Two Cases of Severe Placental Abruption as a First Symptom o
A 33-year-old patient 1G0P at 35 + 2 gestation presented to the obstetric unit because of severe abdominal pain that had started a few hours before presentation. The patient had no significant medical or obstetric history, and the course of this pregnancy had been uneventful. She had last seen her gynecologist 4 weeks prior to this presentation because of a self-limited episode of generalized edema, however, because hypertension and proteinuria had been excluded was discharged home without further follow-up. On presentation, no fetal heartbeat could be found on CTG monitoring which was confirmed on an ultrasound scan. The scan also showed a retroplacental hematoma of approximately 13 × 8 cm. On clinical exam, the abdomen was hard and tender. The patient was normocardic and normotensive, however was extremely pale, and pale lips were especially noted. The digital vaginal exam showed an unfavorable cervix, and there was no vaginal bleeding. A delivery by emergency cesarean section was indicated. Intraoperatively approximately 1L of coagula was emptied. The uterus was livid and showed signs of intramural bleeding compatible with a beginning Couvelaire-uterus. The lividity improved intraoperatively; hence, the uterus was left in situ.

On the first postoperative day, the patient had a large subcutaneous bleed and hematoma formation on the left side of her cesarean scar which required operative evacuation. She was admitted to our intensive care unit and needed 3 units of packed red blood cells with a Hb of 58 g/l. She developed massive generalized edema, headaches, visual changes, and hypertension up to 150/105 mmHg. The platelets dropped to 88 G/L. The blood pressure and laboratory findings improved postoperatively without further therapy. She was discharged home in good physical condition on a postoperative day 7 with a recommendation for antiphospholipid syndrome testing 6 weeks postpartum.

The 2nd patient was a 34-year-old 2G0P. She presented at 38 + 4 weeks gestation with heavy vaginal bleeding. Her obstetric history included a missed abortion 1 year prior. In this pregnancy, bilateral notching in the uterine arteries was noted on an anatomy scan at 21 weeks gestation which was performed at a private ultrasound practice. She has been put on Aspirin 150 mg, however, advised that the recommended time frame for initiation of Aspirin therapy had been missed. She regularly measured her blood pressure at home and noted occasional high blood pressures up to 140/90; however, these episodes were self-limited and never reached levels requiring antihypertensive therapy. She had been checked by her gynecologist regularly, and no proteinuria was seen.

On presentation, fetal bradycardia was noted on ultrasound scan, placental abruption was suspected, and an emergency cesarean section was performed. The patient was delivered of a male fetus with an APGAR 3/7/7, NsvpH 6.92, and NsapH 6.98. The neonate was initially nonresponsive to stimulation, asystolic, and apnoeic. After 30 seconds of reanimation, cardiac activity returned. The neonatal Hb was stable postoperatively, and no blood transfusions were necessary. On the 4th postoperative day, the patient had hypertension up to 155/90 mmHg. She complained of visual changes, edema, and a mild headache. Laboratory findings included elevated liver enzymes and a borderline protein/creatinine ratio. Based on hypertension and elevated liver enzymes, diagnosed preeclampsia. During the hospitalization period, the laboratory findings improved and the patient could be discharged home in good physical condition. The neonate had to be transferred to the neonatology department of the university children's hospital for further investigations; however, his cardiovascular condition improved within a few days, and he could be transferred back to the neonatology unit.