Eduovisual
Pregnancy, Childbirth & Puerperium
Placental abruption: diagnosis and management
— Complicates ~1% of pregnancies; peaks at 24–26 weeks but most clinically severe cases occur in third trimester.
— Responsible for ~10% of preterm births and a leading cause of fetal death and DIC in pregnancy.
— Decidual vessel rupture → bleeding into decidua basalis → hematoma shears placenta off uterine wall.
— Thromboplastin release from injured decidua/placenta drives consumptive coagulopathy (DIC), disproportionate to visible blood loss.
— Sudden painful vaginal bleeding in the second half of pregnancy.
— Abdominal/back pain with uterine tenderness even without external bleeding (20% are "concealed").
— Non-reassuring fetal heart tracing in a pregnant trauma patient.
— Maternal hypotension out of proportion to apparent external blood loss.
— Hypertension (chronic HTN, preeclampsia) — the single strongest medical risk factor.
— Trauma — MVC, intimate partner violence, falls; deceleration shears placenta.
— Cocaine/methamphetamine use and tobacco — vasoconstrictive injury.
— Others: prior abruption (recurrence ~10–15%), PPROM, polyhydramnios with rapid decompression, advanced maternal age, multiparity, thrombophilias.
Board pearl: In any pregnant patient ≥20 weeks presenting after trauma — even minor MVC with a properly worn seatbelt — assume abruption until proven otherwise and obtain minimum 4 hours of continuous fetal monitoring. External bleeding is absent in ~20% of abruptions, so a "dry" exam does not exclude the diagnosis. Pain plus a firm, tender, hypertonic uterus is the abruption signature.
— Vaginal bleeding (80%) — dark, non-clotting, often less than the degree of shock suggests.
— Abdominal or low back pain — sudden onset, constant (not crampy like labor).
— Uterine contractions or hypertonus — high-frequency, low-amplitude "irritability."
— Fetal distress — bradycardia, late decelerations, loss of variability, or fetal demise.
— Revealed (~80%): Blood dissects to cervical os → external bleeding; lower DIC risk because pressure is decompressed.
— Concealed (~20%): Blood trapped behind placenta → no external bleed, but higher rates of DIC, Couvelaire uterus, and fetal death. Suspect when pain and shock are present without bleeding.
— Grade 1: Slight bleeding, no maternal/fetal distress, often diagnosed postpartum on placental inspection.
— Grade 2: Moderate bleeding, uterine tenderness, fetal distress, fibrinogen 150–250.
— Grade 3: Severe bleeding, tetanic uterus, fetal demise, fibrinogen <150, DIC; subdivided by absence (3A) or presence (3B) of coagulopathy.
— Gestational age (LMP, prior ultrasound) — drives viability and delivery decisions.
— Recent trauma, including IPV screen — ask privately, away from partner.
— Substance use, especially cocaine and methamphetamine within 24–72 h.
— Hypertension history, preeclampsia features (headache, visual changes, RUQ pain).
— Prior abruption, prior cesarean, placenta previa on any prior imaging.
— PPROM or sudden uterine decompression after amniocentesis/polyhydramnios drainage.
Key distinction: Abruption = painful bleeding with a tender, firm uterus; placenta previa = painless bright-red bleeding with a soft, non-tender uterus. Never perform a digital cervical exam in third-trimester bleeding until previa is excluded by ultrasound — this is a recurrent Step 3 trap.
— Anxious, diaphoretic, pale; severity often exceeds visible blood loss because of concealed hemorrhage and rapid third-spacing.
— Look for bruising patterns (seatbelt sign, IPV-pattern injuries) in trauma presentations.
— Pregnancy physiology masks early shock: blood volume up 40–50%, so a patient can lose 1500 mL before classic tachycardia/hypotension.
— Tachycardia >110, narrowed pulse pressure, orthostasis, cool extremities, and shock index >0.9 (HR/SBP) are earlier markers than frank hypotension.
