ABRUPTIO PLACENTAE Definition:

Placental abruption occurs when the placenta separates from the wall of the uterus prior to the birth of the baby. This can result in severe, uncontrollable bleeding (hemorrhage).

Placental abruption (also known as abruptio placentae) is an obstetric catastrophe (complication of pregnancy), wherein the placental lining has separated from the uterus of the mother. It is the most common cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies world wide with a fetal mortality rate of 20-40% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality. Many women can die from this type of abnormality.The heart rate of the fetus can be associated with the severity.

Lasting effectsOn the mother:

A large loss of blood or hemorrhage may require blood transfusions and intensive care after delivery. 'APH weakens, for PPH to kill'.

The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract.

The mother may have problems with blood clotting for a few days. If the mother's blood does not clot (particularly during a caesarean section) and too many transfusions

could put the mother into disseminated intravascular coagulation (DIC) due to increased thromboplastin, the doctor may consider a hysterectomy.

A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland. Diffuse cortical necrosis in the kidney is a serious and often fatal complication.

In some cases where the abruption is high up in the uterus, or is slight, there is no bleeding, though extreme pain is felt and reported.

On the baby: If a large amount of the placenta separates from the uterus, the baby will probably be in distress until

delivery and may die in utero, thus resulting in a stillbirth. The baby may be premature and need to be placed in the newborn intensive care unit. He or she might

have problems with breathing and feeding. If the baby is in distress in the uterus, he or she may have a low level of oxygen in the blood after birth. The newborn may have low blood pressure or a low blood count. If the separation is severe enough, the baby could suffer brain damage or die before or shortly after birth.

Types of abruption placentae:Concealed hemorrhage - the placenta separation centrally, and a large amount of blood is accumulated under the placenta.External hemorrhage – the separation is along the placental margin, and blood flows under the membranes and through cervix.Mixed type both revealed and concealed-- predominantly concealed,the membrane gradually separate from the uterine walland blood escapes through the cervix.

Etiology: • Mother having hypertension

Accidental trauma to mother like sharp blow, motor accident etc Retroplacental fibromyoma Short cord Prolonged rupture of membranes Cigarette smoking and other form of tobacco abuse Maternal age of 30 years or older Low socioeconomic status Needle puncture during amniocentesis Infections Uterine abnormalities

The incidence of placenta abruptio, including any amount of placental separation prior to delivery, is about 1 out of 150 deliveries. The severe form, which results in fetal death, occurs only in about 1 out of 500 to 750 deliveries.

Risk Factors:

The cause of placental abruption is unknown. However, a number of risk factors have been identified. These factors include:

older age of the mother history of placental abruption during a previous pregnancy high blood pressure certain disease states (diabetes, collagen vascular diseases) the presence of a type of uterine tumor called a leiomyoma twins, triplets, or other multiple pregnancies cigarette smoking heavy alcohol use cocaine use malformations of the uterus malformations of the placenta injury to the abdomen (as might occur in a car accident) short umbilical cord

Causes:While multiple risk factors are associated with abruptio placentae, only a few events have been closely linked to this condition, including the following:

Cigarette smoking/tobacco abuse Cigarette smoking increases a patient's overall risk of placental abruption. A prospective cohort study showed the risk of abruption to be increased by 40% for each year of

smoking prior to pregnancy. In addition to the increased risk of abruption caused by tobacco abuse, the perinatal mortality

rate of infants born to women who smoke and have an abruption is increased. Cocaine (powder or crack) abuse

The hypertension and increased levels of catecholamines caused by cocaine abuse are thought to be responsible for a vasospasm in the uterine blood vessels that causes placental separation and abruption. However, this hypothesis has not been definitively proven.

The rate of abruption in patients who abuse cocaine has been reported to be approximately 13-35% and may be dose-dependent.

