Vaginal bleeding is the most common symptom of abruptio placentae and is seen in 80% of the cases. The severity of bleeding varies from patient to patient and may not correspond to the extent of placental abruption. Abdominal/back pain, and tenderness in the uterus are also very common, and are seen in 70% of the patients presenting with placental abruption. About 60% of the cases present with fetal distress. Frequency of uterine contractions increases in some patients. Some patients may have to go for premature labor to alleviate fetal or maternal distress. Pain, both abdominal and back, often have a sudden onset. In some cases, bleeding may be limited to the uterine cavity without any external signs. This is more serious as the amount of bleeding is often underestimated.

• Abdominal Pain

  Symptoms Like Allison, most women experiencing placental abruption will complain of severe abdominal pain and vaginal bleeding. The abdominal pain is unlike contractions because it is usually constant, whereas contractions come and go. [study.com]

  A primigravid woman at 35 weeks' gestation was admitted with abdominal pain, fever, and vomiting. Forceful contractions and signs of fetal distress suggested abruptio placentae. [ncbi.nlm.nih.gov]

  The abdominal pain had started three hours prior to admission, like a vague posterior abdominal colicky pain. The patient and her husband did not relate physical efforts prior the onset of the pain. She did not have abdominal surgery in the past. [hindawi.com]

• Severe Abdominal Pain

  A 25-year-old woman, grayida 4, para 2012, presented with acute onset of severe abdominal pain; frequent, low-amplitude contractions; and a nonreassuring fetal heart tracing. [ncbi.nlm.nih.gov]

  Symptoms Like Allison, most women experiencing placental abruption will complain of severe abdominal pain and vaginal bleeding. The abdominal pain is unlike contractions because it is usually constant, whereas contractions come and go. [study.com]

  You have severe abdominal pain or contractions. You are leaking fluid from your vagina, or a large amount of fluid comes out of your vagina. You have new and sudden chest pain or trouble breathing. [drugs.com]

  Diagnosis Symptoms Acute constant severe abdominal pain which may be localised or diffuse. Dark vaginal bleeding results from escape of blood from the retroplacental haematoma. Cessation of foetal movement is common. [gfmer.ch]

• Acute Abdomen

  Other causes of acute abdomen. Investigations Ultrasound: detects normally sited placenta with retroplacental haematoma that may dissect the placental margin. Tests for DIC (see later). Treatment At home The same as in placenta praevia. [gfmer.ch]

• Tachycardia

  Petechiae around BP cuff site, maternal tachycardia and diaphoresis. FIBRINOGEN LEVELS (ELEVATED in PREGNANCY) DROP IN MIN TO THE POINT AT WHICH BLOOD WILL NO LONGER COAGULATE. Large amounts of thromboplastin = DIC resulting in hypofibrinogenemia. [quizlet.com]

  Tachycardia. (B) Abdominal examination: Uterus is large for date and increasing gradually in size due to retained blood. Uterus is very tender and hard (board-like). Foetal parts are difficult to be felt. [gfmer.ch]

  tachycardia (>160 bpm) Uterine tenderness Foul odor of amniotic fluid[4] Exclusions: Maternal upper respiratory infection. [en.wikipedia.org]

  The uterus is painful, the mother suffers from hypotension, tachycardia and hypo-fibrinogenemia and the fetus suffers from distress. [intechopen.com]

• Hypotension

  Physical Exam Grade Uterine Irritability Maternal Hemodynamics Maternal Fibrinogen Fetal Heart Rate Mild Mild Normal Normal Normal Moderate Moderate Postural hypotension, tachycardic Low decreased variability, late decelerations Severe Tetany Hypotension [sharinginhealth.ca]

  MANAGEMENT PREVENTION 1 .Prevention of known factors  Early detection and effective therapy  Needle puncture  Avoidance of trauma  To avoid supine hypotension  routine administration of folic acid 24. [slideshare.net]