— Paradoxically, a patient with preeclampsia may have a "normal" BP of 120/80 that is actually relative hypotension.
— Tender, rigid, "wood-hard" uterus — pathognomonic when present.
— Hypertonic uterus with frequent low-amplitude contractions on tocometry (>5 per 10 min).
— Fundal height may rise acutely as the retroplacental hematoma expands.
— Fetal parts difficult to palpate; fetal movement decreased or absent.
— Perform speculum first, never digital, until previa excluded by bedside ultrasound.
— Dark, non-clotting blood at the os supports abruption (vs bright red in previa).
— Assess for amniotic fluid (PPROM is a risk factor and changes management).
— Continuous external fetal monitoring is mandatory: look for late decelerations, prolonged decelerations, bradycardia, sinusoidal pattern, or loss of variability.
— A sinusoidal tracing suggests fetomaternal hemorrhage — order a Kleihauer-Betke test.
Step 3 management: In the ED, place the patient in left lateral decubitus (relieves IVC compression), apply oxygen, establish two large-bore IVs, send type and crossmatch for 4 units PRBCs, and begin balanced crystalloid resuscitation while obtaining bedside ultrasound and continuous fetal monitoring simultaneously — do not sequence these steps.
— CBC — baseline hemoglobin (may be normal initially), platelet count (thrombocytopenia early sign of DIC).
— Type and crossmatch ≥2–4 units PRBCs; activate massive transfusion protocol thresholds early.
— Coagulation panel: PT/INR, aPTT, fibrinogen, D-dimer. Fibrinogen <200 mg/dL is concerning; <150 strongly suggests significant abruption (pregnancy baseline fibrinogen is 400–500).
— Comprehensive metabolic panel — assess renal function (acute kidney injury from hypoperfusion).
— Urinalysis — proteinuria suggests preeclampsia overlap.
— Kleihauer-Betke test — quantifies fetomaternal hemorrhage; guides Rh immunoglobulin dosing in Rh-negative mothers (standard 300 mcg covers 30 mL fetal whole blood; larger bleeds need additional doses).
— Urine toxicology — cocaine/methamphetamine.
— Blood gas and lactate if shock features present.
— Bedside transabdominal ultrasound: Primary role is to exclude placenta previa before any digital exam.
— Sensitivity for abruption is poor (~25–50%) — a retroplacental hypoechoic or hyperechoic collection is specific but commonly absent.
— Acute hematomas appear isoechoic to placenta and can be missed; absence of ultrasound findings does NOT rule out abruption.
— MRI has higher sensitivity but rarely used acutely; reserve for stable patients with diagnostic uncertainty.
Board pearl: A falling fibrinogen is the most sensitive lab marker of clinically significant abruption and predicts postpartum hemorrhage. Trend it q1–2h alongside CBC and coags during active resuscitation.
— Repeat fibrinogen, platelets, PT/INR, aPTT, D-dimer every 1–2 hours during active bleeding.
— DIC in obstetrics is defined by ISTH-modified pregnancy criteria: platelet drop, fibrinogen <200, PT prolongation, elevated FDP/D-dimer.
— TEG/ROTEM (thromboelastography) is increasingly used at obstetric centers to guide product-specific transfusion (cryoprecipitate vs FFP vs platelets).
— Transvaginal ultrasound can clarify placental location when transabdominal is equivocal — safe in suspected abruption (does not disrupt placenta) but contraindicated in confirmed previa.
— Sonographic abruption signs (when present): retroplacental clot, preplacental "jello-like" movement of chorionic plate with maternal ballottement, marginal subchorionic hematoma, intra-amniotic hematoma.
— Ultrasound is also used to confirm fetal viability and estimate gestational age in unbooked patients.
— Biophysical profile if stable and remote from term.
— Umbilical artery Doppler if growth restriction suspected from chronic abruption.
— Gross: retroplacental clot with overlying placental indentation.
— Histology: decidual hemorrhage, infarction, hemosiderin-laden macrophages (chronic abruption).
