Editing Placental abruption

{{Distinguish|Abruptio}}
{{Infobox medical condition (new)
| name            = Placental abruption
| synonyms        = Abruptio placentae
| image           = Blausen 0737 PlacentalAbruption.png
| caption         = Drawing of internal and external bleeding from placental abruption
| pronounce       =
| field           = [[Obstetrics]]
| symptoms        = [[Vaginal bleeding]], low [[abdominal pain]], [[hemorrhagic shock|dangerously low blood pressure]]<ref name=Merck2017/>
| complications   = '''Mother''': [[disseminated intravascular coagulopathy]], [[kidney failure]]<ref name=Tik2011/><br>'''Baby''': [[low birthweight]], [[preterm delivery]], [[stillbirth]]<ref name=Tik2011/>
| onset           = 24 to 26 weeks of pregnancy<ref name=Tik2011/>
| duration        =
| types           =
| causes          = Unclear<ref name=Tik2011/>
| risks           = Smoking, [[preeclampsia]], prior abruption<ref name=Tik2011/>
| diagnosis       = Based on symptoms, [[ultrasound]]<ref name=Merck2017/>
| differential    = [[Placenta previa]], [[bloody show]], [[chorioamnionitis]]<ref name=Sax2014/>
| prevention      =
| treatment       = [[Bed rest]], [[Childbirth|delivery]]<ref name=Merck2017/>
| medication      = [[Corticosteroids]]<ref name=Merck2017/>
| prognosis       =
| frequency       = ~0.7% of pregnancies<ref name=Tik2011/>
| deaths          =
}}
<!-- Definition and symptoms -->
'''Placental abruption''' is when the [[placenta]] separates early from the [[uterus]], in other words separates before [[childbirth]].<ref name=Tik2011>{{cite journal|last1=Tikkanen|first1=M|title=Placental abruption: epidemiology, risk factors and consequences|journal=Acta Obstetricia et Gynecologica Scandinavica|date=February 2011|volume=90|issue=2|pages=140–9|doi=10.1111/j.1600-0412.2010.01030.x|pmid=21241259|s2cid=10871832|doi-access=free}}</ref> It occurs most commonly around 25 [[Gestational age (obstetrics)|weeks of pregnancy]].<ref name=Tik2011/> Symptoms may include [[vaginal bleeding]], lower [[abdominal pain]], and [[hemorrhagic shock|dangerously low blood pressure]].<ref name=Merck2017/> Complications for the mother can include [[disseminated intravascular coagulopathy]] and [[kidney failure]].<ref name=Tik2011/> Complications for the baby can include [[fetal distress]], [[low birthweight]], [[preterm delivery]], and [[stillbirth]].<ref name=Tik2011/><ref name=Sax2014>{{cite book|last1=Saxena|first1=Richa|title=Bedside Obstetrics & Gynecology|date=2014|publisher=JP Medical Ltd|isbn=9789351521037|pages=205–209|url=https://books.google.com/books?id=kLOHAwAAQBAJ&pg=PA209|language=en}}</ref>

<!-- Cause and diagnosis -->
The cause of placental abruption is not entirely clear.<ref name=Tik2011/> Risk factors include [[smoking]], [[pre-eclampsia]], prior abruption (most important and predictive risk factor), [[Major trauma|trauma]] during pregnancy, [[cocaine]] use, and previous [[cesarean section]].<ref name=Tik2011/><ref name=Merck2017/> Diagnosis is based on symptoms and supported by [[ultrasound]].<ref name=Merck2017>{{cite web|title=Abruptio Placentae - Gynecology and Obstetrics|url=http://www.merckmanuals.com/en-ca/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/abruptio-placentae|website=Merck Manuals Professional Edition|access-date=9 December 2017|language=en-CA|date=October 2017}}</ref> It is classified as a [[complication of pregnancy]].<ref name=Merck2017/>

<!-- Prevention and treatment -->
For small abruption, [[bed rest]] may be recommended, while for more significant abruptions or those that occur near term, [[Childbirth|delivery]] may be recommended.<ref name=Merck2017/><ref>{{cite book |last1=Gibbs |first1=Ronald S. |title=Danforth's Obstetrics and Gynecology |date=2008 |publisher=Lippincott Williams & Wilkins |isbn=9780781769372 |page=385 |url=https://books.google.com/books?id=v4krPhqFG8sC&pg=PA385 |language=en}}</ref> If everything is stable, [[vaginal delivery]] may be tried, otherwise [[cesarean section]] is recommended.<ref name=Merck2017/> In those less than 36 weeks pregnant, [[corticosteroids]] may be given to speed development of the baby's lungs.<ref name=Merck2017/> Treatment may require [[blood transfusion]] or [[emergency hysterectomy]].<ref name=Tik2011/>

