Acute placental abruption: Management and long-term prognosis

INTRODUCTION — Acute placental abruption is a significant cause of both maternal morbidity and neonatal morbidity and mortality, particularly when it occurs preterm. Prompt intervention can reduce these risks. This topic will discuss the management of pregnancies complicated by acute abruption. The clinical features, diagnosis, and potential consequences of acute abruption are reviewed separately. (See "Acute placental abruption: Pathophysiology, clinical features, diagnosis, and consequences".)

INITIAL APPROACH FOR ALL PATIENTS — Pregnant people with symptoms of abruption should be evaluated promptly on a labor and delivery unit to establish the diagnosis, assess maternal and fetal status, and initiate appropriate management. Even those with an apparently small abruption who are initially stable may deteriorate rapidly if placental separation progresses or they develop sequelae from potential comorbidities, such as preeclampsia, trauma, or cocaine use.

The following actions are reasonable initial interventions:

●Maternal and fetal monitoring

•Initiate continuous fetal heart rate monitoring, since the fetus is at risk of becoming hypoxemic and developing acidosis.

•Closely monitor maternal hemodynamic status (heart rate, blood pressure, respiratory rate, urine output). Assessment of multiple parameters is important because blood pressure in the normal range may mask hypovolemia if the mother has chronic hypertension or pregnancy-associated hypertension, which are risk factors for abruption.

In patients who may have a severe abruption, urine output should be monitored closely, but a bladder catheter is not necessary unless the patient is hemodynamically unstable or having a cesarean birth.

•Quantify blood loss. (See "Overview of postpartum hemorrhage", section on 'Quantify blood loss'.)

Actual blood loss may be far in excess of what is observed due to retained retroplacental, retrochorionic, intraamniotic bleeding, or clot formation.

•Perform an ultrasound examination to evaluate fetal size/growth, amniotic fluid volume, and to examine the placenta for placental location (to rule out placenta previa or vasa previa as causes of bleeding) and for evidence of clot/hematoma.

•Perform a physical examination to rule out other causes for bleeding (such as cervical polyps, cervical erosions, tumors, and vaginal or urethral lesions).  

●Maternal support

•Secure intravenous access. Place one wide-bore intravenous line; two if the patient presents with signs of moderate or severe abruption, such as moderate to heavy bleeding, hypotension, tachysystole, uterine hypertonicity and tenderness, coagulopathy, or an abnormal fetal heart rate pattern.

•Administer crystalloid, preferably Lactated Ringer, to maintain urine output above 30 mL/hour.

•Keep the patient warm and provide supplemental oxygen, as needed.

●Laboratory tests

•All patients:

-Complete blood count

-Blood type and screen (crossmatch if transfusion is likely)

-Coagulation studies (eg, fibrinogen concentration, prothrombin time, activated partial thromboplastin time)

•A baseline complete metabolic panel, including creatinine, is prudent since patients with severe abruption often develop kidney dysfunction.

•In patients with preeclampsia or HELLP syndrome (ie, Hemolysis, Elevated Liver enzymes, Low Platelet count), liver chemistries should be checked. (See "Preeclampsia: Clinical features and diagnosis", section on 'Laboratory tests' and "HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets)", section on 'Diagnostic evaluation'.)

•A quick and crude clotting test (Lee White test) can be performed at the bedside by placing 5 mL of the patient's blood in a tube with no anticoagulant for 10 minutes [1-3]. Failure to clot within this time or dissolution of an initial clot implies impairment of coagulation and is suggestive of a low fibrinogen level. Prolonged oozing from needle puncture or surgical sites also suggests coagulopathy.

•Some clinicians believe urine toxicology is appropriate if substance misuse is suspected, while others believe verbal screening (table 1) alone is adequate. The authors verbally screen all patients with suspected abruption for substance use, particularly cocaine, and perform a urine drug screen in all patients who have risk factors for substance use. (See "Substance use during pregnancy: Screening and prenatal care", section on 'Screening for substance use' and "Substance use during pregnancy: Screening and prenatal care", section on 'Laboratory testing'.)