  Precautions Adverse effects include flushing, blurry vision, headaches, and nausea; more serious adverse effects, seen only at toxic levels, include pulmonary edema, respiratory depression, cardiac arrest, maternal tetany, profound hypotension to reverse [www1.cgmh.org.tw]

  Hypotension BP 1: Inspect skin color, temperature, and capillary refill 2: Count and weigh pads hourly. Record pad saturation amount using a specific amount of time (50mL of dark red blood on pad in 20 min.) 1 g = 1mL of blood. [quizlet.com]

• Narrow Pulse Pressure

  Grade III or Class 3 The patient presents with severe to no vaginal bleeding; severe uterine pain; hypotension; pale, cool, and clammy skin; tachycardia; and a narrow pulse pressure. Fetal death is likely. [emsworld.com]

• Third Trimester Bleeding

  Analyzing 130 cases of abruptio placentae among 26,743 deliveries (1:206), the authors conclude that effective management depends primarily on early recognition of the high-risk patient, immediate hospitalization of all women with third trimester bleeding [jamanetwork.com]

  […] umbilical cord Cocaine Previous third trimester bleeding Alcohol use Types Central : placenta separates centrally - blood trapped between placenta and uterine wall - concealed bleeding - concealed type Complete : total separation - massive vaginal bleeding [examnnotes.com]

  Clinically it most often presents with bleeding, uterine contractions, and fetal distress. It is a significant cause of third trimester bleeding and is associated with both fetal and maternal morbidity and mortality. [www1.cgmh.org.tw]

  It is a potentially fatal complication of pregnancy and is a significant cause of third-trimester bleeding/antepartum hemorrhage. The estimated incidence is ~1% of all pregnancies. [radiopaedia.org]

  Towers CV, Pircon RA, Heppard M (1999) Is tocolysis safe in the management of third-trimester bleeding? Am J Obstet Gynecol 180:1572–1578 CrossRef PubMed Google Scholar 61. [link.springer.com]

• Placental Disorder

  "Cesarean section and placental disorders in subsequent pregnancies--a meta-analysis". Journal of Perinatal Medicine. 42 (5): 571–83. doi:10.1515/jpm-2013-0199. [en.wikipedia.org]

• Reduced Fetal Movement

  Be aware of other symptoms, such as abdominal cramping or severe pain, backache, and reduced fetal movement. If you notice any of these symptoms or any kind of vaginal bleeding during your pregnancy, contact your health care provider right away. [pennstatehershey.adam.com]

• Second Trimester Bleeding

  Spotting (during first and second trimester) Bleeding that is sudden, profuse and PAINLESS (during end of second trimester, or during third trimester) Note: Bleeding may occur until onset of cervical dilatation causing the placenta to loosened from the [slideshare.net]

• Uterine Tenderness

  25% Fetal death - 15% Physical Placental abruption is mainly a clinical diagnosis based on findings of vaginal bleeding, abdominal pain, uterine tenderness, uterine contractions, and fetal distress. [emedicine.com]

  Most women will have some uterine tenderness or back pain. And in close to a quarter of cases, an abruption will cause the woman to go into labor prematurely. [babycenter.com]

  Uterine tenderness/pain. In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany placental abruption, especially with a central abruption and trapped blood behind the placenta. [nurseslabs.com]

  Placenta Abruptio is diagnosed using the following tools: Physical examination to evaluate for vaginal bleeding, uterine tenderness, and rigidity Evaluation of medical history Fetal monitoring to assess the fetal heart and for any lack of oxygen Abdominal [dovemed.com]

• Enlarged Uterus

  Proportionate to GA Disproportionately enlarged Uterus feel Normal with local tenderness Tense, tender and rigid Fetal parts Easily identified Difficult FHS Present Absent UO Normal diminished 10. [pt.slideshare.net]

  In a concealed abruption, blood gets trapped inside the uterus and is pooled behind the placenta. [blog.pregistry.com]

