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# Placental abruption

Placental abruption is the separation of the placenta from the uterine wall before birth; it causes painful bleeding and a hard uterus and is an emergency.

Updated 2026-10-29

## Structures involved

Tap one to see what it is and open it in 3D.

- [Body of uterus](https://durgical.com/en/anatomy/body-of-uterus/)
- [Myometrium](https://durgical.com/en/anatomy/myometrium/)
- [Uterine artery](https://durgical.com/en/anatomy/uterine-artery/)
- [Endometrium](https://durgical.com/en/anatomy/endometrium/)

## In histology

- [Placenta](https://durgical.com/en/histology/placenta/)

## In embryology

- [Placenta: structure, circulation and functions](https://durgical.com/en/embryology/placenta-structure-circulation-and-functions/)
- [Abnormal placentation: previa and the accreta spectrum](https://durgical.com/en/embryology/abnormal-placentation-previa-and-the-accreta-spectrum/)
- [Alcohol: fetal alcohol spectrum disorder](https://durgical.com/en/embryology/alcohol-fetal-alcohol-spectrum-disorder/)
- [Ionizing radiation, tobacco and cocaine](https://durgical.com/en/embryology/ionizing-radiation-tobacco-and-cocaine/)

## In physiology

- [Parturition: onset and uterine contraction](https://durgical.com/en/physiology/parturition-onset-and-uterine-contraction/)

## Why it happens

- [Disseminated intravascular coagulation: how consumption causes both clots and bleeding](https://durgical.com/en/general-pathology/disseminated-intravascular-coagulation-how-consumption-causes-both-clots-and-ble/)
- [Hemorrhage: petechiae, purpura, ecchymosis, hematoma, and what blood loss does](https://durgical.com/en/general-pathology/hemorrhage-petechiae-purpura-ecchymosis-hematoma-and-what-blood-loss-does/)
- [Drugs of abuse: cocaine, opioids, amphetamines, cannabis](https://durgical.com/en/general-pathology/drugs-of-abuse-cocaine-opioids-amphetamines-cannabis/)
- [Coagulation tests: PT/INR, aPTT and platelets](https://durgical.com/en/physiology/coagulation-tests-pt-inr-aptt-and-platelets/)

## What it is

Separation of a normally implanted placenta from the uterine wall before the baby is born, after 20 weeks. It classically causes painful bleeding with a tender, hard uterus and can quickly threaten mother and fetus.

## Who gets it

A major cause of third-trimester bleeding and perinatal death. It is closely linked to hypertensive disorders of pregnancy and to abdominal trauma, including road traffic accidents and intimate partner violence.

## Causes

- Hypertension and preeclampsia
- Abdominal trauma (falls, traffic accidents, assault)
- Sudden uterine decompression (rupture of membranes with polyhydramnios, after the first twin)
- Cocaine use and smoking

## Risk factors

- Previous placental abruption
- Chronic or pregnancy hypertension, preeclampsia
- Prelabour rupture of membranes, chorioamnionitis
- Smoking, cocaine or other vasoconstrictor drugs
- Older maternal age and high parity
- Thrombophilias, multiple pregnancy

## Pathophysiology

Bleeding from maternal vessels in the decidua forms a retroplacental haematoma that pushes the placenta off the uterine wall, reducing the area for gas exchange. Blood may escape through the [cervix](https://durgical.com/en/anatomy/cervix-of-uterus/) or stay hidden behind the placenta. Release of tissue factor from the damaged decidua can trigger disseminated intravascular coagulation.