— Preeclampsia labs (LDH, haptoglobin, AST/ALT, smear for schistocytes) if hypertension present — abruption and HELLP can coexist.
— Thrombophilia workup is not done acutely; deferred to postpartum if recurrent abruption.
— Trauma workup: FAST, CT only if maternal indication overrides fetal radiation concern (fetal dose from abdominal CT ~25 mGy, well below 50 mGy teratogenic threshold).
Key distinction: Ultrasound is far better at ruling in previa than ruling out abruption. A negative ultrasound in a patient with the clinical syndrome does not change management — proceed as if abruption is present.
— Maternal stabilization — airway, IV access, volume, blood products, correct coagulopathy.
— Fetal assessment and delivery decision — viability, gestational age, tracing reassurance.
— Definitive delivery planning — vaginal vs cesarean based on fetal status and maternal stability.
— Term (≥37 wk), stable mother, reassuring fetus: Deliver — vaginal delivery preferred if rapid progress possible; cesarean if not.
— Term, unstable mother OR non-reassuring fetus: Emergent cesarean regardless of cervical exam.
— Preterm (34–36 6/7 wk), stable, mild abruption, reassuring fetus: Admit, monitor, antenatal corticosteroids (betamethasone), deliver if any decompensation; otherwise expectant management to 37 wk is acceptable.
— Preterm (24–33 6/7 wk), stable, mild abruption: Expectant management with corticosteroids, magnesium sulfate for neuroprotection if <32 wk, tocolysis controversial (generally avoided but short course of nifedipine while steroids work is acceptable in select stable cases).
— <23 wk or previable: Maternal stabilization prioritized; counseling on outcomes.
— Fetal demise: Vaginal delivery preferred (lower maternal morbidity) unless maternal hemorrhage demands cesarean.
— Non-reassuring fetal heart tracing → cesarean within 30 minutes (decision-to-incision standard).
— Maternal hemodynamic instability with viable fetus → cesarean.
— Stable mother + reassuring fetus + favorable cervix → amniotomy and oxytocin augmentation for vaginal delivery; abruption labor is often rapid.
Step 3 management: Always give antenatal corticosteroids between 24 0/7 and 36 6/7 weeks if delivery is anticipated within 7 days, and magnesium sulfate neuroprotection between 24 0/7 and 31 6/7 weeks. Do not withhold steroids waiting for stability — they take 24–48 h to work.
— Initial: 1–2 L balanced crystalloid (lactated Ringer's) while awaiting blood.
— Activate massive transfusion protocol if ongoing hemorrhage, shock, or coagulopathy: 1:1:1 ratio of PRBCs:FFP:platelets.
— Cryoprecipitate when fibrinogen <200 mg/dL (target >200, ideally >300 in active obstetric hemorrhage). One pool of 10 units raises fibrinogen by ~70 mg/dL.
— Tranexamic acid (TXA) 1 g IV over 10 min within 3 hours of obstetric hemorrhage onset (WOMAN trial) — repeat dose if bleeding continues at 30 min.
— Betamethasone 12 mg IM q24h × 2 doses (preferred) OR dexamethasone 6 mg IM q12h × 4 doses.
— Reduces RDS, IVH, NEC, and neonatal mortality.
— 4–6 g IV load over 20–30 min, then 1–2 g/hr infusion until delivery or 24 h.
— Monitor reflexes, respirations, urine output; antidote calcium gluconate 1 g IV for toxicity.
— 300 mcg IM/IV within 72 h for all Rh-negative mothers with any third-trimester bleeding.
— Adjust dose based on Kleihauer-Betke: add 300 mcg per additional 30 mL fetal whole blood.
— Labetalol 20 mg IV (repeat doubling up to 80 mg), hydralazine 5–10 mg IV, or nifedipine 10 mg PO — target SBP <160 and DBP <110.
