Placental abruption

Placental abruption (PAB) is generally defined as the complete or partial separation of the placenta from the uterine wall that occurs after 20 weeks of pregnancy and before birth while the fetus is still present in the uterine cavity. Diagnosis is based on clinical findings and sometimes ultrasonography. Treatment for placental abruption includes bed rest for mild symptoms and prompt delivery for severe or persistent symptoms.

There are independent associations of placental abruption with other conditions. These include severe fetal growth restriction, prolonged rupture of membranes, chorioamnionitis (infection of the placenta and membranes), hypertension (including preeclampsia, pregnancy-induced nonproteinuric hypertension, and pre-existing hypertension), cigarette smoking, advanced maternal age, and unmarried status ( Kramer 1997 ). There is also evidence linking crack cocaine use to placental abruption ( Miller 1995 ). Trauma, particularly motor vehicle accidents, can also cause abruption.

Although the risk of placental abruption is often considered a "non-recurring" obstetric complication, one Swedish study found that the risk of placental abruption increased 10-fold in subsequent pregnancies, to 4–5% ( Karegard 1986 ).

Because of the association of placental abruption with hypertension during pregnancy, interventions that can help prevent high blood pressure or the consequences of hypertension could theoretically reduce the likelihood of abruption, a possibility explored in other Cochrane reviews (eg, Abalos 2007; Dooley 2005; Dooley 2007; Hofmeyr 2006 ).

Epidemiology

Although the prevalence of PA is low - about 0.4–1%, [ 1 ], [ 2 ] this complication is the cause of 10% of perinatal deaths occurring in developed countries. [ 3 ]

Causes placental abruption

There are many reports on risk factors for placental abruption, but the data remain conflicting in many aspects.

Numerous studies have confirmed that hypertension during pregnancy is one of the most important risk factors for placental abruption. [ 4 ], [ 5 ], [ 6 ], [ 7 ], [ 8 ] A history of other chronic maternal diseases [9 ], [ 10 ], [ 11 ], [ 12 ] and the presence of genetic factors are also important. [ 13 ] In addition, underweight, advanced maternal age, and teenage pregnancy have been found to be associated with an increased risk of placental abruption. [ 14 ], [ 15 ], [ 16 ] Most studies have confirmed an increased risk of placental abruption in infertility and the use of assisted reproductive technologies. [ 17 ], [ 18 ] Smoking and alcohol are recognized as important risk factors for the development of placental abruption. Moreover, certain complications that occur during pregnancy increase the risk of placental abruption, such as polyhydramnios [ 19 ] and placenta previa. [ 20 ] In general, any uterine trauma, whether old (e.g., previous cesarean section) or current (e.g., caused by physical trauma or iatrogenic injury), increases the risk of placental abruption. [ 21 ], [ 22 ]

Symptoms placental abruption

The classic presentation of placental abruption, regardless of etiology, is painful vaginal bleeding (present in 35–80% of cases). Blood loss may be minimal or life-threatening and may be hidden behind the placenta. Occult placental abruption presents a particular challenge to the clinician because the patient may not have overt signs or symptoms of placental abruption. [ 23 ] The triad of abdominal pain (present in 70%), hypotension, and fetal heart rhythm abnormalities (present in 75% of cases) suggests significant placental abruption. [ 24 ] Mild to moderate placental abruption does not cause acute laboratory findings.

According to Mei et al., the clinical presentation of placental abruption, especially when combined with abdominal pain, was associated with significantly worse maternal and fetal outcomes.

Complications and consequences

Placental abruption is associated with various complications for the newborn child. First of all, it is associated with a higher prevalence of prematurity and all its consequences, including lower Apgar scores, lower birth weight, increased neonatal morbidity, prolonged hospital stay, more frequent admission to intensive care units, and finally [ 25 ] increased mortality.

Diagnostics placental abruption

Acute disseminated intravascular coagulation most commonly occurs when placental abruption is greater than 50%. Laboratory findings then show acute hemolytic anemia, elevated prothrombin time (PT), partial thromboplastin time (PTT), INR, and d-dimer levels with decreased fibrinogen levels. Fibrinogen levels correlate with the degree of bleeding. Fibrinogen levels less than 200 mg/dL in placental abruption have a 100% positive predictive value for severe bleeding. [ 26 ] The Kleihauer-Betke test is an unreliable predictor of placental abruption because it is positive in only a small proportion of cases.

