1. Obstetrical Emergency: Placental Abruption Kelsie Kelly, MD, MPH kkelly3@kumc.edu University of Kansas Department of Family Medicine Partially supported by HRSA Grant #D55HP20647

2. Case 29 yo G1P0 at 35 0/7 wks presents to L&D from the ER after being involved in car accident. Both she and her husband were injured, she was found to have a fractured right humerus and seat belt marks are visible across the abdomen. The patient is monitored overnight at which point she begins to have abdominal pain, vaginal bleeding and NRFHTs.

3. Objectives Recognize signs and symptoms of placental abruption Understand management of placental abruption Know the risk factors of placental abruption

4. What is Placental Abruption? Separation of placenta from uterine wall before delivery Acute or chronic Small, self-limited, complete, concealed Unable to exchange gases and nutrients leading to fetal distress http://www.riversideonline.com/health_reference/Womens-Health/DS00623.cfmhttp://www.riversideonline.com/health_reference/Womens-Health/DS00623.cfm. Accessed May 27, 2014.

5. Epidemiology Most common cause of serious vaginal bleeding Occurs in 1% of pregnancies 50% occur before 36 wks Perinatal death occurs in ~12% of cases Up to 77% occur in utero

6. Risk Factors Tobacco use Cocaine, amphetamine use Chronic HTN Preeclampsia Thrombophilia Abdominal trauma Abruption in previous pregnancy Sudden uterine decompression after ROM Delivery of 1 st twin Multiparity Short umbilical cord Unexplained maternal AFP levels Uterine fibroids, other uterine abnormalities Prior C-section http://www.alphalaserinfo.com/2010/10/15/quitting-smoking-while-pregnant/http://www.alphalaserinfo.com/2010/10/15/quitting-smoking-while-pregnant/. Accessed May 27, 2014.

7. Clinical Presentation Vaginal bleeding Abdominal pain Fetal distress Preterm labor, growth restriction, IUFD may also be presenting sign Chronic abruption may manifest as recurrent vaginal bleeding with episodic pain and contractions http://www.operationalmedicine.org/ed2/Enhanced/LandD/ElectronicFetalMon itoring.htmhttp://www.operationalmedicine.org/ed2/Enhanced/LandD/ElectronicFetalMon itoring.htm. Accessed May 27, 2014.

8. Differential Diagnosis Labor Placenta previa Uterine rupture Subchorionic hemorrhage

9. Management Suspect placental abruption! Assess maternal stability and assess fetal well- being Serial evaluation of Hct and coags If stable: Sterile speculum exam Ultrasound Call anesthesia Decision-to-Delivery < 20 minutes!!!

10. Placental Abruption http://www.med.cmu.ac.th/dept/obgyn/2011/index.php?option=com_content&view=article&id=160:basic-ob- us&catid=38&Itemid=378http://www.med.cmu.ac.th/dept/obgyn/2011/index.php?option=com_content&view=article&id=160:basic-ob- us&catid=38&Itemid=378. Accessed May 27, 2014.

11. Management Immediate delivery if: Severe abruption at any gestational age Non-severe abruption >36 wks Non-severe abruption at 34-36 wks Fetal demise Attempt vaginal delivery if mother is stable and FHT reassuring AND immediate access to cesarean delivery

12. Management Tocolysis = CONTRAINDICATED Unless <34 wks in mild abruption Be prepared for postpartum hemorrhage Chronic abruption – serial US and antepartum surveillance in 3 rd trimester to evaluate for uteroplacental insufficiency

13. Outcomes Maternal: Related to severity of separation DIC, blood loss Emergency C-section Fetal: Related to severity and gestational age Hypoxemia, asphyxia, low birth weight, preterm delivery, death http://ellobonomuerecordero.wordpress.com/http://ellobonomuerecordero.wordpress.com/. Accessed May 27, 2014.

14. Prevention Counsel regarding cessation of tobacco, cocaine, amphetamines Provide appropriate care for hypertensive disorders of pregnancy For future pregnancies: No data on definitive management Consider serial ultrasounds to assess growth Await spontaneous labor or RLTCS if appropriate

15. Key Points Separation of placenta from uterine wall Most common cause of serious vaginal bleeding Risk factors – tobacco use, HTN, abdominal trauma Triad of Vaginal bleeding + Abdominal pain + Fetal distress Management: ASSESS MOM and ASSESS FETAL STATUS! Decision to delivery ratio <20 min!

16. Remember the Case 29 yo G1P0 at 35 0/7 wks presents to L&D from the ER after being involved in car accident  begins to have abdominal pain, vaginal bleeding and NRFHTs. Placental abruption was diagnosed in <20 min thanks to our astute residents, now both mom and baby are doing well! http://www.health4mom.org/s/parenting_preterm_infantshttp://www.health4mom.org/s/parenting_preterm_infants. Accessed May 27, 2014.

17. References Am Fam Physician 2007;75:1199-206. Anath, CV and Kinzler, WL. Placental abruption: Clinical features and diagnosis. In: UpToDate. Lockwood, CJ (Ed), UpToDate. Waltham, MA. 2013. Oyelese, Y and Ananth, CV. Placental abruption: Management. In: UpToDate. Lockwood, CJ (Ed), UpToDate. Waltham, MA. 2013.