  Apart from vaginal bleeding (in revealed abruption), classic placental abruption symptoms and signs include: Back pain [6] Abdominal cramping and pain Abdominal tenderness Rapid uterine contractions [7] Uterine tenderness Pallor Disproportionately enlarged [pregmed.org]

  Common symptoms include sudden-onset abdominal pain, contractions that seem continuous and do not stop, vaginal bleeding, enlarged uterus disproportionate to the gestational age of the fetus, decreased fetal movement, and decreased fetal heart rate.[5 [en.wikipedia.org]

• Pelvic Pain

  This morning, she began feeling painful contractions and noted vaginal bleeding after she fell off her bike while riding to work. She is experiencing lower abdominal and pelvic pain between contractions as well. [step2.medbullets.com]

  Cervical trauma Sudden, typically caused by sexual intercourse Mild to moderate pelvic pain depending on extent of damage Bruised and tender cervix without evidence of active bleeding Placental abruption Definition The partial or complete separation of [amboss.com]

  tender abdomen on palpation Shock monitoring and management before and after surgery Unilateral LQ (abdominal or pelvic pain Prepare for surgery Amenorrhea with (+) PT 24. [slideshare.net]

  Masselli G, Brunelli R, Monti R et al (2014) Imaging for acute pelvic pain in pregnancy. Insights Imaging 5:165–181 CrossRef PubMed PubMedCentral Google Scholar 64. [link.springer.com]

• Uterine Hemorrhage

  In this situation, there often is fear of uterine hemorrhage secondary to atony; however, this usually is not the rule. [glowm.com]

Clinical diagnosis is the most common diagnostic feature for abruptio placentae. Sensitive and reliable confirmatory diagnostic tests are very rare for this condition. Class 0 abruptio placentae is usually diagnosed retrospectively based on the presence of blood clot or a depression in placenta. Physical examination is very important in identifying the origin of hemorrhage in patients who present with bleeding. Prompt stabilization of the patient is also equally important. Severe abruption can be identified by the presence of tense and tender uterus. Imaging techniques like ultrasound may not be effective in diagnosis as it is difficult to distinguish the blood clot from placenta. But his method is often used to rule out other causes of bleeding in the third trimester. Retroplacental clot, concealed hemorrhage, and expanding hemorrhage are all indicators of abruption. Clots may be hyperechoic to isoechoic initially, but this may change to hypoechoic within a week. Cardiotocograph is used to check for abnormalities in the fetal heart rate due to hypoxia.

Platelet count is often reduced in abruption and is often used to confirm the same. Coagulopathy is also common and is indicative of abruption. Coagulopathy is indicated by moderately reduced levels of fibrinogen. Sever abruption often result in fibrinogen level lesser than 200 mg/dL. Coagulation status of the patient is checked before cesarean section. Even with heavy bleeding, blood pressure of the patient may remain normal. This is because a healthy individual is able to tolerate significant loss of blood before presenting signs of decompensation. Other procedures may be recommended on the basis of gestational age, and fetal status. This includes fetal heart monitoring and type of delivery.

• Hematocrit Decreased

  Port wine-colored amniotic fluid was found during amniocentesis, and serial hematocrits decreased from 36 to 25%. [ncbi.nlm.nih.gov]

• Macrocytosis

  Neither red blood cell macrocytosis characteristic of folate deficiency nor iron deficiency could be implicated in the genesis of severe abruptio placentae. [ncbi.nlm.nih.gov]

• Base Deficit

  The newborn at birth weighted 2200 grams, Apgar score was 1, 3, and 5 at 1, 5, and 10 minutes, cord pH was 6.61, and base deficit was 28 millimol/liter. A severe acute cerebral haemorrhage was diagnosed. [hindawi.com]

Reattachment of the placenta to the uterine wall is not possible, and hence, treatment modality depends on the circumstance. Mother has to be resuscitated and stabilized before deciding on delivery, and is independent of gestation period. The criteria include – 1. Assess airway and breathing, 2. Evaluate circulation, and 3. Assess fetal status.