●Blood products and targets

•Patients with initially normal coagulation test results may develop coagulopathy over time. In those who continue to have (or develop) signs of moderate or severe abruption, notify the blood bank so blood replacement products (eg, red blood cells, fresh frozen plasma, cryoprecipitate, platelets) will be readily available, if needed, and repeat the blood count and coagulation studies. A critically low fibrinogen (≤200 mg/dL) is a common finding in severe abruption, thus early use of cryoprecipitate is often part of resuscitation.

•Replace blood and blood products, as required. If bleeding continues and the estimated blood loss has exceeded 500 to 1000 mL, we transfuse blood and initiate a massive transfusion protocol when the estimated or quantitative blood loss is >1500 mL or when ≥4 units of blood are transfused (sample protocol: six units packed red blood cells, six units of fresh frozen plasma, one or two cryoprecipitate pools [each pool is composed of five individual units], and one dose of platelets [either a pool of four to six whole blood-derived platelet concentrates or a single apheresis platelet unit]). (See "Massive blood transfusion".)

Transfusion targets vary among authorities. We aim to maintain the following targets because of the risk for continued bleeding and coagulopathy:

-Hematocrit ≥25 to 30 percent

-Platelet count ≥75,000/microL

-Fibrinogen ≥300 mg/dL

-Prothrombin and partial thromboplastin time <1.5 times control

A detailed description of the management of pregnant people with disseminated intravascular coagulation (DIC) can be found separately. (See "Disseminated intravascular coagulation (DIC) during pregnancy: Management and prognosis".)

●Anesthesia – Notify the anesthesia team. Anesthesia-related issues in patients with moderate or severe abruption include management of hemodynamic instability, technical issues related to bleeding diathesis, and the potential need for emergency cesarean birth. (See "Anesthesia for the patient with peripartum hemorrhage".)

●Medications

•Administer standard medications to patients likely to deliver within 24 to 48 hours:

-Magnesium sulfate for neuroprotection for pregnancies <32+0 weeks of gestation. (See "Neuroprotective effects of in utero exposure to magnesium sulfate".)

-Group B streptococcus prophylaxis according to local guidelines. (See "Prevention of early-onset group B streptococcal disease in neonates".)

•Administer antenatal corticosteroids for pregnancies <34+0 weeks of gestation (and possibly at 34+0 to 36+6 weeks of gestation) likely to deliver within the next seven days, unless birth is imminent (within minutes to a few hours). (See "Antenatal corticosteroid therapy for reduction of neonatal respiratory morbidity and mortality from preterm delivery".)

•Administer anti-D immune globulin to patients who are RhD-negative (See "RhD alloimmunization: Prevention in pregnant and postpartum patients", section on 'Selective prophylaxis for pregnancy complications associated with fetomaternal bleeding'.)

SUBSEQUENT MANAGEMENT

Overview — Our general approach to managing the most common clinical scenarios in patients with acute abruption is described below. In individual patients, some modification may be needed for patient-specific factors. No randomized trials and few observational studies have examined the management of pregnancies complicated by this disorder [4]. Therefore, our recommendations are based on case series and reports, personal experience, and good clinical judgment.

In a patient with abruption, the most important factors influencing the decision to deliver versus manage expectantly with close monitoring are gestational age (which affects the type and frequency of neonatal morbidity) and maternal and fetal status (which reflect the severity of the abruption). Delivery is required for term pregnancies and pregnancies complicated by a severe abruption (ie, maternal disseminated intravascular coagulation [DIC], hypovolemic shock, need for blood transfusion, kidney failure; nonreassuring fetal heart rate pattern or biophysical profile; fetal growth restriction; fetal death) [5].

Clinical setting

Unstable mother with live fetus — Cesarean birth is the best option when vaginal birth is not imminent and rapid control of bleeding is required because of any of the following:

●Maternal hemodynamic instability or deteriorating vital signs

●Significant coagulopathy, which has been associated with an increased risk of fetal acidemia

●Maternal unwillingness to accept adequate blood replacement therapy and a high risk for developing hemodynamic instability during labor

Blood and blood products for correction of hypovolemia and coagulopathy should be replaced prior to and during the cesarean birth. (See "Disseminated intravascular coagulation (DIC) during pregnancy: Management and prognosis", section on 'Delivery'.)

