Acute blood clots and the placenta are hyperechoic on ultranography and difficult to distinguish from one another. Maternal stabilization requires serial evaluation of the hematocrit and coagulation studies to determine whether disseminated intravascular coagulation is present.
When fetal death occurs secondary to abruption, vaginal delivery should be the goal. One trial demonstrated a reduction in the incidence of abruption with intrapartum treatment of preeclampsia using magnesium sulfate. Although it is uncommon the incidence is 1 in 2, births , it is important for physicians to be familiar with vasa previa because rapid intervention is essential for fetal survival. The hemorrhage is fetal blood, and exsanguination can occur rapidly because the average blood volume of a term fetus is approximately mL.
If fetal heart tones are reassuring, a blood sample from the vaginal vault may be obtained to check for fetal blood cells or fetal hemoglobin. The Apt test is most commonly used; it is based on the resistance of fetal hemoglobin to denaturation by alkaline agents and can be performed in the labor and delivery unit. There are no strategies for primary prevention of vasa previa; however, hemorrhage theoretically is preventable with antenatal screening for women at high risk and cesarean delivery at 37 to 38 weeks when vasa previa is present.
Screening is carried out with transvaginal color-f low Doppler to identify the presence of vessels in the fetal membranes. Although it has been suggested for women at increased risk, 41 there is no evidence that screening in a general population changes outcomes, and because the condition is rare one diagnosis per 5, screenings , this approach is cost prohibitive.
Continue Reading. However, findings with either type of ultrasonography may be normal in placental abruption. The fetal heart rate pattern is reassuring. Vaginal delivery is not contraindicated eg, by placenta previa or vasa previa. Hospitalization and observation are advised if all of the following are present: Bleeding does not threaten the life of the mother or fetus. This approach ensures that mother and fetus can be closely monitored and, if needed, rapidly treated.
Women should be advised to refrain from sexual intercourse. Corticosteroids may also be given if all of the following are present: The pregnancy is late preterm 34 to 36 weeks. The mother has not previously received corticosteroids during this pregnancy and has no contraindications. If bleeding resolves and maternal and fetal status remains stable, ambulation and usually hospital discharge are allowed.
If bleeding continues or if status deteriorates, prompt cesarean delivery may be indicated. Complications of placental abruption eg, shock, DIC are managed with aggressive replacement of blood and blood products.
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Solomonia, N. Fetal-maternal hemorrhage: A case and literature review. American Journal of Perinatology Reports, 2 1 , Williamson, M. Wallach's interpretation of diagnostic tests 9th ed. The sensitivity of the Kleihauer—Betke test for placental abruption. Journal of Obstetrics and Gynaecology, 35 2 , Mittal, K.
Comparison of estimation of volume of fetomaternal hemorrhage using Kleihauer-Betke test and microcolumn gel method in D-negative nonisoimmunized mothers. Donnelly, J. False positive Kleihauer—Betke acid elution test caused by elevated maternal fetal haemoglobin F cells. Feto-maternal haemorrhage assessment in a woman with a large population of red blood cells containing fetal haemoglobin.
Ginekologia polska, 85 8 , Soothill, P. Reis, I. The history begins with a review of the prenatal course, especially placental location on prior sonograms and if there is a history of placental abruption in previous pregnancies. Asking about potential trauma, especially in the abdominal area needs to be done in a tactful and supportive manner. Especially in situations of partner abuse, the woman may be reluctant to reveal that she sustained trauma to her abdomen.
The most useful mechanism for recognizing the onset of placental abruption is an assessment of the patient. The physical examination includes palpation of the uterus. The uterus is palpated for tenderness, consistency, and frequency and duration of uterine contractions, if present. The vaginal area is inspected for the presence of bleeding.
However, a digital examination of the cervix should be delayed until a sonogram is obtained for placental location and to rule out a placenta previa. If bleeding is present, the quantity and characteristic of the blood, as well as the presence of clots, is evaluated. Remember, the absence of vaginal bleeding does not eliminate the diagnosis of placental abruption.
Evaluation of vital signs to detect tachycardia or hypotension, which may be indicators of a concealed hemorrhage are taken. Blood specimens such as a complete blood count CBC , fibrinogen, clotting profile, and type and RH may be collected. Evaluation of fetal well-being is also included in the examination. Begin with auscultation of fetal heart sounds and ask about fetal movement, specifically recent changes in activity patterns.
Continuous electronic fetal monitoring is initiated to identify prolonged bradycardia, decreased variability, and the presence of late decelerations. Evaluation There are no laboratory tests or diagnostic procedures to definitively diagnose placental abruption.
However, some studies may be conducted in the effort to eliminate other conditions as well as to provide baseline data. However, the sensitivity of ultrasound in visualizing placental abruption is low. During the acute phase of placental abruption, the hemorrhage is isoechoic or similar to the surrounding placental tissue. Therefore, visualization and differentiation of the concealed hemorrhage associated with placental abruption from the surrounding placental tissue are difficult.
A biophysical profile may be used in the management of patients with marginal placental abruption who are being conservatively treated. A score of 6 or below is an indicator of compromised fetal status. A type and Rh have been obtained if a blood transfusion is necessary.
A Kleihauer-Betke test, which detects fetal blood cells in maternal circulation may be ordered. A Kleihauer-Betke test does not diagnose the presence of placental abruption but quantifies the presence of fetal blood into the maternal circulation. This knowledge is important in women who are Rh-negative, because the mixing of fetal blood in the maternal circulation may lead to isoimmunization. Therefore, if a significant fetal-maternal bleed is present, the Kleihauer-Betke test results will help to determine the needed dose of Rh D immune globulin to prevent isoimmunization.
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