<!-- Epidemiology -->
Placental abruption occurs in about 1 in 200 pregnancies.<ref name="Shef2014">{{Cite book |title=Williams obstetrics |date=2014 |publisher=McGraw-Hill education |isbn=978-0-07-179893-8 |edition=24th |location=New York}}</ref> Along with [[placenta previa]] and [[uterine rupture]] it is one of the most common causes of vaginal bleeding in the later part of pregnancy.<ref>{{cite journal|last1=Hofmeyr|first1=GJ|last2=Qureshi|first2=Z|title=Preventing deaths due to haemorrhage|journal=Best Practice & Research. Clinical Obstetrics & Gynaecology|date=October 2016|volume=36|pages=68–82|doi=10.1016/j.bpobgyn.2016.05.004|pmid=27450867|url=http://www.bestpracticeobgyn.com/article/S1521-6934(16)30029-3/abstract|url-access=subscription}}</ref> Placental abruption is the reason for about 15% of infant deaths around the time of birth.<ref name=Tik2011/> The condition was described at least as early as 1664.<ref>{{cite book|title=The Journal of the Indiana State Medical Association|date=1956|publisher=The Association|page=1564|url=https://books.google.com/books?id=7wEwAQAAMAAJ&q=%22Accidental+Hemorrhage%22+1664|language=en}}</ref>

== Signs and symptoms ==
In the early stages of placental abruption, there may be no symptoms.<ref name=Merck2017/> When symptoms develop, they tend to develop suddenly. Common symptoms include:
* sudden-onset abdominal pain<ref name="Shef2014" /><ref name=":1">{{Cite journal|date=2019-03-01|title=Analysis of 62 placental abruption cases: Risk factors and clinical outcomes|journal=Taiwanese Journal of Obstetrics and Gynecology|language=en|volume=58|issue=2|pages=223–226|doi=10.1016/j.tjog.2019.01.010|issn=1028-4559|last1=Li|first1=Yang|last2=Tian|first2=Yuan|last3=Liu|first3=Ning|last4=Chen|first4=Yang|last5=Wu|first5=Fuju|pmid=30910143|doi-access=free}}</ref>
* contractions that seem continuous and do not stop<ref name="Shef2014" />
* vaginal bleeding<ref name="Shef2014" /><ref name=":1" />
* enlarged uterus (disproportionate to the gestational age of the fetus)<ref name="Shef2014" />
* decreased fetal movement<ref name="Shef2014" />
* decreased fetal heart rate.<ref name="Shef2014" />

[[Vaginal bleeding]], if it occurs, may be bright red or dark.<ref name=Merck2017/>

A placental abruption caused by arterial bleeding at the center of the placenta leads to sudden development of severe symptoms and life-threatening conditions including fetal heart rate abnormalities, severe maternal hemorrhage, and [[disseminated intravascular coagulation]] (DIC). Those abruptions caused by venous bleeding at the periphery of the placenta develop more slowly and cause small amounts of bleeding, [[intrauterine growth restriction]], and [[oligohydramnios]] (low levels of amniotic fluid).<ref name=":0" />