Unstable mother with dead fetus — The optimal route of birth in these cases minimizes the risk of maternal morbidity or mortality since fetal well-being is no longer a factor. In cases with a fetal demise, maternal coagulopathy should be assumed as typically >50 percent of the placenta has separated. Early and aggressive use of blood and blood product replacement are often necessary. Unless vaginal birth appears imminent, expeditious delivery by cesarean is often desirable in this situation.

Stable mother and nonreassuring fetal status

●Category III tracing (or biophysical profile score 0 to 4) – Expeditious delivery is indicated if the fetal heart rate pattern suggests an increased risk of fetal acidemia (ie, category III tracing). A biophysical profile score of 0/10 to 4/10 also suggests an increased risk of fetal acidemia and the need for expeditious delivery. Although tocolytics have been suggested for intrapartum resuscitation in response to intrapartum category III fetal heart rate tracings, we suggest not using tocolytics for this purpose in cases of suspected abruption as these medications can worsen any maternal hemodynamic instability and increase the volume of postpartum bleeding [6].

Usually, cesarean is the preferred route of birth; however, if vaginal birth is imminent, then a spontaneous or instrument-assisted vaginal birth is likely the least morbid route of birth for the mother, regardless of hemodynamic status.

Blood and blood products should be replaced prior to and during birth, when indicated because of hemodynamic instability and coagulopathy.

In one of the only studies that evaluated cesarean birth for severe abruption with fetal bradycardia, a decision-to-delivery interval of less than 20 minutes was associated with better outcomes than a ≥30-minute interval [7]. Although this was a case-control study with only 33 cases, it underscores the principle that minimizing the duration of prolonged bradycardia before birth impacts outcome when the abruption is severe and supports our recommendation for urgent cesarean birth in cases of suspected abruption with fetal bradycardia.

●Category II tracing – Although a category II tracing may be managed expectantly in patients without abruption, it is ominous in the setting of a probable abruption because of the high risk for sudden fetal deterioration to a category III tracing and fetal death. Delivery management depends on gestational age, cervical dilation, and whether progressive deterioration in either the tracing or maternal condition is occurring. In particular, recurrent late decelerations or minimal/absent fetal heart rate variability should lead to emergency cesarean delivery. Close monitoring is essential, and preparations for urgent delivery should be made in expectantly managed cases. (See "Intrapartum category I, II, and III fetal heart rate tracings: Management".)

Stable mother with fetal demise — For the stable mother, vaginal birth is desirable because it is generally less morbid than cesarean. Although a previous classical hysterotomy is a relative contraindication to labor and vaginal birth, the 4 to 9 percent risk of intrapartum rupture may be acceptable in the setting of fetal demise since cesarean birth has no fetal benefit. This decision should be individualized, taking into account factors such as cervical status and local resources for maternal care in the event of rupture. (See "Uterine rupture: After previous cesarean birth".)

In all cases of fetal demise, maternal coagulopathy must be assumed, and blood and blood product replacement should be administered promptly.

Stable mother and reassuring fetal status — If the fetal heart rate pattern or biophysical profile score is reassuring, then the decision to deliver versus manage expectantly depends on gestational age and whether the abruption has led to onset of spontaneous labor.

Abruption at <34+0 weeks of gestation — When the fetus and mother are both stable and there is no evidence of ongoing major blood loss or coagulopathy, conservative management with the aim of delivering a more mature fetus is the main goal before 34+0 weeks of gestation [8-11].

●For patients in preterm labor, when both mother and fetus status is reassuring, we often administer a 48-hour course of nifedipine to enable administration of a full course of antenatal corticosteroids (discussed below). Contractions may be caused by the direct or indirect effect of thrombin and may lead to further placental separation, which may, in turn, cause further bleeding, creating a cycle of bleeding and contractions [12,13]. Administration of tocolytics may prevent further contractions, in theory breaking this cycle. However, tocolytics, especially beta-sympathomimetic agents such as terbutaline, may cause tachycardia and hypotension, which may worsen any hemodynamic instability resulting from abruption, and also may make it difficult to recognize signs of worsening hypovolemia. For these reasons, several authorities have argued against their use in this setting.

Indomethacin is probably best avoided in the setting of abruption as it has been associated with increased risks for oligohydramnios, severe intraventricular hemorrhage, necrotizing enterocolitis, and periventricular leukomalacia in the neonate. (See "Inhibition of acute preterm labor", section on 'Fetal side effects'.)

A few small, retrospective, uncontrolled studies have examined tocolytic use in management of abruption in hemodynamically stable pregnant people with reassuring fetal heart rate tracings [11,14,15]. These studies have not demonstrated harm and have suggested a potential benefit; however, given the limitations of these data, the results need to be interpreted with caution.

●For patients not in labor or with arrested preterm labor, we take the following approach:

•Antenatal corticosteroids – Antenatal corticosteroids to promote fetal lung maturation and reduce complications of preterm birth are administered according to standard guidelines, given the increased risk of need for preterm birth. (See "Antenatal corticosteroid therapy for reduction of neonatal respiratory morbidity and mortality from preterm delivery".)

•Hospitalization – There are no compelling data to guide the length of a hospital stay for these patients. A reasonable approach is to monitor the patient in the hospital until the bleeding has subsided for at least 48 hours, fetal heart rate tracings and ultrasound examinations are reassuring, and the patient is asymptomatic. Discharge may be considered at that time for most patients; however, for patients with sonographic evidence of a large hematoma, we believe it is prudent to keep them in the hospital for a longer period for close monitoring since these patients may be at higher risk of prelabor rupture of membranes or progressive or recurrent placental separation.

Patients who are discharged should be counseled to return immediately if they have more bleeding, contractions, decreased fetal movement, or abdominal pain. Sudden, catastrophic placental separation may occur without warning, regardless of whether patients are managed as inpatients or outpatients and regardless of the degree of initial placental separation. Therefore, a high index of suspicion for severe abruption and thorough patient counseling are important.

•Antenatal fetal assessment – We perform fetal assessment with a nonstress test or biophysical profile twice daily in hospitalized patients with abruption. We also perform serial sonographic estimation of fetal weight to assess growth since these fetuses are at risk of developing growth restriction over time [16]. In patients who are discharged and managed as outpatients, we perform twice-weekly biophysical profiles and sonographic estimation of fetal growth every four weeks.

•Delivery timing – For patients managed conservatively and without any further symptoms, we schedule delivery at 37+0 to 38+0 weeks because of the increased risk of stillbirth [8]. For each patient, the potential risk of neonatal respiratory problems, which is low at this gestational age, should be balanced against the potential risk that a severe abruption will occur while awaiting further fetal maturation.

Delivery before 37+0 weeks is indicated if additional complications arise (eg, fetal growth restriction, preeclampsia, prelabor rupture of membranes, nonreassuring tests of fetal well-being, recurrent abruption with maternal instability). Abruption occurring in the second trimester carries an especially poor prognosis when accompanied by oligohydramnios.

Although the American College of Obstetricians and Gynecologists (ACOG) has published guidance for medically indicated late-preterm and early-term deliveries, they made no recommendations for patients with abruption, stating that data to guide decision-making in these patients were not available [17].

Abruption at 34+0 to 35+6 weeks of gestation

●We deliver most patients who have an acute abruption at 34+0 to 35+6 weeks of gestation, since they remain at risk of maternal or fetal compromise from progressive or recurrent placental separation and neonatal morbidity is relatively low at this gestational age. During labor, partial abruption can progress to total abruption suddenly and without warning, thus the fetus should be continuously monitored and preparations made in case urgent cesarean birth is required.

●For the subgroup of patients at 34+0 to 35+6 weeks of gestation who present with minimal signs and symptoms of acute abruption (eg, light bleeding, normal vital signs and laboratory results, uterine quiescence or mild irritability without tenderness, normal fetal heart rate pattern/biophysical profile score) and then stop bleeding, expectant management is a reasonable approach as long as they remain asymptomatic. Decision-making in these cases is based on patient-specific factors, balancing the estimated risk of progression/recurrence against the relatively small risk of complications associated with preterm birth at this gestational age. We generally suggest delivery between 37+0 and 38+0 weeks of gestation for these patients. (See "Late preterm infants".)

