Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; Cardiovascular Institute of New Jersey and Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ.
Am J Obstet Gynecol. 2023 May;228(5S):S1313-S1329. doi: 10.1016/j.ajog.2022.06.059. Epub 2023 Mar 23.
Placental abruption is the premature separation of the placenta from its uterine attachment before the delivery of a fetus. The clinical manifestations of abruption typically include vaginal bleeding and abdominal pain with a wide variety of abnormal fetal heart rate patterns. Clinical challenges arise when pregnant people with this condition present with profound vaginal bleeding, necessitating urgent delivery, especially when there is a concern for maternal and fetal compromise and coagulopathy. Abruption occurs in 0.6% to 1.2% of all pregnancies, with nearly half of abruption occurring at term gestations. An exposition of abruption at near-term (defined as the late preterm period from 34 0/7 to 36 6/7 weeks of gestation) and term (defined as ≥37 weeks of gestation) provides unique insights into its direct effects, as risks associated with preterm birth do not impact outcomes. Here, we explore the pathophysiology, epidemiology, and diagnosis of abruption. We discuss the interaction of chronic processes (decidual and uteroplacental vasculopathy) and acute processes (shearing forces applied to the abdomen) that underlie the pathophysiology. Risk factors for abruption and strengths of association are summarized. Sonographic findings of abruption and fetal heart rate tracings are presented. In addition, we propose a management algorithm for acute abruption that incorporates blood loss, vital signs, and urine output, among other factors. Lastly, we discuss blood component therapy, viscoelastic point-of-care testing, disseminated intravascular coagulopathy, and management of abruption complicated by fetal death. The review seeks to provide comprehensive, clinically focused guidance during a gestational age range when neonatal outcomes can often be favorable if rapid and evidence-based care is optimized.
胎盘早剥是指胎儿分娩前胎盘与其子宫附着处过早分离。胎盘早剥的临床表现通常包括阴道出血和腹痛，并伴有各种异常的胎儿心率模式。当患有这种疾病的孕妇出现严重阴道出血，需要紧急分娩时，尤其是当存在母体和胎儿受损和凝血功能障碍的风险时，临床就会面临挑战。胎盘早剥在所有妊娠中的发生率为 0.6%至 1.2%，近一半的胎盘早剥发生在足月妊娠。对接近足月（定义为从 34 周零 7 天到 36 周零 6 天的晚期早产）和足月（定义为≥37 周妊娠）的胎盘早剥进行阐述，可以深入了解其直接影响，因为与早产相关的风险不会影响结局。在这里，我们探讨了胎盘早剥的病理生理学、流行病学和诊断。我们讨论了导致其发生的慢性过程（蜕膜和胎盘血管病变）和急性过程（施加于腹部的剪切力）之间的相互作用。总结了胎盘早剥的危险因素及其关联强度。介绍了胎盘早剥的超声表现和胎儿心率图。此外，我们提出了一种急性胎盘早剥的管理算法，其中纳入了出血量、生命体征和尿量等因素。最后，我们讨论了血液成分治疗、黏弹性即时检验、弥漫性血管内凝血以及伴有胎儿死亡的胎盘早剥的处理。本综述旨在提供全面、以临床为重点的指导，涵盖了新生儿结局通常较好的妊娠时间段，如果能优化快速和基于证据的治疗。
