Morning Report: 3/28/2013

Today’s Morning Report is courtesy of Dr. Kazzi!

Placental Abruption

Etiology: Maternal HTN ( #1 cause) , Motor Vehicle Accidents or blunt trauma, cocaine use

Classification: 3 Grades of Severity

Mild – No/Mild Vaginal Bleeding, slightly tender uterus, Normal maternal BP and HR, no coagulopathy or fetal distress

Moderate – No vaginal bleeding to moderate vaginal bleeding, moderate to severe uterine tenderness +/- tetanic contractions, Maternal tachycardia and orthostatic changes in BP/HR, Fetal distress, hypofibrinogenemia (50 – 250 mg/dL)
Severe – No VB to severe VB, very painful tetanic uterus, maternal shock, hypofibrinogenemia ( < 150) , coagulopathy, fetal death.

Clinical Presentation:

Patient profile may be 3rd Trimester s/p trauma, hypertension, cocaine use

Vaginal Bleeding (dark “port wine” blood) ~ 80% (20% of abruptions have concealed hemorrhage)

Abdominal/Back pain + Uterine tenderness ~ 70%

Fetal Distress

Abnormal uterine contractions (hypertonic, high frequency)

Physical Exam:

Perform Ultrasound prior to bimanual examination in order to exclude placenta previa

Uterine Tenderness

Uterine hypertonus may be noted

Contractions progress as abruption expands.

Shock

Fundal height increased due to expanding uterine hematoma

Fetal Distress:

Prolonged fetal bradycardia (FHR < 110 bpm)

Repetitive, late decelerations

Loss of variability

Sinusoidal Fetal Heart Tracing

Work Up:

**Consider Abruption in all pre-term labor cases, 3rd trimester bleeding, post-trauma

a) Labs:

CBC, Blood Type (Rh), Coagulation profile

Fibrinogen – pregnancy is associated with elevated fibrinogen levels thus even moderately depressed levels may suggest coagulopathy. Fibrinogen < 200 suggests severe abruption.

D-dimer

Test for DIC by placing blood in plain tube, inverting at 1 minute intervals. Failure to clot may be taken as evidence of DIC (BMJ best practice)

b) Ultrasound:

Findings are < 25% sensitive for placental abruption.

Image: Retroplacental clot. Acute hemorrhage is hyperechoic compared to placenta.

No clinical difference between patients with placental abruption seen on US and those with it not seen.

Value of US is diagnosis of placental previa as cause of bleeding.

c) Fetal Monitoring

Management:

IV access – 2 large bore IVs
IVF crystalloid administration
Type and Crossmatch blood and FFP if necessary.
Transfuse Hemodynamically unstable patients
Rh Immunoglobulin if patient is Rh negative
Fetal Monitoring
Repeat CBCs, Coags, Fibrinogen to monitor for DIC
Vaginal Delivery: Depending on severity and maternal/fetal stability
Cesarean Section: Likely in severe cases or maternal HD instability or fetal distress