Trauma Abdominal trauma is a major risk factor for placental abruption. Motor vehicle accidents often cause abdominal trauma. The lower seat belt should extend across

the pelvis, not across the mid abdomen, where the fetus is located. Trauma may also be due to domestic abuse or assault, both of which are underreported.

Thrombophilia Some literature supports the association of specific thrombophilias, such as factor V Leiden

mutation, prothrombin gene mutation (A20210 mutation), hyperhomocysteinemia, activated protein C resistance, antithrombin III deficiency, and anticardiolipin immunoglobulin G antibodies, and this risk may be independent of the presence of preeclampsia. The presence of a thrombophilia may also influence the severity of the abruption.

Note, however, that other literature does not support an association between thrombophilias and placental abruption. If a patient with a placental abruption is screened and is positive for a thrombophilia she should be offered treatment with heparin and aspirin during the next pregnancy.

Other notable risk factors include the following: Previous placental abruption Chorioamnionitis Prolonged rupture of membranes (24 h or longer)

Preeclampsia Hypertension Maternal age of 35 years or older Male fetal sex Low socioeconomic status Elevated second trimester maternal serum alpha-fetoprotein (associated with up to a 10-fold

increased risk of abruption)

SIGN AND SYMPTOMS:Symptoms may include vaginal bleeding, contractions, abdominal tenderness, and decreased fetal movement. Eliciting any history of trauma, such as assault, abuse, or motor vehicle accident, is important. A quick review of the patient's prenatal course, such as a known history of placenta previa, may help lead to the correct diagnosis. The patient should also be asked if she has had a placental abruption in a previous pregnancy. Questioning the patient about cocaine abuse, hypertension, trauma, or tobacco abuse is also crucial.

History Vaginal bleeding

Vaginal bleeding is present in 80% of patients diagnosed with placental abruptions. Bleeding may be significant enough to jeopardize both fetal and maternal health in a relatively

short period. Remember that 20% of abruptions are associated with a concealed hemorrhage and the absence

of vaginal bleeding does not exclude a diagnosis of abruptio placentae. Contractions/uterine tenderness

Contractions and uterine hypertonus are part of the classic triad observed with placental abruption.

Uterine activity is a sensitive marker of abruption and, in the absence of vaginal bleeding, should suggest the possibility of an abruption, especially after some form of trauma or in a patient with multiple risk factors.

Decreased fetal movement This may be the presenting complaint. Decreased fetal movement may be due to fetal jeopardy or death.

PhysicalThe physical examination of a patient who is bleeding must be targeted at determining the origin of the hemorrhage. Simultaneously, the patient must be stabilized quickly. With placental abruption, a relatively stable patient may rapidly progress to a state of hypovolemic shock.

Vaginal bleeding Bleeding may be profuse and come in "waves" as the patient's uterus contracts. A fluid the color of port wine may be observed when the membranes are ruptured.

Contractions/uterine tenderness Uterine contractions are a common finding with placental abruption. Contractions progress as the abruption expands, and uterine hypertonus may be noted. Contractions are painful and palpable. Uterine hyperstimulation may occur with little or no break in uterine activity between

contractions. Shock

Patients may present with hypovolemic shock, with or without vaginal bleeding, because a concealed hemorrhage may be present.

As with any hypovolemic condition, blood pressure drops as the pulse increases, urine output falls, and the patient progresses from an alert to an obtunded state as the condition worsens.

Absence of fetal heart sounds: This occurs when the abruption progresses to the point that the fetus dies. Signs of possible fetal jeopardy

Fetal bradycardia is prolonged.

Repetitive, late decelerations are present. Short-term variability is decreased.

Fundal height: This may increase rapidly because of an expanding intrauterine hematoma. Important note: Do not perform a digital examination on a pregnant patient with vaginal bleeding

without first ascertaining the location of the placenta. Before a pelvic examination can be safely performed, an ultrasonographic examination should be performed to exclude placenta previa. If placenta previa is present, a pelvic examination, either with a speculum or with bimanual examination, may initiate profuse bleeding.