Board pearl: Methylergonovine and prostaglandin F2α (carboprost) are useful for postpartum uterine atony after delivery but are contraindicated in hypertension and asthma respectively — recurrent Step 3 distractor.
— Emergent cesarean (decision-to-incision ≤30 min) for: non-reassuring fetal tracing in a viable fetus, maternal hemodynamic instability, suspected uterine rupture, failure to progress in unstable patient.
— Vaginal delivery preferred when: mother stable, fetus stable or demised, labor progressing, no contraindications.
— Amniotomy accelerates labor and may reduce thromboplastin entry into maternal circulation — perform early in stable vaginal candidates.
— Neuraxial anesthesia contraindicated if platelets <70,000, INR elevated, fibrinogen low, or active DIC → use general anesthesia for emergent cesarean.
— Communicate coagulation status to anesthesia early.
— Couvelaire uterus (uteroplacental apoplexy): blood extravasates into myometrium giving purple, mottled appearance at cesarean. Not itself an indication for hysterectomy — uterus typically still contracts with oxytocics.
— Inspect placenta for retroplacental clot to confirm diagnosis.
— Anticipate postpartum hemorrhage — abruption is a leading risk factor.
— Bimanual uterine massage + oxytocin 10–40 units in 1 L NS infusion.
— Methylergonovine 0.2 mg IM (avoid in HTN).
— Carboprost (15-methyl PGF2α) 250 mcg IM q15min (avoid in asthma).
— Misoprostol 800–1000 mcg PR.
— TXA 1 g IV if not already given.
— Intrauterine balloon tamponade (Bakri) → B-Lynch suture → uterine artery ligation → hysterectomy as last resort.
CCS pearl: In a CCS abruption case, order in parallel: two large-bore IVs, type and cross 4 units, CBC/coags/fibrinogen, continuous fetal monitoring, OB consult, anesthesia consult, NICU notification, left lateral positioning, oxygen, and Foley catheter — then reassess vitals and tracing every 15 minutes.
— Mechanisms: hypovolemic prerenal AKI from hemorrhage, acute tubular necrosis from sustained hypoperfusion, cortical necrosis in severe cases (classic obstetric complication, oliguric AKI that may not fully recover).
— Prevention: aggressive volume and blood product resuscitation, avoid nephrotoxins (NSAIDs, contrast when possible, aminoglycosides).
— Monitor urine output via Foley — target ≥0.5 mL/kg/hr.
— If oliguria persists after volume repletion, suspect cortical necrosis; renal ultrasound and nephrology consult.
— Coexisting HELLP syndrome common when abruption complicates preeclampsia — elevated AST/ALT, low platelets, hemolysis.
— Avoid hepatotoxic drugs; magnesium clearance is unaffected by liver but reduced by renal impairment — reduce magnesium infusion rate to 1 g/hr if creatinine elevated, and monitor serum magnesium levels (therapeutic 4.8–8.4 mg/dL).
— Independent risk factor for abruption (RR ~1.3–2.3 at age 40+).
— Higher baseline rates of chronic HTN, diabetes, and thrombophilia compound risk.
— Lower physiologic reserve — decompensate faster with hemorrhage.
— Counsel about recurrence risk in future pregnancies (~10–15% after one, ~25% after two).
— Magnesium sulfate: reduce infusion rate, monitor levels and DTRs closely.
— LMWH for postpartum VTE prophylaxis: dose adjust or switch to unfractionated heparin if CrCl <30.
— Avoid NSAIDs for postpartum analgesia in AKI; use acetaminophen and short opioid course.
Step 3 management: In any abruption patient with oliguria <30 mL/hr for 2 hours despite resuscitation, hold magnesium, check magnesium level, and recheck creatinine before continuing — magnesium toxicity (loss of DTRs → respiratory depression → cardiac arrest) is a preventable iatrogenic death.
— Leading non-obstetric cause of maternal death; abruption complicates 40–50% of severe trauma and 1–5% of minor trauma.