Use of antenatal corticosteroids at this gestational age is reviewed separately. (See "Antenatal corticosteroid therapy for reduction of neonatal respiratory morbidity and mortality from preterm delivery", section on '34+0 or more weeks'.)

Abruption at ≥36 weeks of gestation — We deliver all pregnancies with suspected acute abruption at ≥36 weeks of gestation [8]. This approach balances the relatively low neonatal morbidity of the near-term newborn with the risk of serious maternal-fetal morbidity or mortality from progressive or recurrent abruption during expectant management.

Vaginal birth is preferable, if no obstetric indications for cesarean birth (eg, malpresentation, prior cesarean) are present. With a clinically significant abruption, the patient is often contracting vigorously, but if they are not in active labor, then amniotomy and administration of oxytocin frequently result in rapid delivery.

Pregnancies at or below the limit of neonatal viability — Patients may present with bleeding and sonographic evidence of abruption between 16 and 24 weeks of gestation.

●Most patients with a small amount of bleeding have a favorable prognosis with expectant management.

●Patients with large hematomas, especially associated with oligohydramnios, are at high risk of fetal demise, preterm prelabor rupture of the membranes, and preterm birth. Expectant management with transfusion is an option for patients with substantial blood loss and a live fetus; hospitalization may be necessary. It is crucial that these patients be counseled about the risks for adverse maternal outcome and perinatal outcome. When coagulopathy is present, termination of the pregnancy may be the safest maternal option. (See "Periviable birth (limit of viability)", section on 'Outcomes'.)

DELIVERY AND POSTPARTUM ISSUES

Couvelaire uterus — In severe abruptions, blood may extravasate into the myometrium (called a Couvelaire uterus), which can be seen at cesarean. The Couvelaire uterus is atonic and prone to postpartum hemorrhage. Aggressive management of atony is needed to prevent disseminated intravascular coagulation (DIC) and exsanguination; however, atony in this setting is less likely to respond to standard therapies for postpartum hemorrhage than atony from other causes; thus, these patients are at high risk for requiring hysterectomy. (See "Postpartum hemorrhage: Management approaches requiring laparotomy".)

Cord gases and placenta — We routinely send placentas of patients with abruption for examination by a pathologist. While an acute abruption is a clinical diagnosis, pathology will often show evidence of long-standing placental changes.

We also routinely send umbilical cord gases for analysis of acid-base status.

Postpartum care — Postpartum, we administer an intravenous oxytocin infusion as the first-line uterotonic agent. Maternal vital signs, blood loss, urine output, uterine size and tone, and laboratory results (eg, hemoglobin/hematocrit, coagulation studies) are monitored closely to ensure that bleeding has been controlled and that coagulopathy (if present) is resolving, and to guide replacement of fluids and blood products, as needed.

Patients who develop shock and DIC are at risk of multiorgan failure, especially acute kidney injury. After giving birth, organ function usually improves with aggressive supportive care and treatment of complications, as appropriate. (See "Disseminated intravascular coagulation (DIC) during pregnancy: Management and prognosis".)

Neonate — Neonatal morbidities associated with an abruption are primarily driven by preterm birth [18]. In addition, abruption is the leading cause of neonatal acidemia (relative risk of neonatal metabolic acidemia: 9.07; 95% CI 7.25-11.36) [19], which increases the risk for long-term neurodevelopmental impairment [20,21]. A small proportion of neonates of patients with significant abruptions are born anemic. In a retrospective series, approximately 17 percent of such newborns had anemia, which was sometimes severe [22]. However, the risk of anemia was insignificant when the obstetrician considered the abruption small. A meta-analysis reported that the odds of cerebral palsy was higher in infants born to mothers with placental abruption versus without abruption, but warned this finding should be interpreted cautiously, given high heterogeneity and overall poor quality of the included studies [23].