==Risk factors==
* Pre-eclampsia<ref name=":1" /><ref name="patient">{{cite web|url = http://patient.info/doctor/placenta-and-placental-problems|title = Placenta and Placental Problems &#124; Doctor|publisher = Patient.info|date = 2011-03-18|access-date = 2012-10-23}}</ref>
* Chronic hypertension<ref name=":1" /><ref name="ReferenceA">{{cite journal|last1=Ananth|first1=CV|last2=Savitz|first2=DA|last3=Williams|first3=MA|title=Placental abruption and its association with hypertension and prolonged rupture of membranes: a methodologic review and meta-analysis|journal=Obstetrics and Gynecology|date=August 1996|volume=88|issue=2|pages=309–18|pmid=8692522|doi=10.1016/0029-7844(96)00088-9|s2cid=21246925}}</ref>
* Short [[umbilical cord]]<ref>{{cite journal | vauthors = Balkawade NU, Shinde MA | title = Study of Length of Umbilical Cord and Fetal Outcome: A Study of 1,000 Deliveries | journal = Journal of Obstetrics and Gynecology of India | date=October 2012 | doi = 10.1007/s13224-012-0194-0  | volume = 62 | issue = 5 | pages = 520–525 | pmid = 24082551| pmc = 3526711 }}</ref>
* Premature rupture of membranes<ref name=":1" />
* Prolonged rupture of membranes (>24 hours).<ref name="ReferenceA" />
* Thrombophilia<ref name="patient" />
* Polyhydramnios<ref name=":1" />
* Multiparity<ref name="patient" />
* Multiple pregnancy<ref name="patient" />
* Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk
Risk factors for placental abruption include disease, trauma, history, anatomy, and exposure to substances. The risk of placental abruption increases sixfold after severe maternal trauma. Anatomical risk factors include uncommon uterine anatomy (e.g. [[bicornuate uterus]]), [[uterine synechiae]], and [[leiomyoma]]. Substances that increase risk of placental abruption include cocaine and tobacco when consumed during pregnancy, especially the third trimester. History of placental abruption or previous Caesarian section increases the risk by a factor of 2.3.<ref name="ReferenceA" /><ref>{{cite journal|year=1999|title=Incidence of placental abruption in relation to cigarette smoking and hypertensive disorders during pregnancy: A meta-analysis of observational studies|journal=Obstetrics & Gynecology|volume=93|issue=4|pages=622–8|doi=10.1016/S0029-7844(98)00408-6|pmid=10214847|last1=Ananth|first1=C}}</ref><ref>{{cite journal|last2=Natekar|first2=A|last3=Kim|first3=E|last4=Koren|first4=G|last5=Bozzo|first5=P|date=July 2014|title=Cocaine abuse during pregnancy.|journal=Journal of Obstetrics and Gynaecology Canada|volume=36|issue=7|pages=628–31|pmid=25184982|last1=Cressman|first1=AM|doi=10.1016/S1701-2163(15)30543-0}}</ref><ref>{{cite journal|last2=Michels|first2=KB|date=September 2014|title=Cesarean section and placental disorders in subsequent pregnancies--a meta-analysis|journal=Journal of Perinatal Medicine|volume=42|issue=5|pages=571–83|doi=10.1515/jpm-2013-0199|pmid=24566357|last1=Klar|first1=M|s2cid=21151164}}</ref><ref name=":0" />

== Pathophysiology ==
[[File:Gross pathology of placental abruption.jpg|thumb|170px|Gross pathology of a uterus which has been opened to show a placental abruption, with a hematoma separating the placenta from the uterus.]]
In the vast majority of cases, placental abruption is caused by the maternal vessels tearing away from the [[Decidua|decidua basalis]], not the fetal vessels. The underlying cause is often unknown. A small number of abruptions are caused by trauma that stretches the uterus. Because the placenta is less elastic than the uterus, it tears away when the uterine tissue stretches suddenly. When anatomical risk factors are present, the placenta does not attach in a place that provides adequate support, and it may not develop appropriately or be separated as it grows. Cocaine use during the third trimester has a 10% chance of causing abruption. Though the exact mechanism is not known, cocaine and tobacco cause systemic vasoconstriction, which can severely restrict the placental blood supply (hypoperfusion and ischemia), or otherwise disrupt the vasculature of the placenta, causing tissue necrosis, bleeding, and therefore abruption.<ref name=":0" />

In most cases, placental disease and abnormalities of the [[Spiral artery|spiral arteries]] develop throughout the pregnancy and lead to necrosis, inflammation, vascular problems, and ultimately, abruption. Because of this, most abruptions are caused by bleeding from the arterial supply, not the venous supply. Production of [[thrombin]] via massive bleeding causes the uterus to contract and leads to DIC.<ref name=":0" />

The accumulating blood pushes between the layers of the decidua, pushing the uterine wall and placenta apart. When the placenta is separated, it is unable to exchange waste, nutrients, and oxygen, a necessary function for the fetus's survival. The fetus dies when it no longer receives enough oxygen and nutrients to survive.<ref name=":0" />

== Diagnosis ==
[[Image:Ultrasound Scan ND 370.jpg|thumb|Ultrasound showing placental abruption]]
Placental abruption is suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The [[fundus (uterus)|fundus]] may be monitored because a rising fundus can indicate bleeding. An [[ultrasound]] may be used to rule out [[placenta praevia]] but is not diagnostic for abruption.<ref name=":1" /> The diagnosis is one of exclusion, meaning other possible sources of vaginal bleeding or abdominal pain have to be ruled out in order to diagnose placental abruption.<ref name=Shef2014/> Of note, use of [[magnetic resonance imaging]] has been found to be highly sensitive in depicting placental abruption, and may be considered if no ultrasound evidence of placental abruption is present, especially if the diagnosis of placental abruption would change management.<ref>{{cite journal|last1=Masselli|first1=G|last2=Brunelli|first2=R|last3=Di Tola|first3=M|last4=Anceschi|first4=M|last5=Gualdi|first5=G|title=MR imaging in the evaluation of placental abruption: correlation with sonographic findings.|journal=Radiology|date=April 2011|volume=259|issue=1|pages=222–30|pmid=21330568|doi=10.1148/radiol.10101547|doi-access=}}</ref>

=== Classification ===
Based on severity:{{cn|date=August 2024}}
* '''Class 0:''' Asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.
* '''Class 1:''' Mild and represents approximately 48% of all cases. Characteristics include the following:
** No vaginal bleeding to mild vaginal bleeding
** Slightly tender uterus
** Normal maternal blood pressure and heart rate
** No [[coagulopathy]]
** No [[fetal distress]]
* '''Class 2:''' Moderate and represents approximately 27% of all cases. Characteristics include the following:
** No vaginal bleeding to moderate vaginal bleeding
** Moderate-to-severe uterine tenderness with possible tetanic contractions
** Maternal tachycardia with orthostatic changes in blood pressure and heart rate
** Fetal distress
** Hypofibrinogenemia (i.e., 50–250&nbsp;mg/dL)
* '''Class 3:''' Severe and represents approximately 24% of all cases. Characteristics include the following:
** No vaginal bleeding to heavy vaginal bleeding
** Very painful tetanic uterus
** Maternal shock
** [[Hypofibrinogenemia]] (i.e., <150&nbsp;mg/dL)
** Coagulopathy
** Fetal death

== Prevention ==
Although the risk of placental abruption cannot be eliminated, it can be reduced. Avoiding tobacco, alcohol and cocaine during pregnancy decreases the risk. Staying away from activities which have a high risk of physical trauma is also important. Women who have high blood pressure or who have had a previous placental abruption and want to conceive must be closely supervised by a doctor.<ref>{{cite web|url=http://www.mayoclinic.com/health/placental-abruption/DS00623/DSECTION=prevention |title=Placental abruption: Prevention |publisher=MayoClinic.com |date=2012-01-10 |access-date=2012-10-23}}</ref>

The risk of placental abruption can be reduced by maintaining a good [[diet (nutrition)|diet]] including taking [[folate]], regular [[sleep]] patterns and correction of [[pregnancy-induced hypertension]].{{cn|date=September 2022}}

Use of [[aspirin]] before 16 weeks of pregnancy to prevent [[pre-eclampsia]] also appears effective at preventing placental abruption.<ref>{{cite journal |last1=Roberge |first1=S |last2=Bujold |first2=E |last3=Nicolaides |first3=KH |title=Meta-analysis on the effect of aspirin use for prevention of preeclampsia on placental abruption and antepartum hemorrhage |journal=American Journal of Obstetrics and Gynecology |date=May 2018 |volume=218 |issue=5 |pages=483–489 |doi=10.1016/j.ajog.2017.12.238 |pmid=29305829|doi-access=free }}</ref>

== Management ==
Treatment depends on the amount of blood loss and the status of the fetus.<ref>{{Citation|last1=Merriam|first1=Audrey|title=96 - Placental Abruption|date=2018-01-01|url=http://www.sciencedirect.com/science/article/pii/B9780323445481000966|work=Obstetric Imaging: Fetal Diagnosis and Care (Second Edition)|pages=426–429.e1|editor-last=Copel|editor-first=Joshua A.|publisher=Elsevier|language=en|doi=10.1016/b978-0-323-44548-1.00096-6|isbn=978-0-323-44548-1|access-date=2020-12-10|last2=D'Alton|first2=Mary E.|editor2-last=D'Alton|editor2-first=Mary E.|editor3-last=Feltovich|editor3-first=Helen|editor4-last=Gratacós|editor4-first=Eduard|url-access=subscription}}</ref> If the fetus is less than 36 weeks, and neither mother or fetus are in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first.{{cn|date=August 2024}}

Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother is in distress. Blood volume replacement to maintain blood pressure and [[blood plasma]] replacement to maintain [[fibrinogen]] levels may be needed. Vaginal birth is usually preferred over [[Caesarean section]] unless there is fetal distress. Caesarean section carries an increased risk in cases of disseminated intravascular coagulation. The mother should be monitored for 7 days for [[postpartum hemorrhage]].  Excessive bleeding from uterus may necessitate hysterectomy. The mother may be given [[Rhogam]] if she is [[Blood type#Rhesus|Rh negative]].{{cn|date=August 2024}}

== Prognosis ==
The prognosis of this complication depends on whether treatment is received by the patient, on the quality of treatment, and on the severity of the abruption. Outcomes for the baby also depend on the gestational age.<ref name=Shef2014/>

In the Western world, maternal deaths due to placental abruption are rare. The fetal prognosis is worse than the maternal prognosis; approximately 12% of fetuses affected by placental abruption die. 77% of fetuses that die from placental abruption die before birth; the remainder die due to complications of preterm birth.<ref name=":0">{{Cite web|url=http://www.uptodate.com/contents/placental-abruption-clinical-features-and-diagnosis?source=see_link|title=Placental abruption: Clinical features and diagnosis|website=www.uptodate.com|access-date=2016-06-04}}</ref>

Without any form of medical intervention, as often happens in many parts of the world, placental abruption has a high maternal mortality rate.{{cn|date=September 2022}}

===Mother===
* A large loss of blood may require a [[blood transfusion]].<ref name=Tik2011/>
* If the mother's blood loss cannot be controlled, an emergency [[hysterectomy]] may become necessary.<ref name=Tik2011/>
* The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract.
* The mother may develop a blood clotting disorder, [[disseminated intravascular coagulation]].<ref name=Tik2011/>
* A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland. Diffuse cortical necrosis in the kidney is a serious and often fatal complication.<ref name=Tik2011/>
* Placental abruption may cause bleeding through the uterine muscle and into the mother's abdominal cavity, a condition called [[Couvelaire uterus]].<ref>{{cite journal|last1=Pitaphrom|first1=A|last2=Sukcharoen|first2=N|title=Pregnancy outcomes in placental abruption|journal=Journal of the Medical Association of Thailand = Chotmaihet Thangphaet|date=October 2006|volume=89|issue=10|pages=1572–8|pmid=17128829}}</ref>
* [[Maternal death]].<ref name=Tik2011/>

===Baby===
* The baby may be born at a low birthweight.<ref name=Tik2011/>
* Preterm delivery (prior to 37 weeks gestation).<ref name=Tik2011/>
* The baby may be deprived of oxygen and thus develop asphyxia.<ref name=Tik2011/>
* Placental abruption may also result in death of the baby, or stillbirth.<ref name=Tik2011/>
* The newborn infant may have learning issues at later development stages, often requiring professional pedagogical aid.

== Epidemiology ==
Placental abruption occurs in approximately 0.2–1% of all pregnancies.<ref name=":1" /> Though different causes change when abruption is most likely to occur, the majority of placental abruptions occur before 37 weeks gestation, and 12–14% occur before 32 weeks gestation.<ref name=":1" /><ref name=":0" />

== References ==
{{Reflist}}

{{Medical resources
|  DiseasesDB     = 40
|  ICD10          = {{ICD10|O|45||o|30}}
|  ICD9           = {{ICD9|641.2}}
|  ICDO           =
|  OMIM           =
|  MedlinePlus    = 000901
|  eMedicineSubj  = med
|  eMedicineTopic = 6
|  eMedicine_mult  = {{eMedicine2|emerg|12}}
|  MeshID         = D000037
}}
{{Pathology of pregnancy, childbirth and the puerperium}}

[[Category:Health issues in pregnancy]]
[[Category:Placentation disorders]]
[[Category:Wikipedia medicine articles ready to translate]]