Placental abruption

How does this happen?

The placenta is attached to the wall of the uterus and is the baby's entire supply of oxygen and nutrients. Abruption means part or all of it detaches before the baby is born.

Once an area separates, that part of the placenta stops working. If a small area separates, the rest can compensate. If a large area separates, the baby's oxygen supply falls sharply, which is why abruption is one of the acute events recognized as capable of causing brain injury from oxygen deprivation. ²

Bleeding comes from the torn vessels at the separation site. It can track down and appear vaginally, or it can be trapped behind the placenta, where it is invisible. That is the concealed form, and it is why the visible blood is not a measure of severity. ¹

There is a further complication. The material released from a separating placenta can trigger a body-wide clotting disturbance, in which clotting factors are consumed and the person then cannot clot at all. That is why clotting studies are checked urgently in a suspected abruption and why blood products are prepared. ³

Abruption is also the mechanism by which trauma injures a pregnancy. A fall, a car crash or an assault can shear the placenta from the uterine wall even where there is no external injury.

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• No identifiable cause, which is common. Abruption frequently happens without warning to people with no risk factors.
• preeclampsia and high blood pressure, which affect the placental blood vessels. ¹
• Trauma, including a car crash or a fall.
• Previous abruption, which raises the risk in a later pregnancy. ¹
• Rapid loss of fluid, for example when the waters break with a lot of fluid present.
• Twin pregnancy, particularly after the first baby is born.
• Smoking and cocaine use, which are established associations. ¹

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• preeclampsia or high blood pressure not identified or not managed, where guidance sets out screening and treatment. ¹
• Abdominal trauma in pregnancy not assessed with a period of fetal monitoring, since abruption can develop after apparently minor trauma. ⁴
• Bleeding or severe abdominal pain in pregnancy not assessed urgently.
• The fetal heart rate not monitored, or an abnormal tracing not acted on. ⁴
• Delay in delivery once abruption was suspected and the baby was compromised. ⁵
• Blood loss underestimated, because bleeding was concealed. ³
• Clotting not checked, where a body-wide clotting disturbance is a recognized complication. ³

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record. Abruption occurs without warning and without any preventable cause in many cases.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• Vaginal bleeding, which may be dark, and which may be absent.
• Sudden severe abdominal or back pain.
• A uterus that feels hard, tender and does not relax between contractions.
• Contractions that come very frequently.
• An abnormal fetal heart rate, or reduced fetal movement. ⁴
• Signs of blood loss: rising heart rate, falling blood pressure, faintness.

The first week

For the mother

• Recovery from bleeding and often from emergency delivery. ³
• Anemia.
• Clotting problems requiring blood products in severe cases.

For the baby

• Assessment for hypoxic-ischemic encephalopathy where oxygen supply was interrupted, including whether cooling criteria are met within six hours. ⁶
• Effects of prematurity if delivery was early. ⁷

Around 3 months

• Physical recovery for the mother.
• Post-traumatic stress, which is common after a sudden emergency. ⁸
• Developmental follow-up for the baby where there was oxygen deprivation or preterm birth. ⁹

Around 6 months

• Most physical recovery is complete.
• Grief where the pregnancy was lost, which is its own path and deserves proper support.

Around 12 months

• Questions about future pregnancy, which should be discussed with an obstetrician.

Toddler years

• For the baby, effects follow any brain injury or prematurity. ²

School age

• For the baby, effects follow any brain injury or prematurity.

How is it diagnosed?

Abruption is a clinical diagnosis. There is no test that reliably rules it out. ¹

Clinical assessment: pain, uterine tenderness and tone, bleeding, and the mother's vital signs.

Continuous fetal monitoring, which often shows the effect before anything else does. ⁴

Ultrasound, which can show a collection of blood behind the placenta but frequently does not. A normal ultrasound does not rule out abruption, and this is one of the most important points on this page. It is useful for locating the placenta and excluding placenta previa.

Blood tests, including blood count and clotting studies, because a body-wide clotting disturbance is a recognized complication. ³

placental pathology after delivery, which can confirm abruption and can show whether the process was recent or long-standing. Ask whether the placenta was sent to pathology and request that report separately, because it is often filed apart from the rest of the chart.

What is the treatment?

Treatment depends on how severe it is, how far along the pregnancy is, and how the baby and mother are doing.

Immediate delivery, usually by cesarean, where the baby is compromised or the mother is unstable. ⁵

Blood transfusion and management of clotting, where bleeding is significant. ³

Close observation for a small abruption with a stable baby well before term, sometimes with steroids for the baby's lungs. ¹⁰

Magnesium for the baby's brain if delivery before 32 weeks is expected. ¹¹

Anti-D immune globulin if the mother is Rh negative, since abruption can allow the baby's blood to mix with hers. ¹²

For the baby: resuscitation, and assessment for hypoxic-ischemic encephalopathy including whether cooling is indicated within six hours. ^{13 6}

What is the long-term outlook?

Outcome depends on how much of the placenta separated and how quickly delivery followed.

A small abruption with a stable baby can end with an uneventful birth.

A large abruption is an emergency for both, and it is one of the acute events associated with brain injury from oxygen deprivation in the baby and with severe hemorrhage in the mother. ^{2 3}

For the mother, physical recovery is usually complete. Anemia is often under-treated, and profound fatigue afterward is frequently anemia rather than ordinary tiredness. ¹⁴

Post-traumatic stress is common. Abruption is sudden, painful and frightening, and it often ends in an emergency delivery under general anesthesia. ⁸

For a future pregnancy, a previous abruption raises the risk of another and changes monitoring. Raise it at the first appointment. ¹

What does daily life look like?

Recovery from emergency surgery and blood loss, often alongside a baby who is unwell or in the NICU.

Ask for iron. Ask for a debrief. Ask for the placental pathology report.

Where the pregnancy was lost, the grief is compounded by how sudden it was and by the absence of any explanation in many cases. Support for that is not optional and it is available. ¹⁵

Get the abruption written into your permanent record, not only your maternity notes.

What does care cost over a lifetime?

No agency publishes a lifetime cost estimate for placental abruption, and this site does not invent one.

Immediate costs are emergency delivery, blood products and neonatal care.

Where the baby has lasting brain injury, the published anchor for cerebral palsy is CDC's estimate of about $921,000 in 2003 dollars. ¹⁶ See the cost of care estimator.

What can you do this week?

1. Ask whether the placenta was sent to pathology and request that report separately.
2. Request the fetal monitoring strips and the delivery record.
3. Ask what your blood loss was and what your hemoglobin is now.
4. Ask about intravenous iron if you are exhausted.
5. For the baby, ask for the cord gases and whether cooling was considered.
6. Ask what this means for a future pregnancy.
7. Ask for a debrief appointment.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the obstetrician

• How much of the placenta separated?
• Was there concealed bleeding, and what was my measured blood loss?
• Did I have a clotting problem, and what was given?
• Was the placenta sent to pathology?
• What does this mean for a future pregnancy?

For the neonatal team

• What were the cord gases and Apgar scores?
• How long between the event and delivery?
• Was cooling considered?
• What follow-up does my baby need?

You can also build a printable list with the question generator.