Management of suspected placental abruption should include prompt assessment of maternal and fetal status, and a subsequent individualized management algorithm based on severity of disease, underlying etiology, and gestational age. In severe cases of placental abruption with life-threatening hemorrhage, maternal hemodynamic stabilization is the priority. As previously mentioned, the majority of maternal complications result from hypovolemic shock secondary to massive blood loss, whether concealed or clinically visible. Maternal vital signs, including blood pressure, heart rate, and urine output should be closely monitored. Hypovolemia may be masked in cases of abruption in which severe hypertension is the etiology.
Crystalloid, colloid, and blood product resuscitation may be initiated through two wide-bore intravenous lines, if necessary. Identification and correction of underlying risk factors, such as trauma, or a hypertensive crisis also play an important role in the management of placental abruption. A multidisciplinary approach should be undertaken, if available, with appropriate consultations with perinatologists, neonatologists, anesthesiologists, operating room staff, blood bank, and intensive care specialists.
Laboratory evaluation should include blood type and Rhesus-D status, complete blood counts, coagulation studies, and cross-matching of blood products. Hypofibrinogenemia is a result of the intense thrombin response and is the most sensitive indicator of coagulopathy. Prothrombin time and partial thromboplastin time may be elevated in cases of severe abruption. Kleihauer-Betke, an acid elution test employed to assess the presence of fetal hemoglobin in maternal circulation, may be useful in calculation of Rhesus-D immunoglobulin dosage in patients who are Rhesus-D negative.
If the fetus is at a gestational age deemed to be potentially viable, continuous fetal cardiotocography should be initiated to determine fetal well-being. Antenatal corticosteroids may be administered between 24 + 0/7 to 33 + 6/7 weeks of gestation for promotion of fetal lung maturity and prevention of prematurity-associated complications. If fetal decompensation unresponsive to intrauterine resuscitation occurs or the fetus is above 34 + 0/7 weeks of gestation, delivery should be expeditiously effected. Vaginal delivery can be attempted if the fetal heart rate tracing remains reassuring and the maternal status remains stable. Given the intense uterotonic effects of thrombin, patients may often undergo spontaneous labor without need for induction or augmentation. Cesarean delivery should be performed if the patient is remote from delivery with evidence of fetal distress, intolerance of labor, or for routine obstetrical indications.
In the case of an intrauterine fetal demise secondary to a massive abruption, the mode of delivery is dependent on maternal status, severity of hemorrhage, and other obstetrical complicating factors, such as prior classical hysterotomy incision. Vaginal delivery is the preferred modality in most cases, unless urgent delivery is necessary for maternal stabilization.
If the mother and fetus are both stable, such as in a mild, subacute, or chronic abruption, ultrasound evaluation of the intrauterine environment may be undertaken, including assessment of the placental location, placental appearance, amniotic fluid index, and fetal growth. Placenta previa may be present in 10% of placental abruptions.
Ultrasonographic appearance of a hematoma evolves over time. In the acute phase, the blood is hyperechoic to isoechoic when compared to the placenta. () As the hematoma organizes and resolves, the insult appears hypoechoic within a week and may be anechoic within two weeks.67
() Exclusion of a retroplacental hematoma, however, does not exclude the presence of placental abruption.
The use of tocolytics in placental abruption has classically been discouraged, however, a few small non-randomized studies have shown possible benefit to administration of tocolytic agents to prolong gestation.68–69
Further studies are needed to elucidate the risks and benefits of tocolysis.
Careful management of a patient with placental abruption should continue into the postpartum period, given the risks of DIC and postpartum uterine atony. Uterotonic agents, such as oxytocin, carboprost, misoprostol, and methyl-ergonovine, should be readily available.