The Low Down on Placenta Abruptio
Colleen M Hayes, MBA, RN, EMT-P
Normally the placenta does not separate from the uterine wall until the baby
is born. When the placenta prematurely separates from the uterine wall severe
hemorrhage can occur and threatens the life of both the baby and mother. Placenta
abruptio is the leading reason for hemorrhage related deaths in pregnant women.
Other causes of maternal death include cardiac disease, infection, pulmonary
embolism, and pregnancy-induced hypertension complications. Most cases of abnormal
bleeding during the second and third trimesters of pregnancy are caused by premature
separation of the placenta from the uterine wall and abnormal placental implantation.
This article, Part 2 in 3-Part series: "The Low Down on Placenta Abruptio"
will first review the tragic outcome of a case of placenta abruptio that ended
in a lawsuit against EMS. Then this article will discuss the pathophysiology,
incidence, causes, risk factors and emergency treatment for bleeding caused
by placenta abruptio. The next edition of EMSvillage.com will present Part 3
of this series and will discuss pregnancy induced hypertension, eclampsia and
other OB complications.
A True Story and A Real Lawsuit Case Against EMS
The headlines in newspapers after the lawsuit's verdict case read: "Paramedics
Fail to Diagnose Symptoms of Abruptio Placenta and Hypovolemic Shock - Failure
to Transport Mother to Hospital in Timely Manner - Emotional Distress Damages
for Death of Infant, Born Alive, Who Died Next Day - $4.5 Million New York Verdict".
The following information below is excerpted from the case summary:
The plaintiff, a forty-two year old self-employed consultant in her 36th week
of pregnancy, claimed that at 3 a.m. on November 20, 1989, her membranes broke
and she developed stabbing abdominal pains. Her treating obstetrician advised
her to call 911. The evidence indicated that the ambulance arrived in a timely
manner and that the two paramedics started an IV line, conducted a head to toe
examination, and placed her on an EKG monitor before bringing her to the ambulance.
The plaintiff claimed that the defendant paramedics failed to promptly recognize
signs of abruptio placenta and signs of hypovolemic shock, and negligently failed
to immediately rush her to the hospital. Specifically, the plaintiff contended
that her systolic blood pressure was ninety-six, which, she claimed, was indicative
of internal bleeding, when taken together with the severe stabbing abdominal
pains, and was indicative of abruptio placenta, a clear emergency situation
for which she should have been rushed to the hospital. The plaintiff also contended
that as a result, she arrived at least eighteen minutes later than would be
acceptable under the circumstances.
The plaintiff claimed that this delay caused hypoxia to the fetus, which was
delivered by cesarean section, and led to the death of the baby the following
day. The plaintiff further contended that the published paramedic protocols
for making a presumptive diagnosis of hypovolemic shock would be systolic pressure
under 100 and diaphoresis, or excessive perspiration. The plaintiff contended
that diaphoresis was present and that in view of this finding, taken together
with the low blood pressure, she should have been treated in accordance with
the protocol, which stated that the patient should be brought to the hospital
The plaintiff claimed that the IV line could have been inserted and the examination
conducted in the ambulance while en route to the hospital. She contended that
immediately upon arriving at the hospital, the nurses realized that she was
suffering an abruptio placenta and a cesarean section was completed in a timely
fashion at 4:40 a.m. The plaintiff contended, however, that the baby was born
hypoxic with Apgar scores of two and four. Testimony indicated that the placenta
was completely detached from the uterus at the time of birth. The plaintiff
contended that if the baby had been brought to the hospital eighteen minutes
earlier, the cesarean section could have been completed at a time when the fetal
pulse was only slightly depressed and the placenta still attached. The plaintiff's
expert testified that when the child became hypoxic, the fetus experienced pain
and suffering from suffocation that would last several minutes in utero. The
plaintiff also claimed that the procedures used during the one day of life,
including intubation and the insertion of IV lines, were painful.
