Placental abruption.

Placental abruption complicates about 1% of pregnancies and is a leading cause of vaginal bleeding in the latter half of pregnancy. It is also an important cause of perinatal mortality and morbidity. The maternal effect of abruption depends primarily on its severity, whereas its effect on the fetus is determined both by its severity and the gestational age at which it occurs. Risk factors for abruption include prior abruption, smoking, trauma, cocaine use, multifetal gestation, hypertension, preeclampsia, thrombophilias, advanced maternal age, preterm premature rupture of the membranes, intrauterine infections, and hydramnios. Abruption involving more than 50% of the placenta is frequently associated with fetal death. The diagnosis of abruption is a clinical one, and ultrasonography and the Kleihauer-Betke test are of limited value. The management of abruption should be individualized on a case-by-case basis depending on the severity of the abruption and the gestational age at which it occurs. In cases where fetal demise has occurred, vaginal delivery is preferable. Disseminated intravascular coagulopathy should be managed aggressively. When abruption occurs at or near term and maternal and fetal status are reassuring, conservative management with the goal of vaginal delivery may be reasonable. However, in the presence of fetal or maternal compromise, prompt delivery by cesarean is often indicated. Similarly, abruption at extremely preterm gestations may be managed conservatively in selected stable cases, with close monitoring and rapid delivery should deterioration occur. Most cases of placental abruption cannot be predicted or prevented. However, in some cases, maternal and infant outcomes can be optimized through attention to the risks and benefits of conservative management, ongoing evaluation of fetal and maternal well-being, and through expeditious delivery where appropriate.