MANAGEMENT OF FUTURE PREGNANCIES

Recurrence risk

●After one abruption – Patients with abruption are at severalfold higher risk of abruption in a subsequent pregnancy [24-30]. Three to 15 percent of these patients have a recurrence, compared with a baseline incidence of 0.4 to 1.3 percent in the general population [25,31-33].

In one longitudinal population-based study, the risk of abruption in a subsequent pregnancy was approximately 6 percent in patients with an abruption in their first pregnancy versus 0.06 percent in patients without an abruption [30]. In this study, patients with a term abruption were at higher risk for recurrence than those with preterm abruption.

●After two abruptions – After two consecutive abruptions, the risk of a third rises to 20 to 25 percent [29,34].

●After a severe abruption – The risk of recurrence is higher after a severe abruption than after a mild abruption. When the abruption is sufficiently severe to result in fetal demise, the risk of recurrence with fetal demise is 7 percent [35].

●After trauma – Placental abruption resulting from trauma is not likely to recur in the absence of recurrent trauma, so these patients can be reassured.

There are no laboratory screening tests that predict a patient’s risk for abruption. Testing patients with a history of abruption for antiphospholipid antibodies or an inherited thrombophilia is not indicated to predict recurrence. (See "Antiphospholipid syndrome: Obstetric implications and management in pregnancy" and "Inherited thrombophilias in pregnancy".)

Other pregnancy-related risks — Abruption, preeclampsia, and growth restriction appear to be variable clinical manifestations of uteroplacental underperfusion, chronic hypoxia, and uteroplacental ischemia [28,36-42]. These disorders often coexist in a pregnancy, or one may occur in one pregnancy while another occurs in a subsequent pregnancy.

For example, in large retrospective cohort studies, patients who gave birth to a preterm growth-restricted neonate in their first pregnancy were at threefold increased risk of experiencing abruption in the subsequent pregnancy [36], and those with preeclampsia in the first pregnancy carried at least a twofold increased risk of developing abruption in the subsequent pregnancy [38,43].

Reducing the risk of recurrence — No intervention has been proven to reduce the risk of abruption. However, it is reasonable to identify and address modifiable risk factors, which also benefits general health:

●Patients who smoke cigarettes or use cocaine should be encouraged and helped to stop. (See "Overview of smoking cessation management in adults" and "Stimulant use disorder: Treatment overview", section on 'Cocaine use disorder'.)

●Poorly controlled hypertension should be controlled. (See "Treatment of hypertension in pregnant and postpartum patients", section on 'Preconception management of chronic hypertension'.)

Submucosal myomas may be associated with abruption. When a patient with a submucosal myoma has an abruption, we consider hysteroscopic resection/removal of the myoma prior to the next pregnancy; the decision depends on patient-specific factors (eg, severity of abruption, size and location of the myoma with respect to the placenta). (See "Uterine fibroids (leiomyomas): Treatment overview", section on 'Patients desiring fertility'.)

In a meta-analysis of randomized trials, prophylactic low-dose aspirin did not decrease the risk for abruption [44].

Monitoring subsequent pregnancies — Because abruption, preeclampsia, and growth restriction appear to be variable clinical manifestations of uteroplacental underperfusion, in our practice, in subsequent pregnancies, we perform an ultrasound examination to screen for growth restriction approximately every four weeks starting at 24 to 28 weeks of gestation and continuing until birth. If growth restriction is detected, we manage these pregnancies accordingly. Monitoring for preeclampsia is already a standard focus of routine antenatal care. (See "Fetal growth restriction: Evaluation" and "Preeclampsia: Clinical features and diagnosis" and "Preeclampsia: Antepartum management and timing of delivery".)

Routine periodic fetal antepartum surveillance (eg, nonstress test, biophysical profile score) in the absence of a documented high-risk condition is not helpful, as fetuses at risk of death from a sudden unpredictable insult, such as complete abruption, are rarely identified, and thus there is no opportunity for intervention to prevent fetal death or neurologic disability. Antenatal fetal testing is performed for standard obstetric indications. (See "Overview of antepartum fetal assessment".)