Ultrasound is also a limited diagnostic tool. Immediately after placental abruption, ultrasound reveals the lesion as echogenic amniotic fluid with a retroplacental hyperechoic fluid pool, which becomes hypoechoic a couple of weeks after the event.[ 27 ],[ 28 ] Although placental ultrasound is the mainstay of placental abruption investigation, only 25–50% of cases will be positive, with 50% being false negative.[ 29 ]

Contrast-enhanced CT is highly sensitive for detecting placental abruption and can determine the extent of placental separation, but the risk to the fetus from radiation must be considered in the decision-making process. The fetus is at greatest risk from radiation during the first 2 to 7 weeks of gestational age, during organogenesis. During the second and third trimesters, the fetus is more resistant to the adverse effects of radiation. Because imaging and laboratory studies can be harmful and are not reliable, the diagnosis of placental abruption is made clinically.

Treatment placental abruption

If the bleeding is not life-threatening to the mother or fetus, the fetal heart rate is good, and if the due date has not yet arrived, hospitalization and bed rest are recommended. These measures may help reduce bleeding. If the bleeding stops, the woman is usually allowed to stand and is discharged from the hospital. If bleeding continues, prompt delivery is indicated; the method is selected using criteria similar to those for preeclampsia or eclampsia. Vaginal delivery, accelerated by intravenous oxytocin, or cesarean section is usually performed, depending on the condition of the mother and fetus. Amniotomy (artificial rupture of membranes) is performed early, as it may hasten delivery and prevent DIC. The results of treatment of complications of a condition such as placental abruption (eg, shock, DIC) are positive.

