guidelines for further guidance.
corticosteroid
Treatment recommended for ALL patients in selected patient group
Corticosteroids should be given to promote fetal lung maturation in women between 24 to 34 weeks’ gestation who are at risk of preterm delivery within 7 days.[63]American College of Obstetricians and Gynecologists. Committee opinion no. 713: antenatal corticosteroid therapy for fetal maturation. Aug 2017 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/antenatal-corticosteroid-therapy-for-fetal-maturation
Primary options
betamethasone sodium phosphate: 12 mg intramuscularly every 24 hours for 2 doses
OR
dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses
tocolytic
Additional treatment recommended for SOME patients in selected patient group
Tocolytics (e.g., nifedipine) may be used with extreme caution in cases where there are uterine contractions in pregnancies >24 weeks. This is controversial, but small studies have confirmed that careful use of tocolytics may be safe in these circumstances.[66]Saller DN Jr, Nagey DA, Pupkin MJ, et al. Tocolysis in the management of third trimester bleeding. J Perinatol. 1990 Jun;10(2):125-8. http://www.ncbi.nlm.nih.gov/pubmed/2358893?tool=bestpractice.com [67]Towers CV, Pircon RA, Heppard M. Is tocolysis safe in the management of third-trimester bleeding? Am J Obstet Gynecol. 1990 Jun;10(2):125-8. http://www.ncbi.nlm.nih.gov/pubmed/10368505?tool=bestpractice.com [68]Henderson CE, Goldman B, Divon MY. Ritodrine therapy in the presence of chronic abruptio placentae. Obstet Gynecol. 1992 Sep;80(3 Pt 2):510-2. http://www.ncbi.nlm.nih.gov/pubmed/1365698?tool=bestpractice.com
Primary options
nifedipine: 10-20 mg orally (immediate-release) every 4 hours; dose should not be given sublingually
urgent caesarean delivery
If the fetus or mother is not stable, delivery should take place promptly, with concurrent stabilisation of the fetus and mother. This is usually by caesarean, unless delivery is imminent and can be achieved safely.
magnesium sulfate
Treatment recommended for ALL patients in selected patient group
If delivery is planned or expected before 34 weeks' gestation, intravenous magnesium sulfate is recommended for neuroprotection of the baby.[64]American College of Obstetricians and Gynecologists. Committee opinion no. 455: magnesium sulfate before anticipated preterm birth for neuroprotection. Mar 2010 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2010/03/magnesium-sulfate-before-anticipated-preterm-birth-for-neuroprotection Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria, treatment regimens, and concurrent tocolysis.[64]American College of Obstetricians and Gynecologists. Committee opinion no. 455: magnesium sulfate before anticipated preterm birth for neuroprotection. Mar 2010 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2010/03/magnesium-sulfate-before-anticipated-preterm-birth-for-neuroprotection There is no evidence that magnesium sulfate has any value as a tocolytic agent, and its use should only be for neuroprotection in appropriate groups of women.[65]Crowther CA, Brown J, McKinlay CJ, et al. Magnesium sulphate for preventing preterm birth in threatened preterm labour. Cochrane Database Syst Rev. 2014 Aug 15;2014(8):CD001060. http://www.ncbi.nlm.nih.gov/pubmed/25126773?tool=bestpractice.com
The US Food and Drug Administration (FDA) recommends against using magnesium sulfate injection for more than 5 to 7 days to stop preterm labor in pregnant women (an off-label use), as it may lead to low calcium levels and bone problems in the fetus or baby. The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) also recommends against any use of magnesium sulfate in pregnancy for more than 5 to 7 days. If prolonged or repeated use occurs during pregnancy (e.g., multiple courses or use for >24 hours), consider monitoring of neonates for abnormal calcium and magnesium levels and skeletal adverse effects.[69]US Food and Drug Administration. FDA drug safety communication: FDA recommends against prolonged use of magnesium sulfate to stop pre-term labor due to bone changes in exposed babies. May 2013 [internet publication]. https://www.fda.gov/Drugs/DrugSafety/ucm353333.htm [70]Medicines and Healthcare products Regulatory Agency. Magnesium sulfate: risk of skeletal adverse effects in the neonate following prolonged or repeated use in pregnancy. 2019 May;12(10):3. https://www.gov.uk/drug-safety-update/magnesium-sulfate-risk-of-skeletal-adverse-effects-in-the-neonate-following-prolonged-or-repeated-use-in-pregnancy#previous-safety-concerns-about-prolonged-use-of-magnesium-sulfate-in-pregnancy
Primary options
magnesium sulfate: consult specialist for guidance on dose
More magnesium sulfateDose depends on the indication, route of administration, and local guidelines. Consult your local drug formulary or guidelines for further guidance.
corticosteroid
Treatment recommended for ALL patients in selected patient group
Corticosteroids should be given to promote fetal lung maturation in women between 24 to 34 weeks’ gestation who are at risk of preterm delivery within 7 days.[63]American College of Obstetricians and Gynecologists. Committee opinion no. 713: antenatal corticosteroid therapy for fetal maturation. Aug 2017 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/antenatal-corticosteroid-therapy-for-fetal-maturation
Primary options
betamethasone sodium phosphate: 12 mg intramuscularly every 24 hours for 2 doses
OR
dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses
pre/intra-operative blood coagulation products
Additional treatment recommended for SOME patients in selected patient group
Blood and blood products should be replaced before and during the surgery if needed.
post-placental delivery utero-tonic agent
Additional treatment recommended for SOME patients in selected patient group
Uterus may not contract adequately in these cases, and therefore haemorrhage may be difficult to control. Utero-tonic agents such as oxytocin, methylergometrine, and prostaglandin analogues may be given.