The plaintiff claimed that she suffered excessive bleeding, requiring a second
surgery to control the bleeding after the baby was born, and that the massive
blood loss resulted in kidney failure for a brief period. The plaintiff underwent
multiple blood transfusions which rectified the difficulties and plaintiff suffered
no permanent injury to the kidneys. She contended that the excessive bleeding,
the need for a second surgery, and the kidney failure were additional injuries
that were independent of the complications that would have stemmed from the
abruptio placenta if it had been recognized and treated promptly. The plaintiff
claimed that the onset of such an independent injury constituted an exception
to the general rule precluding an award for damages for emotional distress stemming
from the baby's death, and she brought this action for emotional distress stemming
from the death of the child.
The plaintiff, who had a history of chronic depression and several incidents
of severe depressive episodes, contended that the happiest time in her life
was during the first three to four years following the birth of her son eight
years before this incident. The plaintiff testified that she became pregnant
again one year before the subject incident, but miscarried shortly thereafter,
and that she had greatly desired another child. The plaintiff stated that she
was very happy when she became pregnant with this child, and contended that
the loss occasioned a severe depression. The plaintiff contended that although
she has experienced significant improvement through therapy and the use of Prozac,
she will require the medication for the rest of her life, and will suffer some
residual depression. The defendant contended that the patient's signs and symptoms
did not fall clearly into any mandated paramedic protocol and that the paramedics
acted appropriately in using their clinical judgment. The defendant also contended
that plaintiff required an examination, which included the taking of her vital
signs, pursuant to and mandated by protocols. The defendant also contended that
plaintiff's depression predated the incident, and partially stemmed from the
earlier miscarriage, citing her psychiatrist's records describing a major depression
prior to these incidents. The defendant argued that any depression stemming
from this episode fully resolved. The defendant further claimed that any continuing
difficulties and the need for Prozac stemmed from her prior depression. According
to The New York Jury Verdict Reporter, the jury awarded plaintiff $4,500,000.
Incidence, causes and risk factors:
Placenta abruptio usually occurs in the third trimester of pregnancy, but it
may occur any time after the 20th week. Placenta abruptio occurs in just a little
less than 1% of pregnancies. However, the severe form (resulting in fetal death)
occurs only in about 1 out of 500 to 750 deliveries. About 15% of all fetal
deaths are caused by severe placenta abruptio.
While the cause of abruptio placenta is generally not known, there are risk
factors associated with it. The known risk factors are as follows:
- Hypertension or high blood pressure during pregnancy is the most common
risk factor and is associated with 2.5 to 17.9% incidence. However, approximately
50% of placenta abruptio cases severe enough to cause fetal death are associated
- Trauma to the abdomen, such as in the case of domestic violence (1.5% -
9.4% of all cases)
- Cocaine use
- Use of alcohol (more than 14 drinks per week)
- Mother over 40 years of age
- Previous abruptio placenta (after 1 prior episode there is a 4% recurrence,
after 2 prior episodes the incidence of recurrence exceeds 20%)
- Premature rupture of the amniotic sac
- Diabetes mellitus in the pregnant woman
- Increased uterine distention (as may occur with multiple pregnancies or
abnormally large volume of amniotic fluid)
Pathophysiology and Types of Placenta Abruptio
Recall that the placenta and umbilical cord connect the mother and the developing
fetus. The placenta and umbilical cord provides oxygen and nutrients to the
baby and eliminates carbon dioxide and waste products through a filtering system.
A normal placenta is implanted high in the uterus and its surface attaches to
the uterus completely. (Fig.1)
1: The placenta normally implants high in the uterus.
Placenta abruptio happens when the placenta prematurely peels away from the
normally implanted uterus with associated bleeding occurring between the separated
placenta and the uterine wall. The amount of separation from the uterus in placenta
abruptio ranges from partial to complete. (To view two photographs of placenta
abruptio click here
Either the blood may accumulate in the uterus, causing a concealed hemorrhage
(Fig. 2) because it is trapped between the placenta and uterine wall, or there
may be an external hemorrhage (Fig 3.) when blood drains through the
cervix and out the body. In placenta abruptio, blood vessels rupture and create
a hematoma. This hematoma shears off the adjacent blood vessels, creating further
bleeding and separation of the placenta.
