A 32-year-old primigravida at 34 weeks gestation presents with sudden-onset vaginal bleeding, severe abdominal pain, and uterine tenderness. Fetal heart rate is 110 bpm with late decelerations. Ultrasound confirms placental abruption with 40% placental separation. Which of the following is NOT a typical feature or management principle in abruptio placentae?

Explanation

## Abruptio Placentae: Key Distinguishing Features **Key Point:** Expectant (conservative) management is NOT appropriate for all cases of abruptio placentae. Management is stratified by severity, gestational age, maternal stability, and fetal viability. ### Management Principles by Severity | Feature | Mild Abruption | Severe Abruption | |---------|---|---| | **Placental separation** | <25% | >25% | | **Maternal stability** | Stable, no shock | Shock, coagulopathy | | **Fetal status** | Reassuring FHR | Fetal distress/death | | **Management** | Expectant (if >34 wks + stable) | Urgent delivery (vaginal or cesarean) | | **Delivery route** | Vaginal delivery acceptable | Usually cesarean (unless imminent vaginal delivery) | **High-Yield:** Expectant management is reserved for: - Mild abruption (<25% separation) - Gestational age >34 weeks - Maternal hemodynamic stability - Reassuring fetal heart rate tracing - Absence of DIC In this case, with 40% separation, fetal distress (late decelerations), and maternal pain/tenderness, **immediate delivery is indicated**, not expectant management. ### Why the Other Options Are Correct **Concealed vs. Revealed Abruption & DIC:** - Concealed abruption (blood trapped behind placenta) → greater placental separation → more tissue factor release → **higher DIC risk** - Revealed abruption (vaginal bleeding visible) → usually milder separation **Maternal Shock Disproportionate to Visible Loss:** - In concealed abruption, internal bleeding is not visible - Maternal blood loss can be 1–2 L without external bleeding - Shock develops from **hidden retroplacental hemorrhage**, not from visible vaginal bleeding **Fetal Distress Pattern:** - Late decelerations and bradycardia reflect **placental insufficiency** from abruption - Loss of placental exchange surface → fetal hypoxia [cite:Williams Obstetrics 26e Ch 34] **Clinical Pearl:** The classic teaching: "Shock out of proportion to visible bleeding" is pathognomonic for concealed abruption and should trigger immediate delivery.