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2/1/2016

Management of Fetal Demise caused by Abruption at Term

Placental abruption complicates 0.5 to 1% of pregnancies, but very rarely results in fetal demise.  Fetuses that survive are at increased risk of significant morbidity. Management must address maternal and fetal status, severity of the abruption, and gestational age and viability of the fetus. When placental abruption results in fetal demise, there should be significant concern that the abruption is severe and potentially life threatening to the mother as well.

The initial evaluation needs to include a comprehensive history and physical exam to identify causes of abruption that could impact management such as hypertensive disorders of pregnancy, abdominal trauma, or drug use. Tobacco and drug usage by the mother, in particular cocaine use, have all been linked as risk factors for abruption. The mother’s hemodynamic status must be closely evaluated and monitored. Fetal demise should raise concern for significant hemorrhage. Two large-bore intravenous catheters should be placed, and volume resuscitation initiated with crystalloid or uncross-matched O negative blood as clinically warranted. Blood samples should be sent for type and crossmatch, complete blood count, fibrinogen, and PT/aPTT to assess for acute blood loss anemia and coagulopathy. Elevated d-dimer may be associated with severe placental abruption but is not diagnostic. Consumptive coagulopathy (disseminated intravascular coagulation) is more common with concealed abruption.

The patient should also be assessed for vaginal bleeding and for concealed retroplacental hemorrhage. Bleeding per vagina can be assessed objectively using quantitative blood loss(QBL). Concealed hemorrhage may be assessed serially by ultrasonography or measuring fundal height. Ultrasonography may miss some cases of placental abruption, as the echotexture of clot is similar to that of placenta. Ultrasonography should be performed to determine fetal presentation and confirm fetal demise.

Many patients who have experienced a severe abruption and fetal demise have regular contractions on tocodynamometer and may deliver spontaneously. Vaginal delivery is the preferred route as the coagulopathy associated with abruption may complicate cesarean delivery. Prior classical cesarean, which carries a risk of uterine rupture of 4-9%, is not an absolute contraindication for vaginal delivery, and shared decision making should be used to determine route of delivery keeping in mind the risks of surgical hemorrhage due to coagulopathy, pAmniotomy or oxytocin augmentation will usually result in a rapid vaginal delivery. During labor, ongoing blood loss should be noted and replaced as necessary.

In the presence of placental abruption, cesarean delivery has a significant risk of intraoperative hemorrhage due to atony or coagulopathy potentially leading to peripartum hysterectomy. If surgical delivery is necessary, marked thrombocytopenia (platelets less than 50,000/µL) or hypofibrinogenemia (fibrinogen less than 100 mg/dL) should be corrected with platelet or cryoprecipitate infusion to mitigate the risk of intraoperative hemorrhage. Packed red blood cells should be transfused to maintain the hematocrit between 25 and 30%.  Massive transfusion protocols should be initiated if necessary.

Couvelaire uterus, defined as widespread extravasation of blood into the myometrium and beneath the serosa, may be encountered but is not necessarily an indication for hysterectomy. Rh immunoglobulin should be administered per protocol.

Further reading:

American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine in collaboration with; Metz TD, Berry RS, Fretts RC, Reddy UM, Turrentine MA. Obstetric Care Consensus #10: Management of Stillbirth: (Replaces Practice Bulletin Number 102, March 2009). Am J Obstet Gynecol. 2020 Mar;222(3):B2-B20. doi: 10.1016/j.ajog.2020.01.017. Epub 2020 Jan 29. PMID: 32004519.

Initial approval November 2015; Reaffirmed May 2017; Revised November 2018. Minor Revision September 2020, Minor Revision March 2022, Minor Revision January 2024

 

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