Primary options
oxytocin: 10 units intramuscularly as a single dose
Secondary options
methylergometrine: 0.2 mg intravenously/intramuscularly after delivery of shoulder and then every 2-4 hours when required
OR
misoprostol: 800-1000 micrograms rectally/vaginally as a single dose
OR
carboprost tromethamine: 250 micrograms intramuscularly as a single dose, additional doses may be given every 15-90 minutes when required, maximum 2 mg/total dose
post-delivery haemostatic interventions
Additional treatment recommended for SOME patients in selected patient group
In severe cases, where bleeding is unresponsive to delivery and to administration of utero-tonic agents, surgical ligation of the uterine arteries or the hypogastric arteries may be life-saving.
Selective embolisation of these vessels may also lead to cessation of this life-threatening haemorrhage.
In cases that fail to respond to these conservative methods, hysterectomy may be necessary. Coagulation derangement should be actively corrected while these procedures are taking place.
fetal demise
vaginal delivery
If the mother is in a stable condition, then vaginal delivery can be attempted.
amniotomy + oxytocin induction
Additional treatment recommended for SOME patients in selected patient group
Often the mother is having vigorous contractions, but if the mother is not in active labour, amniotomy and oxytocin induction usually results in delivery.
Primary options
oxytocin: 0.5 to 1 milliunits/minute intravenous infusion initially, increase in 1-2 milliunits/minute increments gradually according to response every 15-60 minutes, maximum 10 milliunits/minute
blood coagulation products
Additional treatment recommended for SOME patients in selected patient group
Women who have had an abruption sufficient to cause fetal demise are highly likely to have DIC. Blood coagulation products should be readily available and replaced aggressively if needed.
post-placental delivery utero-tonic agent
Additional treatment recommended for SOME patients in selected patient group
Uterus may not contract adequately in these cases, and therefore haemorrhage may be difficult to control. Utero-tonic agents such as oxytocin, methylergometrine, and prostaglandin analogues may be given.
Primary options
oxytocin: 10 units intramuscularly as a single dose
Secondary options
methylergometrine: 0.2 mg intravenously/intramuscularly after delivery of shoulder and then every 2-4 hours when required
OR
misoprostol: 800-1000 micrograms rectally/vaginally as a single dose
OR
carboprost tromethamine: 250 micrograms intramuscularly as a single dose, additional doses may be given every 15-90 minutes when required, maximum 2 mg/total dose
post-delivery haemostatic interventions
Additional treatment recommended for SOME patients in selected patient group
In severe cases, where bleeding is unresponsive to delivery and to administration of utero-tonic agents, surgical ligation of the uterine arteries or the hypogastric arteries may be life-saving.
In centres with an adequately skilled interventional radiologist, selective embolisation of these vessels may lead to cessation of this life-threatening haemorrhage.
In cases that fail to respond to these conservative methods, hysterectomy may be necessary. Coagulation derangement should be actively corrected while these procedures are taking place.
urgent caesarean delivery
If the maternal condition is worsening with severe haemorrhage, caesarean delivery may be indicated. Unnecessary delay should be avoided.
pre/intra-operative blood coagulation products
Additional treatment recommended for SOME patients in selected patient group
Blood and blood products should be replaced before and during the surgery if needed.
post-placental delivery utero-tonic agent
Additional treatment recommended for SOME patients in selected patient group
Uterus may not contract adequately in these cases, and therefore haemorrhage may be difficult to control. Utero-tonic agents such as oxytocin, methylergometrine, and prostaglandin analogues may be given.
Primary options
oxytocin: 10 units intramuscularly as a single dose
Secondary options
methylergometrine: 0.2 mg intravenously/intramuscularly after delivery of shoulder and then every 2-4 hours when required
OR
misoprostol: 800-1000 micrograms rectally/vaginally as a single dose
OR
carboprost tromethamine: 250 micrograms intramuscularly as a single dose, additional doses may be given every 15-90 minutes when required, maximum 2 mg/total dose
post-delivery haemostatic interventions
Additional treatment recommended for SOME patients in selected patient group
In severe cases, where bleeding is unresponsive to delivery and to administration of utero-tonic agents, surgical ligation of the uterine arteries or the hypogastric arteries may be life-saving.
In centres with an adequately skilled interventional radiologist, selective embolisation of these vessels may lead to cessation of this life-threatening haemorrhage.
In cases that fail to respond to these conservative methods, hysterectomy may be necessary. Coagulation derangement should be actively corrected while these procedures are taking place.
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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