Treatment also depends on the quantity of blood lost and fetal distress. If the gestation period is less than 36 weeks, and there is no indication of maternal or fetal distress, only monitoring may be required. This is continued till the condition changes or until the maturity of the fetus, whichever comes first. Blood transfusion may be required based on blood loss.

Immediate delivery is indicated if there are signs of maternal or fetal distress, or if fetal maturity is attained. Blood transfusion is needed to maintain blood volume,  while platelet transfusion may be needed to maintain fibrinogen levels . Vaginal delivery is preferred if there are no indications of fetal distress, particularly if the mother is hemodynamically stable. Uterine tone and contractions increase, and this makes delivery rapid.

In the presence of disseminated intravascular coagulations, Cesarean section is preferred. For mothers with premature fetus and small placental separation, close observation is the method suggested. In case of excessive bleeding hysterectomy is recommended. Prior to hysterectomy, other procedures like correction of coagulopathy, ligation of uterine artery, administration of uterotonics, packing of uterus and control of hemorrhage are important.
If the fetus is premature, tocolytics are used for glucocorticoids administration. This will help to enhance maturation of fetal lungs. In case of chronic abruption this will help to delay delivery until complications are less. Tocolysis is induced by magnesium sulfate or nifedipine.

Prognosis depends on the extent of abruption, and also on promptness and quality of the treatment given. In more than half of the cases, fetal distress can be noted early in the condition. Infants have 40-50% chances of complications. Most of the complications are related to premature delivery which is done to alleviate fetal or maternal distress. Maternal morbidity may be caused by transfusion-related issues, cesarean delivery, and hysterectomy. Placental abruption may lead to shock, disseminated intravascular coagulation, acute blood loss, and failure of organs like kidney, in mother. In babies, placental abruption may lead to hypoxia and lack of nutrients, premature birth, or still birth.

The actual cause of separation is unclear. Multiple factors are known to enhance the risk of abruptio placentae [1] [2]. Trauma or injury to abdomen due to fall or an accident is one of the direct causes of abruption. Sudden reduction in uterine volume due to an amniotic fluid loss or multiple pregnancy, is also implicated in the separation of placenta from uterine wall. Factors that increase the risk of the condition include

• History of placental abruption
• Hypertension – whether primary or secondary, this is one of the most common risk factor for placental separation.
• Substance abuse – smoking and cocaine use during pregnancy increase the risk of abruption. One of the studies report that risk of abruption increase by 40% for an year indulged in smoking prior to pregnancy. Risk of abruption in cocaine users depends on the dose and is reported to range from 13% to 35% [3].
• Premature rupture of membranes – break or leak of amniotic sac before labor results in reduced amniotic fluid, increasing the risk of placental separation.
• Blood-clotting disorders 
• Multiple pregnancy – Changes in the uterus after the first delivery in a twin gestation may cause placental separation before the delivery of other babies. 
• Maternal age – risk of placental abruption is more in women above the age of 40 years. 

Incidence of abruption placentae is about 1 in 150 deliveries. This abruption is severe in approximately one in 800 to 1,600 deliveries. Separation of placentae usually occurs during the third trimester, but may also happen after 20 weeks of gestation. Placental abruption is one of the most common causes of antepartum hemorrhage accounting to 30% of all cases [4]. Risk of placental abruption is more in young women below 20 years of age, and those above 40 years.

Avulsion of placental villi from the lower uterine segment results bleeding into the decidua basalis. This abruption may be caused by any of the etiological factors. Hemorrhage into dedicua basalis pushes the placenta further away from the uterine wall and this in turn increases bleeding, resulting in a vicious cycle. Abruption of placentae may be classified into

• Class 0 – this is the asymptomatic form of placental abruption.
• Class 1 – this is characterized by vaginal bleeding with uterine tenderness . It is less serious as fetal or maternal distress is not present. This type accounts for 48% of all cases. 
• Class 2 – this is a moderate form of abruption characterized by bleeding with some amount of fetal distress. This form is seen in 27% of all cases of placental abruption.
• Class 3 – this is the most severe form of abruption placentae and is characterized by severe maternal bleeding, shock, and death of fetus. Maternal disseminated intravascular coagulation might also be noted. With forced entry of blood into the serosa, it may result in couvelaire uterus. 