— All pregnant trauma patients ≥20 wk require minimum 4 hours of continuous EFM; extend to 24 h if >6 contractions/hour, vaginal bleeding, abdominal pain, ROM, or any non-reassuring tracing.
— Kleihauer-Betke in all Rh-negative trauma patients regardless of mechanism.
— Always screen for intimate partner violence — IPV is a major cause of "minor trauma" abruption.
— FAST and CT as clinically indicated; do not withhold imaging for maternal indications.
— Higher risk due to late prenatal care, substance use, IPV.
— Confidentiality and consent: adolescent has decision-making capacity for pregnancy-related care in most US states; parental notification varies — know local law.
— Cocaine and methamphetamine cause vasospasm and acute HTN → abruption; obtain urine toxicology even in well-appearing patients.
— Counseling and social work referral; mandatory reporting of perinatal substance exposure varies by state (CAPTA Plans of Safe Care apply).
— Smoking: 2-fold risk; smoking cessation reduces recurrence in future pregnancies.
— Abruption can mimic uterine rupture — both present with pain, bleeding, fetal distress. Loss of fetal station and palpable fetal parts on abdominal exam favor rupture.
— Prior abruption itself is a strong risk factor; counsel about 10–15% recurrence, rising to 25% after two events.
Board pearl: A pregnant patient in an MVC with a normal exam, normal FAST, and no contractions still needs 4 hours of cardiotocographic monitoring before discharge — Step 3 will test the discharge decision, not the resuscitation.
— Hemorrhagic shock — leading cause of maternal mortality in abruption.
— Disseminated intravascular coagulation (DIC) — occurs in 10–20% of clinically significant abruptions; up to 50% in severe abruption with fetal demise. Driven by tissue factor release.
— Postpartum hemorrhage — 2–3× baseline risk; uterine atony, retained products, coagulopathy.
— Acute kidney injury / renal cortical necrosis — may require dialysis; cortical necrosis can cause permanent renal failure.
— Sheehan syndrome — pituitary necrosis from prolonged hypotension; presents postpartum with failure to lactate, amenorrhea, fatigue.
— Couvelaire uterus — myometrial blood extravasation; usually contractile preservation, but increases atony risk.
— Amniotic fluid embolism — rare but catastrophic; sudden cardiovascular collapse, DIC, hypoxia.
— Transfusion-related complications: TRALI, TACO, hemolytic reactions.
— Maternal death — ~1% in severe abruption, higher in resource-limited settings.
— Fetal hypoxia and demise — perinatal mortality 10–30%; up to 50% with severe abruption.
— Preterm birth — leading driver of long-term morbidity.
— Intrauterine growth restriction — chronic abruption.
— Hypoxic-ischemic encephalopathy, cerebral palsy — survivors of severe acute abruption.
— Fetomaternal hemorrhage with fetal anemia — sinusoidal tracing.
— Recurrence in subsequent pregnancies (10–15% after one event).
— Increased lifetime cardiovascular disease risk in mothers (parallels preeclampsia association).
— Maternal PTSD and depression after perinatal loss — screen at postpartum visits.
Key distinction: DIC severity correlates with concealed hemorrhage and fetal demise, not with the volume of visible vaginal bleeding. A patient with no external blood and a dead fetus is at the highest DIC risk — do not be falsely reassured by a "clean" perineum.
— Persistent hemodynamic instability despite resuscitation.
— Massive transfusion (≥10 units PRBCs in 24 h or ≥4 units in 1 h).
— Established DIC requiring ongoing product replacement.
— Acute kidney injury with oliguria or rising creatinine requiring close monitoring or CRRT.
— Severe preeclampsia/eclampsia with end-organ dysfunction.
— ARDS from massive transfusion or amniotic fluid embolism.
— Postoperative monitoring after peripartum hysterectomy.
— Preterm abruption managed expectantly.
— Recurrent abruption history.
— Coexisting severe preeclampsia, growth restriction, or thrombophilia.