2: Concealed hemorrhage (gray color)
External hemorrhage (gray color)
Classification of placental abruption is based on extent of separation (i.e.,
partial vs complete) and location of separation (i.e., marginal Vs central).
A classification system and corresponding clinical characteristics include the
Class 1 is the mildest type and represents approximately 48% of all
No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy (clotting problems)
No fetal distress
Class 2 is moderate and represents approximately 27% of all cases.
No vaginal bleeding to moderate vaginal bleeding
Moderate-to-severe uterine tenderness with possible tetanic contractions
Maternal tachycardia with orthostatic changes in BP and heart rate
Low fibrinogen levels present (causing clotting problems)
Class 3 is severe and represents approximately 24% of all cases.
No vaginal bleeding to heavy vaginal bleeding
Very painful tetanic uterus
Coagulopathy (Life threatening clotting problems)
Signs and Symptoms: Making the Diagnosis of Placenta Abruptio
While in the hospital ultrasound is used to locate the placenta's location
and will help rule out placenta previa, the study is not reliable to diagnose,
or rule out the diagnosis of placenta abruptio. The diagnosis of placenta
abruptio is made primarily on clinical presentation. Symptoms may vary,
depending on how much of the placenta has separated and when in the pregnancy
it occurs. 30% of placenta abruptios are small and produce no symptoms. The
main symptom of abruptio placenta is bright red or dark red bleeding from the
vagina. The bleeding does not always occur, though, because the blood can be
trapped behind the placenta or the baby. Other symptoms include abdominal pain,
tenderness around the belly, lower back pain, rigidity of the uterus, uterine
contractions, and decreased fetal movement.
The frequency of the most common symptoms are:
- Vaginal bleeding - 80%
- Abdominal or back pain and uterine tenderness - 70%
- Fetal distress - 60%
- Abnormal uterine contractions (e.g., hypertonic, high frequency) - 35%
- Idiopathic premature labor - 25%
- Fetal death - 15%
Vaginal bleeding that varies in amount (scant to heavy) or color (bright to
dark red), depending on the location and amount of separation. Light bleeding
does not necessarily mean a minor problem, because major bleeding may be occurring
internally. Vaginal bleeding usually does not occur if the separation is slight.
Vaginal bleeding may not occur in a small number of large separations if blood
is trapped between the placenta and the wall of the uterus.
Considerations Related to Assessment
The classic presentation of placenta abruptio is painful cramps or contractions
with dark red or bright red vaginal bleeding after the 20th week of pregnancy.
The bleeding may be heavy or scant depending on the degree of separation and
whether the hemorrhage is concealed or external. There is usually severe pain,
uterine tenderness, and contractions or cramps. Remember the physiological changes
in the pregnant woman that alters the way the EMS provider interprets certain
vital sign changes. Click
here to review the physiologic changes related to pregnancy from Part 1
"The 'Low Down' on Placenta Previa" of this series.
Your assessment may reveal signs of compensated or decompensated shock. Remember
that some of the classic changes in the pregnant female effect cardiovascular,
respiratory and fluid-volume status. These normal changes may conceal the earliest
signs of hypovolemia. For example, due to the increased fluid volume during
the normal pregnant state the mother can lose up to 35% of her blood volume
before signs of shock are evident! The uterus can also contain up to 2 liters
of blood. Just because external blood loss is absent or minimal, there may be
significant occult hemorrhage. In meantime, the brain has told the sympathetic
nervous system to vasoconstrict vessels supplying the fetus as a method to compensate
for blood loss to the mother. While the mother appears stable the fetus is in
Resuscitative measures are indicated even if the mother appears stable and
is normotensive because the fetus is most likely being be hypoperfused and in
serious life threatening shock. Therefore, maintaining a high index of suspicion
even in the absence of the "classic" signs of shock is warranted.
Massive bleeding will threaten both the lives of the mother and the baby. If
bleeding is massive, blood transfusion, and probably preterm delivery may be
Prehospital Management of Placenta Abruptio
The first step in appropriate treatment is recognition of the emergency. Even
if the mother is stable, the assumption must be made that a life threatening
problem exists. After assessing your patient, provide any airway, ventilatory
and circulatory support as needed. Immediate administration of high-flow oxygen
and positioning the patient onto her left side for optimal perfusion is indicated.