Sources

• Aylamazyan, E. K. Obstetrics. National leadership. Brief edition / ed. E. K. Ailamazyan, V. N. Serov, V. E. Radzinsky, G. M. Savelyeva. - Moscow: GEOTAR-Media, 2021. - 608 p.
• 1. DesJardin JT, Healy MJ, Nah G., Vittinghoff E., Agarwal A., Marcus GM, Velez JMG, Tseng ZH, Parikh NI Placental abruption as a risk factor for heart failure. Am. J. Cardiol. 2020;131:17–22. doi: 10.1016/j.amjcard.2020.06.034.
• 2. Odendaal H., Wright C., Schubert P., Boyd TK, Roberts DJ, Brink L., Nel D., Groenewald C. Associations of maternal smoking and drinking with fetal growth and placental abruption. Eur. J. Obstet. Gynecol. Reprod. Biol. 2020;253:95–102. doi: 10.1016/j.ejogrb.2020.07.018.
• 3. Tikkanen M. Placental abruption: Epidemiology, risk factors and consequences. Acta Obstet. Gynecol. Scand. 2011;90:140–149. doi: 10.1111/j.1600-0412.2010.01030.x.
• 4. Ananth CV, Keyes KM, Hamilton A, Gissler M, Wu C, Liu S, Luque-Fernandez MA, Skjaerven R, Williams MA, Tikkanen M, et al. An international contrast of rates of placental abruption: An age-period-cohort analysis. PLoS ONE. 2015;10:e0125246. doi: 10.1371/journal.pone.0125246.
• 5. Li Y., Tian Y., Liu N., Chen Y., Wu F. Analysis of 62 placental abruption cases: Risk factors and clinical outcomes. Taiwan J. Obstet. Gynecol. 2019;58:223–226. doi: 10.1016/j.tjog.2019.01.010.
• 6. Bręborowicz G. Położnictwo i Ginekologia. PZWL Wydawnictwo Lekarskie; Warsaw, Poland: 2020.
• 7. Mei Y., Lin Y. Clinical significance of primary symptoms in women with placental abruption. J. Matern.-Fetal Neonatal Med. 2018;31:2446–2449. doi: 10.1080/14767058.2017.1344830.
• 8. Hiersch L., Shinar S., Melamed N., Aviram A., Hadar E., Yogev Y., Ashwal E. Recurrent placenta-mediated complications in women with three consecutive deliveries. Obstet. Gynecol. 2017;129:416–421. doi: 10.1097/AOG.0000000000001890.
• 9. Schmidt P, Skelly CL, Raines DA Placental Abruption. StatPearls; Treasure Island, FL, USA: 2021.
• 10. Yamamoto R., Ishii K., Muto H., Ota S., Kawaguchi H., Hayashi S., Mitsuda N. Incidence of and risk factors for severe maternal complications associated with hypertensive disorders after 36 weeks' gestation in uncomplicated twin pregnancies: A prospective cohort study. J. Obstet. Gynaecol. Res. 2018;44:1221–1227. doi: 10.1111/jog.13650.
• 11. Shoopala HM, Hall DR Re-evaluation of abruptio placentae and other maternal complications during expectant management of early onset pre-eclampsia. Pregnancy Hypertens. 2019;16:38–41. doi: 10.1016/j.preghy.2019.02.008.
• 12. Naruse K., Shigemi D., Hashiguchi M., Imamura M., Yasunaga H., Arai T., Group Advanced Life Support in Obstetrics-Japan Research Placental abruption in each hypertensive disorder of pregnancy phenotype: A retrospective cohort study using a national inpatient database in Japan. Hypertens. Res. 2021;44:232–238. doi:10.1038/s41440-020-00537-6.
• 13. de Moreuil C., Hannigsberg J., Chauvet J., Remoue A., Tremouilhac C., Merviel P., Bellot C., Petesch BP, le Moigne E., Lacut K., et al. Factors associated with poor fetal outcome in placental abruption. Pregnancy Hypertens. 2021;23:59–65. doi: 10.1016/j.preghy.2020.11.004.
• 14. Rodger MA, Betancourt MT, Clark P., Lindqvist PG, Dizon-Townson D., Said J., Seligsohn U., Carrier M., Salomon O., Greer IA The association of factor V leiden and prothrombin gene mutation and placenta-mediated pregnancy complications: A systematic review and meta-analysis of prospective cohort studies. PLoS Med. 2010;7:e1000292. doi: 10.1371/journal.pmed.1000292.
• 15. Maraka S., Ospina NM, O'Keeffe DT, de Ycaza AEE, Gionfriddo MR, Erwin PJ, Coddington CC, III, Stan MN, Murad MH, Montori VM Subclinical hypothyroidism in pregnancy: A systematic review and meta-analysis. Thyroid. 2016;26:580–590. doi: 10.1089/thy.2015.0418.
• 16. Liu L., Sun D. Pregnancy outcomes in patients with primary antiphospholipid syndrome: A systematic review and meta-analysis. Medicine. 2019;98:e15733. doi: 10.1097/MD.0000000000015733.
• 17. Mills G., Badeghiesh A., Suarthana E., Baghlaf H., Dahan MH Associations between polycystic ovary syndrome and adverse obstetric and neonatal outcomes: A population study of 9.1 million births. Hum. Reprod. 2020;35:1914–1921. doi: 10.1093/humrep/deaa144.
• 18. Workalemahu T., Enquobahrie DA, Gelaye B., Sanchez SE, Garcia PJ, Tekola-Ayele F., Hajat A., Thornton TA, Ananth CV, Williams MA Genetic variations and risk of placental abruption: A genome-wide association study and meta-analysis of genome-wide association studies. Placenta. 2018;66:8–16. doi: 10.1016/j.placenta.2018.04.008.
• 19. Martinelli KG, Garcia EM, Santos Neto ETD, Gama S. Advanced maternal age and its association with placenta praevia and placental abruption: A meta-analysis. Cad. Saúde Publica. 2018;34:e00206116. doi: 10.1590/0102-311x00206116.
• 20. Adane AA, Shepherd CCJ, Lim FJ, White SW, Farrant BM, Bailey HD The impact of pre-pregnancy body mass index and gestational weight gain on placental abruption risk: A systematic review and meta-analysis. Arch. Gynecol. Obstet. 2019;300:1201–1210. doi:10.1007/s00404-019-05320-8.
• 21. Kyozuka H., Murata T., Fukusda T., Yamaguchi A., Kanno A., Yasuda S., Sato A., Ogata Y., Endo Y., Hosoya M., et al. Teenage pregnancy as a risk factor for placental abruption: Findings from the prospective Japan environment and children's study. PLoS ONE. 2021;16:e0251428. doi: 10.1371/journal.pone.0251428.
• 22. Qin J., Liu X., Sheng X., Wang H., Gao S. Assisted reproductive technology and the risk of pregnancy-related complications and adverse pregnancy outcomes in singleton pregnancies: A meta-analysis of cohort studies. Fertil. Steril. 2016;105:73–85.e6. doi: 10.1016/j.fertnstert.2015.09.007.
• 23. Vermey BG, Buchanan A., Chambers GM, Kolibianakis EM, Bosdou J., Chapman MG, Venetis CA Are singleton pregnancies after assisted reproduction technology (ART) associated with a higher risk of placental anomalies compared with non-ART singleton pregnancies? A systematic review and meta-analysis. Int. J. Obstet. Gynaecol. 2019;126:209–218. doi: 10.1111/1471-0528.15227.