— Gestational age <32 weeks (need Level III/IV NICU).
— No on-site obstetrics or anesthesia.
— No blood bank capable of massive transfusion.
— Transfer ONLY if maternal-fetal status permits — an unstable mother delivers locally; do not delay delivery for transfer.
— Massive transfusion protocol at the first signs of hemodynamic compromise.
— Code OB / Code Crimson / institution-specific obstetric hemorrhage protocol.
— Rapid response team if outside L&D.
CCS pearl: Document a clear goal of care timeline: "OB consulted at HH:MM, decision for cesarean at HH:MM, incision at HH:MM" — the 30-minute decision-to-incision standard is a quality metric the exam may probe through chart-review style stems.
— Painless, bright red vaginal bleeding, often recurrent.
— Soft, non-tender uterus; normal fetal tracing usually.
— Diagnosis by transvaginal ultrasound — placental edge over or within 2 cm of internal os.
— No digital cervical exam until previa excluded.
— Management: pelvic rest, cesarean delivery at 36–37 wk (uncomplicated) or sooner if bleeding.
— Fetal vessels traverse membranes over the internal os.
— Painless bleeding + rapid fetal deterioration (sinusoidal tracing, bradycardia) after ROM.
— Small maternal blood loss but catastrophic fetal exsanguination.
— Diagnosis prenatally by color Doppler; managed with scheduled cesarean at 34–36 wk before labor.
— Apt test can confirm fetal blood in vaginal effluent.
— Sudden severe abdominal pain, loss of fetal station, fetal bradycardia, hemodynamic collapse.
— Highest risk: prior cesarean (especially classical), TOLAC, oxytocin augmentation, prior uterine surgery.
— Loss of contractions, recession of presenting part — emergent laparotomy.
— Usually presents at delivery with failure of placental separation and massive PPH.
— Risk factors: prior cesarean + previa, multiple prior cesareans.
— Antenatal diagnosis by ultrasound/MRI; planned cesarean hysterectomy at 34–35 6/7 wk.
Key distinction: Memorize the pain-bleeding-uterus triad: abruption = painful, dark, hard uterus; previa = painless, bright red, soft uterus; rupture = catastrophic pain, fetal parts palpable, lost station; vasa previa = painless small maternal bleed, dying fetus.
— Regular contractions, cervical change, no significant bleeding or uterine tenderness between contractions.
— Tocolysis appropriate if no contraindications.
— Maternal fever, uterine tenderness, fetal tachycardia, foul-smelling discharge.
— Risk factors: prolonged ROM, multiple exams.
— Management: broad-spectrum antibiotics (ampicillin + gentamicin) and delivery.
— Appendix displaced upward and laterally; RUQ pain in third trimester.
— Leukocytosis is unreliable (pregnancy baseline elevated).
— MRI preferred imaging; ultrasound first-line.
— Red (carneous) degeneration in pregnancy → localized pain, low-grade fever, leukocytosis, no bleeding/fetal compromise.
— Conservative management with acetaminophen ± short-course NSAIDs (avoid after 32 wk).
— Sudden lateralized pain, nausea, vomiting; ultrasound with Doppler.
— RUQ pain, nausea, elevated transaminases, thrombocytopenia.
— May coexist with or mimic abruption; check labs.
— Fever, CVA tenderness, dysuria, pyuria; can trigger preterm contractions.
— Rib fractures, abdominal wall hematoma, splenic injury — FAST and CT as indicated.
Board pearl: Fever + uterine tenderness = chorioamnionitis; no fever + uterine tenderness + bleeding = abruption. A single vital sign (temperature) reorients the entire differential.
— Uterotonics: scheduled oxytocin infusion x several hours post-delivery; PRN methylergonovine (if no HTN) for atony.
— Iron supplementation: ferrous sulfate 325 mg PO daily–TID; consider IV iron (ferric carboxymaltose) for moderate-severe anemia or PO intolerance.
