Placental Abruption: An Obstetrical Emergency

• A diagnosis of placental abruption is considered an obstetrical emergency because it can lead to both maternal morbidity and neonatal morbidity. 
• Patients with a placental abruption can present with nonreasoning fetal heart rate patterns, uterine tenderness, tach systole, abdominal pain, a rigid abdomen, back pain, and vaginal bleeding. It is important to note that some of the clinical findings will differ between patients in severity and presence. 
• Maternal treatment of placental abruption for the patient discussed would be an emergency cesarean section.
  

An Obstetrical Emergency Case Study

While working in labor and delivery, you receive a phone call from a patient indicating that she is on her way in and is having period-like vaginal bleeding. You asked her for some more information while she is on the phone, including her name, date of birth, and distance from hospital.  

While waiting for the patient to arrive you pull her history to review and prep a triage room for her arrival. Notifying additional team members of incoming patient and information that was given over the phone. Upon reviewing the patient history, the following information was discovered: 

• Gravida 1 
• Gestational age of 36.3 weeks 
• Adequate prenatal care within facility OB/GYN clinic-last appointment 1 week ago 
• No previous medical/surgical history 
• Maternal family history of hypertension with both parents 
• ½ pack a day smoker for 5 years 
• Gestational hypertension-controlled with antihypertensive medication, that was started 10 weeks ago 
• Patient currently taking labetalol and prenatal vitamins 

Patient arrives to facility shortly after calling via phone; she is placed in an OB triage room and called down to admitting to be registered in the EMR. You then complete a physical assessment and information intake on the patient.

Case Study Cont.

Physical assessment reveals the following information: 

• Blood Pressure- 127/74 
• Pulse-84 
• Temperature-98.2 
• Respirations-16 
• Pulse Ox-98% on room air 
• Pain-8/10 abdominal pain reported, patient is holding abdomen 
• Upon palpation of uterus- tender and firm 
• Fetal Heart Rate (FHR) (External US)-130 baseline with no accelerations or decelerations and minimal variability 
• Uterine Assessment (TOCO) – Uterine tach systole present 
• Perineum- Noted to be soaked with bright red bleeding 
• Patient is alert, but appears to be in significant pain 

Patient intake revealed that she started bleeding 30 minutes ago and put a peri-pad on, that had been soaked through by the time she arrived. Her abdominal pain started last night with mild contractions that were irregular, and she was able to sleep through. Patient reports good fetal movement until about 3 hours ago, and has not felt any movement since then.  

She attempted to eat and drink something, but was not able to because she became nauseous and went to lay down. She awoke from the intense abdominal pain and noticed the bleeding when she went to the bathroom. Patient denies any recent abdominal trauma or sexual intercourse.  

The on call OB/GYN physician is called and notified of the patient assessment and reported findings. Physician presented at bedside within 5 minutes of notification.

What is Going On?

The physician performed a bedside ultrasound confirming placental detachment in-utero, known as placental abruption. A diagnosis of placental abruption is considered an obstetrical emergency because it can lead to both maternal morbidity and neonatal morbidity. Maternal complications can include renal failure, hemorrhage, hysterectomy, DIC, hypovolemic shock, and death.  

Fetal complications can include non-reassuring status, growth restrictions, and death.  Patients with a placental abruption can present with nonreasoning fetal heart rate patterns, uterine tenderness, tach systole, abdominal pain, a rigid abdomen, back pain, and vaginal bleeding. It is important to note that some of the clinical findings will differ between patients in severity and presence.  

The back and abdominal pain experienced may change based on the location of the placenta. Whereas, vaginal bleeding may range from severe (if an artery was compromised in the separation) to minimal amounts of bleeding. Patients may even present with no bleeding if blood is trapped in the uterus and not being expelled.  

Placental abruption has a higher likelihood to occur in future pregnancies or with a family history of abruption.  There are self-induced risk factors for placenta abruption, which can include smoking and cocaine use. Additional medical and pregnancy related risk factors include hypertension, congenial uterine anomalies, fetal congenital anomalies, and abdominal trauma.

Diagnosis: Placental Abruption

The patient that presented to labor and delivery for triage demonstrated clinical findings consistent with placental abruption including the vaginal bleeding, fetal heart rate indicating minimal variability, tach systole, tender and firm uterus on palpation, and abdominal pain. Her maternal history also had risk factors of gestational hypertension and smoking.

Treatment for Placental Abruption

Maternal treatment of placental abruption for the patient discussed would be an emergency cesarean section. The entire medical overview of patient present status and history would be reviewed to determine the best course of treatment for both the maternal and newborn patient outcome. 

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