Timing of delivery in subsequent pregnancies

●For patients with one prior abruption with a live birth and who have no bleeding, growth restriction, or preeclampsia in the subsequent pregnancy, we provide routine prenatal care until spontaneous labor ensues, or schedule labor induction or repeat cesarean birth at 39+0 to 39+4 weeks of gestation. We deliver all patients with one prior abruption who are being managed expectantly by 39+4 weeks.

●For patients who have had more than one prior abruption or a prior perinatal death, we offer early-term delivery at 37+0 to 38+0 weeks because of the high risk for recurrent abruption, which may not be predictable.

There are limited data on which to base timing of delivery in these patients. A cohort study using data from the Medical Birth Registry of Norway estimated that patients with a history of a complicated abruption are at highest risk of recurrence during the six weeks prior to the gestational age of the initial abruption [33]. Since most patients do not have a recurrence and most recurrences do not result in fetal death, a policy of delivery six weeks prior to the gestational age of the previous abruption would result in substantial morbidity from preterm birth, with minimal reduction in abruption-related perinatal death.

LONG-TERM MATERNAL PROGNOSIS — There is increasing evidence that maternal vascular, metabolic, and inflammatory complications of pregnancy increase the risk for future cardiovascular disease (CVD; coronary artery disease, myocardial infarction, coronary revascularization, peripheral arterial disease, transient ischemic attack, stroke). In a meta-analysis of 11 cohort studies including over 6 million pregnancies, nearly 70,000 abruptions, and nearly 50,000 cases of CVD (including stroke), the morbidity plus mortality rate from CVD among abruption and nonabruption groups was 16.7 and 9.3 per 1000 births, respectively (risk ratio [RR] 1.76, 95% CI 1.24-2.50) [45]. The mortality risk was higher than the risk of nonfatal CVD complications and increased with an increasing number of abruptions. Thus, patients who have had a placental abruption may benefit from postpartum counseling and therapeutic interventions to help mitigate CVD risks. (See "Overview of primary prevention of cardiovascular disease" and "Atherosclerotic cardiovascular disease risk assessment for primary prevention in adults: Our approach".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Obstetric hemorrhage".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Placental abruption (The Basics)")

SUMMARY AND RECOMMENDATIONS

●When to suspect abruption – Pregnant people with bleeding, abdominal pain, or other symptoms suggestive of abruption should be evaluated promptly on a labor and delivery unit to establish the diagnosis, assess maternal and fetal status, and initiate appropriate management. A patient who is initially stable may deteriorate rapidly if placental separation progresses. (See 'Initial approach for all patients' above.)

●Evaluation – The initial approach includes continuous fetal heart rate monitoring, placement of large bore intravenous lines, assessment of blood loss and maternal hemodynamic status, ruling out other causes of bleeding (eg, placenta previa, vasa previa, cervical polyps or lesions), and evaluation for coagulopathy. Blood and blood products should be replaced aggressively, when indicated. An ultrasound should be performed to assess fetal growth, amniotic fluid volume, fetal activity, placental location and appearance, and evidence of clots/hematomas. (See 'Initial approach for all patients' above.)

●Initial management

•Stabilization and triage – After initial evaluation and stabilization, the management of pregnancies complicated by clinically significant abruption depends on whether the fetus is alive or dead, maternal hemodynamic stability, and, if the fetus is alive, the fetal heart rate pattern and gestational age. (See 'Subsequent management' above.)

•Transfusion – Blood and blood products should be replaced prior to and during delivery, when indicated, because of hemodynamic instability and coagulopathy. (See 'Initial approach for all patients' above.)

●Approach to delivery

•Fetal demise – If the fetus is dead, the mode of delivery should minimize the risk of maternal morbidity or mortality. For most hemodynamically stable patients without coagulopathy, vaginal birth is preferable. Cesarean birth is preferable when vaginal birth is not imminent and rapid control of bleeding is required because of maternal hemodynamic instability or significant coagulopathy, or the mother is unwilling to accept adequate blood replacement therapy and is therefore likely to develop hemodynamic instability or coagulopathy during labor. (See 'Unstable mother with dead fetus' above.)