— VTE prophylaxis: mechanical (SCDs) plus pharmacologic (enoxaparin 40 mg SC daily) for post-cesarean patients and high-risk vaginal deliveries — abruption with transfusion and prolonged immobility is high VTE risk.
— Rh immunoglobulin if Rh-negative and not already given (confirm Kleihauer-Betke-adjusted dose).
— Antihypertensives continued if preeclampsia/chronic HTN — labetalol or nifedipine; avoid ACEi/ARBs while breastfeeding (some are compatible — enalapril, captopril — but avoid in early postpartum).
— Pelvic rest 4–6 weeks; no intercourse, tampons, or douching.
— Pain control: acetaminophen, short-course NSAIDs (avoid in AKI), short opioid taper if needed.
— Return precautions: heavy bleeding (>1 pad/hr), fever, severe pain, calf swelling, shortness of breath, headache/visual changes (delayed postpartum preeclampsia up to 6 wk).
— Recurrence risk: 10–15% after one abruption, 20–25% after two.
— Modifiable risk reduction:
– Smoking cessation — single most impactful intervention.
– Cocaine/methamphetamine cessation with addiction medicine referral.
— Optimize chronic hypertension (target <140/90 preconception).
— Adequate folic acid 400–800 mcg daily.
— Low-dose aspirin 81 mg daily from 12 wk gestation if preeclampsia risk factors are present (does NOT directly prevent abruption but addresses shared placental pathology).
— MFM consultation in next pregnancy; serial growth ultrasounds; early delivery planning at 36–37 wk for prior severe abruption.
Step 3 management: Postpartum blood pressure monitoring at 3–7 days and again at 1–2 weeks is mandatory after any hypertensive pregnancy or abruption; delayed postpartum preeclampsia and stroke are exam-favorite complications.
— Vitals q15 min during active resuscitation, q1h post-stabilization, then q4h.
— Strict I/O, Foley with hourly urine output target ≥0.5 mL/kg/hr.
— Serial CBC, fibrinogen, coags until trending up and bleeding controlled.
— Daily creatinine until normalized.
— Lochia and fundal checks q4–8h.
— Postpartum BP check at 3–7 days if hypertensive disease.
— Comprehensive postpartum visit at 4–6 weeks — wound check, contraception, mood screening (Edinburgh Postnatal Depression Scale), breastfeeding support.
— Hemoglobin recheck at 4–6 weeks if discharged anemic.
— Perinatal loss (stillbirth from abruption) confers high risk of complicated grief, depression, PTSD.
— Screen at every postpartum encounter; refer to perinatal psychiatry early.
— Connect to support groups (Share, Resolve Through Sharing).
— Safe options post-abruption: progestin-only methods (POPs, DMPA, implant, levonorgestrel IUD) any time; copper IUD immediate or at 6 wk; combined hormonal contraception after 3–6 wk if no VTE risk (longer wait if obese, smoker, prior VTE).
— Discuss interpregnancy interval — recommend ≥18 months before next conception to reduce recurrent adverse outcomes.
— Tobacco cessation pharmacotherapy (nicotine replacement, varenicline, bupropion) — compatible with breastfeeding (NRT preferred).
— Substance use disorder treatment referral.
— Blood pressure self-monitoring and home log.
Board pearl: A history of abruption (like preeclampsia and gestational diabetes) is now recognized as a cardiovascular risk enhancer in long-term women's health — incorporate into 10-year ASCVD discussions at primary care visits.
— In a hemodynamically unstable patient with non-reassuring fetal tracing, implied consent governs emergent cesarean if the patient cannot consent.
— When competent and refusing cesarean despite fetal jeopardy: respect maternal autonomy after thorough counseling; a competent pregnant patient may refuse intervention even when refusal risks the fetus. Document extensively, involve ethics, do not seek court order in acute settings — this is established US case law (In re A.C., 1990).
— Universal screening in all pregnant patients, private setting, partner absent.
— IPV is a leading cause of "minor trauma" abruption.
