Differential diagnosis of placental abruption
Premature detachment of a normally situated placenta (placental abruption) requires differentiation from rare pathologies and detachment of a low-lying placenta.
- Hepatopathic uterine rupture: symptoms are identical to placental abruption (pain, hypertonus, fetal hypoxia). Difficult to distinguish without ultrasound; the strategy in both cases is emergency delivery.
- Detachment of placenta previa: accompanied by bleeding, but pain syndrome and uterine hypertonus are absent; diagnosis is easily confirmed by ultrasound.
- Umbilical cord vessel rupture: characterized by bright red bleeding and hypoxia in the absence of localized pain and uterine hypertonus.
Management of placental abruption
The choice of treatment strategy depends on five factors: extent of detachment, volume of blood loss, maternal and fetal status, gestational age, and hemostatic status.
- Mild degree: in stable condition up to 34–35 weeks, expectant management with continuous monitoring (cardiotocography, ultrasound, Doppler) is possible. Vaginal delivery is possible in non-progressive forms with normal uterine tone, accompanied by mandatory early amniotomy.
- Moderate and severe degree: emergency cesarean section via lower midline laparotomy regardless of gestational age.
- Couvelaire uterus: modern standards prioritize uterus-preserving surgeries if conditions are met (Cell Saver, arterial embolization), however, in case of persistent bleeding, hysterectomy is indicated.
Massive hemorrhage and evaluation
Upon admission of a pregnant woman with vaginal bleeding, general status assessment, external obstetric examination, cardiotocography, and ultrasound (in massive blood loss — directly in the operating room) are performed.
- Placenta previa: if diagnosed in advance and bleeding begins, the patient is immediately transferred to the operating room.
- Speculum examination: performed to rule out cervical and vaginal pathologies if abruption is not confirmed.
- Vaginal examination: performed exclusively in a fully prepared operating room to assess dilation and detect blood clots.
Placental attachment and invasion anomalies
The pathology includes morbidly adherent placenta and true invasion, the incidence of which is increasing due to the rising number of cesarean sections.
- Placenta adhaerens (firm attachment): the placenta is attached to the basal layer and can be manually removed without massive blood loss.
- Placenta accreta: attachment to the muscular layer or scar.
- Placenta increta: invasion into the thickness of the myometrium.
- Placenta percreta: invasion through the myometrium to the serosa.
Briefly: answers to topical questions
What are the main etiological factors of early postpartum hemorrhage included in the "4Ts" rule?
The "4Ts" rule includes four main groups of etiological factors for postpartum hemorrhage.
- "Tone" (Tone) — decreased tone and contractility of the uterus (hypotonia and atony).
- "Tissue" (Tissue) — presence of retained products of conception (retained placental fragments or membranes) in the uterine cavity.
- "Trauma" — lacerations of the soft birth canal and uterus.
- "Thrombin" (or "Clots") — hemostatic disorders requiring transfusion of blood clotting factors.
What uterotonic drugs are used for medical management of hypotonic postpartum hemorrhage?
For medical management and prevention of hypotonic postpartum hemorrhage, the following are used:
- Oxytocin — intravenously at the end of the second stage of labor, after fetal extraction during cesarean section, or after delivery of the placenta.
- Carbetocin — also used as a uterotonic drug.
Methylergometrine is contraindicated in arterial hypertension due to its pronounced vasopressor effect.
What surgical hemostasis methods are used in massive obstetric hemorrhage to preserve the uterus?
To preserve the uterus in massive obstetric hemorrhage, the following uterus-preserving surgical hemostasis methods are used:
- Placement of compression sutures — mattress sutures or the B-Lynch suture for total longitudinal compression of the uterine body.
- Ligation of arteries — surgical ligation of uterine vessels or internal iliac arteries (a. iliaca interna).
- Endovascular methods — uterine artery embolization or temporary balloon occlusion.
- Tourniquet hemostasis — use of a Foley catheter.
- Placement of sutures on the placental bed — local suturing of the inner surface of the uterus.
For placental abruption: Pain, Hypertonus, Loss (of blood or fetal hypoxia). In mild cases during labor — early amniotomy.
Class and exam questions
What are the main indications for emergency cesarean section in placental abruption?
Pronounced clinical presentation (moderate and severe degree) of abruption is an indication for emergency cesarean section regardless of gestational age and fetal condition.
What is the difference between placenta adhaerens and placenta accreta?
In placenta adhaerens, the placenta is fixed in the basal layer and can be successfully removed manually. In placenta accreta (true invasion), the decidua is thinned or absent, and the placenta invades the muscular layer.
What management strategy should be chosen for mild placental abruption in labor?
Vaginal delivery is possible in stable condition, with normal uterine tone and mandatory early amniotomy to reduce blood loss.
What else to study on this topic
- Management of the second stage of labor in progressive placental abruption and choice of delivery method
- Surgical hemostasis methods: embolization and ligation of internal iliac arteries
- Intraoperative autologous blood reinfusion (Cell Saver) in obstetrics
- Features of "uterine aneurysm" formation in a previous cesarean scar
- Differential diagnosis of rare causes of bleeding: vaginal varicosities and cervical cancer
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