Eliminating risk factors is the best way to prevent abruptions in subsequent pregnancies. Smoking and cocaine use are two most important risk factors which can be completely avoided. Rehabilitation programs and education about the risk associated with its use will help in spreading awareness.

Abruptio placentae, commonly known as placental abruption, is an uncommon complication during pregnancy, characterized by premature separation of placenta from the uterine wall. This is a serious condition as placenta is a structure developed during gestation for nourishment of developing fetus. Abruptio placentae result in heavy bleeding and also deprives the fetus of oxygen and nourishment. The two main forms of abruption placentae are
Concealed abruption – refers to a condition in which bleeding is limited to uterine cavity and hence blood loss is underrated in most of the cases. It is seen in 20% of the cases and is more serious than revealed form of abruption
Revealed abruption – this form is characterized by bleeding and incomplete separation of placenta from the uterus. It is more common than concealed form and is less serious.
This condition may be categorized on the basis of extent of separation as partial or complete abruption. On the basis of location of separation, placental abruption is grouped into marginal and central abruption. Patients with placental abruption present with heavy bleeding, contractions and fetal distress. It has a sudden onset and is a serious condition that requires medical attention.

Abruptio placentae is commonly known as placental abruption, and is characterized by the separation of placenta from the uterine lining. This is an uncommon complication in pregnancy, and reduce oxygen and nutrition for fetus. It may cause heavy bleeding and fetal distress. The actual cause of the condition is not yet known. Risk of abruption is increased by factors  like smoking, cocaine or substance abuse, age above 40 years, high blood pressure, uterine infection, water breakage before 37 weeks of pregnancy, history of abruption in earlier pregnancy, uterus or umbilical cord problems, multiple pregnancies like twins or triplets, or injury or trauma to abdomen.

Patients with placental abruption often present with heavy bleeding, abdominal pain, back pain, uterine contractions, and fetal distress. Many complain of sudden belly and back pain. They may also have discomfort or tenderness in the belly. If the blood is limited in the uterine cavity, bleeding may be absent. Physical examination is the most common diagnostic procedure to identify uterine tenderness or rigidity. The actual cause of vaginal bleeding may be checked using ultrasound. This imaging technique is useful in the diagnosis of most form of abruptions.

Abruptio placentae is  serious and requires immediate medical attention. In some cases, the doctor may be able to indicate chances of abruption even before the separation happens. Treatment is based on the gestational age and also the severity of separation. If the fetus is premature and abruption is mild, close monitoring is the only recommendation. Medications may be given for maturation of fetal lungs, of delivery is necessary. If the fetus is full-term or near full-term with minimal placental abruption, vaginal delivery is suggested. If abruption may interrupt normal delivery, C-section may be needed. Prevention of abruption is not possible. The risk of placental separation can be reduced by quitting smoking or abuse of cocaine. Controlling blood pressure and avoiding accidents also help to reduce the risk of abruption placentae.

1. Abu-Heija A, al-Chalabi H, el-Iloubani N. Abruptio placentae: risk factors and perinatal outcome. J Obstet Gynaecol Res. 1998 Apr. 24(2):141-4.
2. Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006 Oct. 108(4):1005-16.
3. Hoskins IA, Friedman DM, Frieden FJ. Relationship between antepartum cocaine abuse, abnormal umbilical artery Doppler velocimetry, and placental abruption. Obstet Gynecol. 1991 Aug. 78(2):279-82.
4. Neilson JP. Interventions for treating placental abruption. Cochrane Database Syst Rev. 2003;(1):CD003247.