— Mandatory reporting laws for IPV vary by state — most states require reporting of injuries from weapons; few mandate reporting of all IPV. Know local statute.
— Always provide safety planning, hotline (1-800-799-7233), and social work referral.
— CAPTA requires notification to child protective services for newborns affected by maternal substance use; specifics vary by state.
— Counsel non-punitively; emphasize treatment and continuity of care.
— Handoff at change of shift in unstable obstetric patients is a high-risk moment — use structured SBAR handoffs and include fetal status, last fibrinogen, transfusion totals, and active orders.
— Discharge from ED after trauma: clear written return precautions; document the 4-hour monitoring period explicitly.
— Confirm Rh status and document Rh immunoglobulin administration; missed RhoGAM is a recurrent malpractice claim.
— Offer bereavement support, memory-making (footprints, photos), chaplaincy after stillbirth.
— Discuss autopsy and placental pathology — important for counseling future pregnancies.
Step 3 management: A competent pregnant patient refusing emergent cesarean for fetal distress retains the right of refusal — document informed refusal with risks acknowledged, involve ethics if time permits, never coerce. This is a frequently tested ethics scenario.
Board pearl: When you see "MVC + pregnant + seatbelt + normal exam" → answer is 4-hour continuous fetal monitoring, type and screen, and Kleihauer-Betke if Rh-negative, not CT or discharge.
— "32-year-old G3P2 at 34 weeks with chronic hypertension presents with sudden abdominal pain and dark vaginal bleeding. BP 90/50, HR 120. Uterus tense and tender. FHR 90s with late decelerations." → Answer: emergent cesarean, large-bore IV access, type and cross, MTP activation.
— "28-year-old G1 at 28 weeks, restrained driver in MVC, no bleeding, normal vitals, normal FAST. What next?" → Continuous fetal monitoring for at least 4 hours, Kleihauer-Betke if Rh-negative, RhoGAM.
— "Severe abdominal pain, minimal bleeding, fibrinogen 120, platelets 80, PT prolonged, fetal demise." → Diagnosis: concealed abruption with DIC. Management: vaginal delivery if stable, MTP with cryoprecipitate, TXA, ICU.
— "Painless bright red bleeding at 30 weeks, normal fetal tracing." → Previa; transvaginal US; no digital exam; pelvic rest.
— "ROM followed by small bleed and sudden fetal bradycardia." → Emergent cesarean; postpartum Apt test confirms fetal blood.
— "Young woman, agitated, hypertensive, abdominal pain at 32 weeks." → Urine tox, manage abruption, social work, addiction treatment.
— "Boggy uterus, ongoing bleeding after vaginal delivery." → Massage, oxytocin, TXA, methylergonovine (if no HTN), carboprost (if no asthma), misoprostol, Bakri balloon, B-Lynch, hysterectomy.
— "Competent patient refuses cesarean despite fetal distress." → Respect autonomy, document, do not seek court order.
— Always include Kleihauer-Betke and RhoGAM in the answer.
— "Postpartum hemorrhage history, now failure to lactate and amenorrhea." → Sheehan syndrome; check TSH, free T4, cortisol, prolactin; replace hormones.
Key distinction: When the question gives vital signs disproportionate to visible bleeding, the answer is almost always concealed abruption with imminent DIC — pivot to coagulation labs and MTP.
Placental abruption is a clinical diagnosis of premature placental separation presenting with painful vaginal bleeding, a tender hypertonic uterus, and a non-reassuring fetal heart tracing — managed by simultaneous maternal resuscitation with blood products and TXA, fetal monitoring, and prompt delivery (emergent cesarean for instability or fetal distress; vaginal if both mother and fetus permit), while anticipating DIC, postpartum hemorrhage, and AKI.
Board pearl: When a Step 3 stem combines hypertension or trauma + pain + bleeding + fetal distress, abruption is the answer — and your first orders are blood products, fibrinogen, fetal monitoring, and OB consult, all in parallel.