Clinical Practice Guidelines: Obstetrics/Placental abruption

Disclaimer and copyright©2016 Queensland Government

All rights reserved. Without limiting the reservation of copyright, no person shall reproduce, store in a retrieval system or transmit in any form, or by any means, part or the whole of the Queensland Ambulance Service (‘QAS’) Clinical practice manual (‘CPM’) without the priorwritten permission of the Commissioner.

The QAS accepts no responsibility for any modification, redistribution or use of the CPM or any part thereof. The CPM is expressly intended for use by QAS paramedics whenperforming duties and delivering ambulance services for, and on behalf of, the QAS.

Under no circumstances will the QAS, its employees or agents, be liable for any loss, injury, claim, liability or damages of any kind resulting from the unauthorised use of, or reliance upon the CPM or its contents.

While effort has been made to contact all copyright owners this has not always been possible. The QAS would welcome notification from any copyright holder who has been omitted or incorrectly acknowledged.

All feedback and suggestions are welcome, please forward to: Clinical.Guidelines@ambulance.qld.gov.au

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Date April, 2016

Purpose To ensure consistent management of a Placental abruption.

Scope Applies to all QAS clinical staff.

Author Clinical Quality & Patient Safety Unit, QAS

Review date April, 2018

URL https://ambulance.qld.gov.au/clinical.html

125QUEENSLAND AMBULANCE SERVICE

Placental abruption

Placental abruption occurs when a normally situated placenta

separates either partially or completely from the uterine wall,

resulting in haemorrhage prior to the delivery of the foetus. It is an obstetric emergency that is associated with serious maternal complications such as disseminated intravascular

coagulation (DIC), shock, uterine rupture, or acute renal failure, and also contributes to high rates of foetal perinatal mortality.[1]

The incidence of placental abruption is approximately one in 100 – 200 pregnancies; however the frequency is increasing,

possibly due to a trend towards later motherhood, or a higher

incidence of caesarean sections.[1]

Although blunt trauma can be a causative factor, the majority of cases are idiopathic.

Risk factors for placental abruption include:[2]

• gestational hypertension and pre-eclampsia

• previous history of abruption or caesarean section

• multiparity and advanced maternal age

• intrauterine infection

• ruptured membranes in the presence of polyhydramnios

• tobacco or cocaine use

Management is based upon a high index of suspicion and early

recognition, especially in occult bleeds, and preventing maternal

hypotension in order to avoid foetal hypoxia.

Clinical features

• Constant pain in the abdomino-pelvic region

• Bleeding may range from absent to profuse,

occurring in waves as the uterus contracts

• Tetanic uterine contractions

• Uterine hypertonicity – feels rigid on palpation

• Fundal height may increase due to expanding

intrauterine haemorrhage

• Signs of maternal shock

Risk assessment

• Due to the possibility of occult bleed, diagnosis of placental abruption should be considered in any pregnant woman with abdominal pain, even without evidence of haemorrhage

• Mild cases may not be clinically obvious

April, 2016

Figure 2.36

UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED

126QUEENSLAND AMBULANCE SERVICE

Additional information

Placental abruption can be classified into three categories:[2]

e

Note: Officers are only to perform procedures for which they have received specific training and authorisation by the QAS.

Consider:

• IV access• IV fluid• Analgesia• Antiemetics

YEvidence of shock?

Avoid aortocaval compression by

appropriate patient posturing

Manage as per:

• CPG: Hypovolaemic shock

N

IMPORTANT: Officers must be prepared for spontaneous delivery

 

NOTE: As can be seen from the

Illustrations, only a marginal abruption is likely to result in a visible PV haemorrhage. It is advisable to transport for assessment to an obstetrics unit.

Central: where the centre has detached

Complete: where the whole placenta

has come away from the uterine wall.

Marginal: where an edge has separated away

CPG: Paramedic Safety

CPG: Standard Cares

Transport to hospital

Pre-notify as appropriate

UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED