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This article looks at the causes of, signs and symptoms of placental abruption and the importance of prompt diagnosis and management.
I have been instructed in relation to a number of clinical negligence cases recently involving the mismanagement of placental abruption, a complication which can occur during pregnancy. It was not a complication I knew a lot about previously and I have been interested to learn more, particularly the guidelines for management of the complication published by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2011.
A placental abruption occurs when there is separation of the placenta before delivery of the baby. Bleeding occurs between the placenta and the wall of the womb. The extent of the bleeding varies between expectant mothers. If there is a large amount of blood loss, the placenta may partially or, completely separate from the lining of the uterus before the baby is born. This can cause complications for both the mother and baby.
No one knows exactly what causes a placental abruption but it has been linked to the following:
• Bleeding in early pregnancy
• Patients who have a blood disorder which increases the likelihood of blood clots (thrombophilia).
• Where an unborn baby is not growing as well as would be expected (intrauterine growth restriction).
• Waters break early.
• An expectant mum has too much amniotic fluid (polyhydramnios).
• An expectant mum has suffered a trauma or blow to the tummy, such as from a car accident.
• An expectant mum who smokes or takes drugs.
• Mums who have had many babies, or older mum’s, as the risk increases with age.
Unfortunately, there is also an increased risk of a mum suffering a placental abruption if she has suffered it in a previous pregnancy.
Mothers suffering a placental abruption may experience some but not necessarily all of the following symptoms: vaginal bleeding; abdominal pain; back pain; uterine contraction, reduced fetal movements; waters breaking early and the fluid is bloody; signs of shock such as feeling weak, pale, sweaty or disorientated.
For the unborn baby, if the placenta is damaged, the baby may not receive the necessary nutrients and oxygen supply leading to fetal distress and reduced fetal movements. Placental abruption increases the risk of the baby being born prematurely, having growth problems, being stillborn and dying in the first 28 days of life.
For these reasons, placental abruption is a medical emergency and an expectant mother should seek urgent medical attention if she experiences any of these symptoms.
It depends on how large the placental abruption is, and how severe the symptoms are. If the mother and baby are very unwell on admission to hospital emergency treatments such as oxygen, fluids and a blood transfusion may be given.
A doctor will gently palpate the abdomen to feel how hard it is and check whether mum is having contractions, and if so, the frequency of the contractions. The doctor will examine the mother to locate the cause of the bleeding.
At the same time, hospital staff will monitor the baby’s heart rate to see how the baby is doing. An ultrasound scan will be undertaken to check the placenta.
The treatment provided will depend upon how near a mother is to her due date, how severe the bleeding is, and whether there are signs that the baby is in distress.
A mother may be admitted to hospital so doctors can find out more and observe both mother and baby’s condition. If the bleeding stops then a mother may be allowed home. If the mother is close to their due date, labour maybe induced or, if it is best for the baby to be delivered straight away, an emergency caesarean section should be undertaken.
In some cases, it may be safer for the baby to be born, even if it means the baby would be premature. The doctor will weigh up with the mother, the risk of a worsening abruption against the risk of premature birth.
A placental abruption is a medical emergency and it is imperative to seek urgent medical attention if any of the symptoms are experienced during pregnancy to ensure both mother and baby receive the best possible care.
Unfortunately, we act for a number of clients who, despite attending hospital with concerning symptoms, experienced a delay in diagnosing the placental abruption causing injury to either mother or baby and sometimes both. The issues in these cases are usually the failure to act on early signs of placental abruption, failing to monitor the condition of mother and baby and delays in performing a caesarean section to deliver the baby causing prolonged oxygen starvation. With clear guidelines in place from the RCOG an Obstetrician needs to have very good reasons for not following them when treating a patient with suspected or confirmed placental abruption.