•Nonreassuring fetal heart rate pattern – When the fetal heart rate pattern is nonreassuring (category III), expeditious delivery is indicated. If vaginal birth is imminent, then a spontaneous or instrument-assisted vaginal birth is preferable, whether or not the mother is hemodynamically stable. Otherwise, cesarean birth is indicated. (See 'Stable mother and nonreassuring fetal status' above.)

-A category II tracing is ominous in the setting of a probable abruption because of the high risk for sudden fetal deterioration to a category III tracing and fetal death. A category II fetal heart rate pattern with recurrent late decelerations or minimal or absent variability is particularly ominous. Close monitoring is essential, and preparations for urgent delivery should be made in expectantly managed cases. (See 'Stable mother and nonreassuring fetal status' above.)

•Reassuring fetal heart rate pattern – When the fetal heart rate pattern is reassuring (category I), management depends on the maternal status and gestational age.

For pregnancies where the mother is unstable at any gestational age, we deliver the patient expeditiously. If vaginal birth is imminent, then a spontaneous or instrument-assisted vaginal birth is preferable. Otherwise, cesarean birth is indicated. (See 'Unstable mother with live fetus' above.)

When the mother is stable, the decision to deliver depends primarily on gestational age, with consideration of ongoing maternal symptoms.

-For most pregnancies <34+0 weeks of gestation with no evidence of ongoing major blood loss or coagulopathy, we suggest conservative management until 37+0 to 38+0 weeks. We administer a course of antenatal corticosteroids (see 'Abruption at <34+0 weeks of gestation' above). Pregnancies below or at the limit of neonatal viability require a more individualized approach. (See 'Pregnancies at or below the limit of neonatal viability' above.)

-For most pregnancies at 34+0 to 35+6 weeks of gestation, we suggest delivery because these patients remain at risk of maternal or fetal compromise from progressive or recurrent placental separation. For the subgroup of patients at 34+0 to 35+6 weeks who present with minimal signs and symptoms of abruption (eg, light bleeding, normal vital signs and laboratory results, uterine quiescence or mild irritability without tenderness, normal fetal heart rate pattern/biophysical profile score) and then stop bleeding, expectant management is a reasonable approach as long as they remain asymptomatic. (See 'Abruption at 34+0 to 35+6 weeks of gestation' above.)

-We deliver all pregnancies with acute abruption at ≥36+0 weeks of gestation. (See 'Abruption at ≥36 weeks of gestation' above.)

●Couvelaire uterus – The Couvelaire uterus is atonic and prone to postpartum hemorrhage. Aggressive management of atony is needed to prevent disseminated intravascular coagulation (DIC) and exsanguination; however, atony in this setting is less likely to respond to standard therapies for postpartum hemorrhage than atony from other causes. These patients are at high risk for requiring hysterectomy. (See 'Couvelaire uterus' above.)

●Management of future pregnancies

•Risk of recurrent abruption – The risk of recurrent abruption is 3 to 15 percent, compared with a baseline incidence of 0.4 to 1.3 percent in the general population. No intervention has been proven to lower the risk of recurrent abruption, and no tests are available that identify pregnancies at risk of recurrence or fetuses at risk of harm. (See 'Recurrence risk' above.)

•Prognosis – A past history of placental abruption also predicts a greater likelihood of a small for gestational age neonate, preeclampsia, and spontaneous preterm birth in future pregnancies, even in the absence of recurrent abruption. We monitor patients for these complications.

Placental abruption also appears to increase the risk for future maternal cardiovascular disease, thus postpartum counseling and therapeutic interventions to help mitigate this risk may be useful. (See 'Other pregnancy-related risks' above and 'Long-term maternal prognosis' above.)

•Timing of delivery – For most patients with a past history of abruption, we wait until spontaneous labor ensues, or schedule labor induction or repeat cesarean birth at 39+0 to 39+4 weeks of gestation. We deliver all such patients by 39+4 weeks.

For patients who have had a prior perinatal death or more than one prior abruption, we offer early-term delivery at 37+0 to 38+0 weeks. (See 'Timing of delivery in subsequent pregnancies' above.)