## Classification

- Revealed (bleeding visible) or concealed (blood trapped behind the placenta)
- Partial or complete
- Severity grades from mild (no maternal or fetal compromise) to severe (fetal death, maternal shock or coagulopathy)

## Symptoms and signs

- Vaginal bleeding with abdominal or back pain
- Tender, firm uterus, sometimes described as woody
- Frequent, strong contractions or a raised uterine tone
- Abnormal fetal heart rate or reduced fetal movements
- Signs of shock out of proportion to the visible bleeding (concealed haemorrhage)

## Red flags

- Maternal tachycardia or hypotension
- Fetal distress or absent fetal heartbeat
- Bleeding from IV sites or gums (coagulopathy)
- Any abdominal trauma in the second half of pregnancy

## Diagnosis

**Clinical**
Mainly clinical: painful bleeding, uterine tenderness and hypertonus, with continuous fetal heart monitoring. After abdominal trauma, monitoring is continued for several hours even if the woman looks well.

**Tests**
Full blood count, fibrinogen, coagulation studies, blood group and Rh, crossmatch, [kidney](https://durgical.com/en/anatomy/kidney/) function; a test for fetal-maternal haemorrhage in Rh-negative women.

**Imaging**
Ultrasound may show a retroplacental clot and excludes placenta previa, but a normal scan does not rule out abruption.

## Differential diagnosis

- Placenta previa
- Uterine rupture
- Preterm labour
- Vasa previa
- Chorioamnionitis
- Acute [abdomen](https://durgical.com/en/anatomy/region/abdomen/) unrelated to pregnancy

## Goal of treatment

Stabilise the mother, correct blood loss and coagulopathy, and decide the timing and route of delivery according to maternal and fetal condition and gestational age.

## Treatment

**Acute**
IV access, fluids, early blood products and correction of coagulopathy (fibrinogen, plasma, platelets).

**Surgical**
Urgent caesarean delivery when the fetus is alive and compromised or the mother is unstable.

**Procedure**
Vaginal delivery when the mother is stable, especially if the fetus has died, with close monitoring of clotting.

**Follow-up**
Mild abruption, stable, preterm: expectant care in hospital with continuous monitoring and antenatal corticosteroids.

**Medical**
Anti-D immunoglobulin for Rh-negative women; treatment of hypertension.

## Complications

- Haemorrhagic shock
- Disseminated intravascular coagulation
- Couvelaire uterus (blood infiltrating the [myometrium](https://durgical.com/en/anatomy/myometrium/)) and postpartum haemorrhage
- Acute kidney injury, Sheehan syndrome
- Fetal hypoxia, preterm birth, stillbirth
- Recurrence in later pregnancies

## Prognosis

Depends on the extent of separation and how fast the woman reaches care. Mild cases often end well; severe abruption carries a high risk of fetal death and maternal complications.

## Prevention

- Control of hypertension in pregnancy
- Avoiding tobacco and cocaine
- Seat belt use in pregnancy and screening for intimate partner violence

## Test yourself

Think of the answer, then tap the question to see it.

## How does the bleeding of placental abruption differ from that of placenta previa?

Abruption causes painful bleeding with a tender, hard uterus; previa causes painless bleeding with a soft uterus.

## What are the two classic causes of placental abruption?

Hypertension (including preeclampsia) and abdominal trauma.

## Which coagulation complication is typical of severe abruption?

Disseminated intravascular coagulation, with low fibrinogen.

## Does a normal ultrasound exclude placental abruption?

No. Ultrasound often misses it; the diagnosis is mainly clinical.

## What is a Couvelaire uterus?

A uterus infiltrated by blood from a severe abruption, which may contract poorly after birth.

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## Related conditions

- [Preeclampsia](https://durgical.com/en/conditions/preeclampsia/)
- [Placenta praevia](https://durgical.com/en/conditions/placenta-praevia/)
- [Postpartum haemorrhage](https://durgical.com/en/conditions/postpartum-haemorrhage/)
- [Arterial hypertension](https://durgical.com/en/conditions/arterial-hypertension/)
- [Hypovolaemic shock](https://durgical.com/en/conditions/hypovolaemic-shock/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Placental Abruption](https://www.ncbi.nlm.nih.gov/books/NBK482335/) (StatPearls (NCBI Bookshelf), 2025).

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Source: https://durgical.com/en/conditions/placental-abruption/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/placental-abruption/