Pregnant women are susceptible to vena cava syndrome (compression of the abdominal
aorta and vena cava) and should be placed in the left lateral recumbent position.
Vena cava syndrome can be prevented and simply positioning the patient on her
left side will optimize blood flow to both the fetus and mother.
Placenta abruptio is a surgical emergency when the patient and/or the fetus
is in distress. It is impossible for the paramedic to make the actual diagnosis
or gauge the degree of maternal risk or fetal distress in the field setting.
Therefore your plan of care for the patient must include beginning transport
immediately and enroute start a large bore IV and begin fluid resuscitation
with an isotonic crystalloid IV fluid such as Normal Saline. Remember that even
in the normotensive pregnant patient the fetus is still at risk and physiological
body changes can mask the classic signs of shock we expect to see in the non-pregnant
patient. Limit scene time to 10 minutes or less as you would with a trauma patient
who would require emergent surgery for survival. Follow your local protocols
Notify the ED of the patient's parity, gravidity, history of any past cesarean
section, maternal lifestyle (ETOH, smoking, etc.), LMP, due date, uterine size
by fundal height, past medical history, medications taken, present condition
and treatment being administered. This will allow the ED to alert the Labor
& Delivery team so they may be prepared to serve this patient's special
In-Hospital Management of Placenta Abruptio
The diagnosis for abuptio placenta is made by ruling out any other possible
causes of the symptoms. Sometimes an ultrasound is used to help find the abruption,
but it does not detect an abruption every time. If the baby is not in danger
the mother will be hospitalized to allow the fetus to mature before delivery.
A fetal monitor will be used to observe the baby's heart rate. If the bleeding
is severe or there is apparent danger to the baby, a Cesarean Section will be
Maternal death rates, in various parts of the world range from 0.5 to 5% .
Early diagnosis of the condition and adequate intervention should decrease the
maternal death rate to 0.5 to 1%. Fetal death rates range from 50% to 80%. 15%
of all causes of fetal deaths are caused by placenta abruptio. Upon hospital
admission, no fetal heart tone is detectable in about 15% of cases. Fetal distress
appears early in the condition in approximately 50% of cases. The infants who
live have a 40 to 50% incidence of illness. Concealed vaginal bleeding in pregnancy,
excessive loss of blood resulting in shock, absence of labor, a closed cervix,
and delayed diagnosis and treatment are unfavorable factors that may increase
the risk of maternal or fetal death.
The challenge the EMS provider faces is that the the true amount of blood being
lost may be occult (hidden), or difficult to reliably assess due to physiological
norms related to pregnancy. Learn from the issues presented in the legal case
presentation and the unique physiological considerations that apply to all pregnant
women. Remember the rule for EMS is: Any pregnant woman, especially after the
first trimester, who presents with abnormal bleeding (spotting or frank bleeding),
with or without pain, must be treated, stabilized and promptly transported for
OB evaluation. Unlike first trimester bleeding, second and third trimester bleeding
is most often secondary to premature separation of the placenta. Placenta
previa is another serious cause of bleeding. Treat these patients like you
would treat any hemorrhagic shock patient, limit field time, and keep in mind
some of the special considerations for pregnant women. Oxygen administration,
fluid resuscitation and aggressive treatment based on a high index of suspicion
or known diagnosis are warranted.
Coming next edition: Part Three: The Low Down on Pregnancy Induced Hypertension,
Eclampsia and other complications
Comments or feedback on this article? Click
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surveillance--United States, 1987-1990. Morbidity and Mortality Weekly Report
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- Gaufberg, Slava V. E-Medicine Online: Abruptio Placentae from Emergency
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- Crane S, Chun B, Acker D: Treatment of obstetrical hemorrhagic emergencies.
Curr Opin Obstet Gynecol 1993 Oct; 5(5): 675-82
- Sanders, M. Mosby's Paramedic Textbook. 2000 St. Louis, MO. pp. 1170-1171.