Common Clinical Manifestations:1. Intense, localized uterine pain, with or without vaginal bleeding 2. Concealed or external dark red bleeding 3. Uterus firm to boardlike, with severe continuous pain 4. Increase uterine activity resulting in rapid uterine contractions 5. Uterine outline possibly enlarged or changing shape 6. FHR present or absent 7. Fetal presenting part may be engaged 8. Severe pain in lower abdomen9. pain in back10.uterine area is tender to touch11.Decrease fatal movement maybe due to fetal death12.pallor13.sign of shock

Complications: Renal failure Disseminated intravascular coagulation Maternal death Fetal death Post partum hemorrhage Hysterectomy may be considered in some cases If fetus is delivered then it may have low blood pressure Brain damage to the baby Mother may suffer severe shock which may affect various organs

Currently, placental abruption is responsible for approximately 6% of maternal deaths. Maternal and fetal complications include issues related to (1) cesarean delivery, (2) hemorrhage/coagulopathy, and (3) prematurity, described as follows:

Cesarean delivery: Cesarean delivery is often necessary if the patient is far from her delivery date or if significant fetal compromise develops. If significant placental separation is present, the fetal heart rate tracing typically shows evidence of fetal decelerations and even persistent fetal bradycardia. A cesarean delivery may be complicated by infection, additional hemorrhage, the need for transfusion of blood products, injury of the maternal bowel or bladder, and/or hysterectomy for uncontrollable hemorrhage. In rare cases, death occurs.

Hemorrhage/coagulopathy: Disseminated intravascular coagulation (DIC) may occur as a sequela of placental abruption. Patients with a placental abruption are at higher risk of developing a coagulopathic state than those with placental previa. The coagulopathy must be corrected to ensure adequate hemostasis in the case of a cesarean delivery.

Prematurity: Delivery is required in cases of severe abruption or when significant fetal or maternal distress occurs, even in the setting of profound prematurity. In some cases, immediate delivery is the only option, even before the administration of corticosteroid therapy in these premature infants. All other problems and complications associated with a premature infant are also possible.

ANATOMY AND PHYSIOLOGY :

This medical illustration series depicts placental abruption (detachment of the placenta) and the subsequent interruption of fetal circulation. Two images display the baby and the placenta within the uterus, comparing normal placental attachment to abnormal placental abruption. Enlargements contrast the normal fetal and maternal circulation with abnormal, interrupted circulation with bleeding, resulting in a compromised oxygen supply to the baby.

ANATOMY/PHYSIOLOGY OF NORMAL PLACENTA :

Anatomy of a Normal Placenta

The placenta provides the fetus with oxygen and nutrients and takes away waste such as carbon dioxide via the umbilical cord.

Cesarean Section

1. The uterus is exposed through the abdominal wall, and an incision is made in the uterine covering.

2. The muscles of the uterus are separated, producinga hole for the delivery of the infant. 3. The infant is delivered throughthe opening in the uterine wall, after which, the uterus is stitched

closed.

Abruptions are classified according to severity in the following manner: Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta. Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no

distress of mother or fetus. Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be

found with fetal heart rate monitoring. Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be

maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.

Couvelaire uterus (also known as uteroplacental apoplexy)[1] is a life threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity.

DIAGNOSTIC PROCEDURE: Abdominal ultrasound. Complete blood count. Fibrinogen level. Partial thromboplastin time. Pelvic examaintion. Prothrombin time.

Laboratory Studies No laboratory studies have been shown to definitively help with the differential diagnosis of abruptio

placentae; however, multiple laboratory studies may be helpful in the management of this problem. CBC count

A CBC count can help determine the patient's current hemodynamic status, but findings are not reliable for estimating acute blood loss.

In an acute hemorrhage, the fall in hematocrit value lags several hours behind the bleeding and may be falsely decreased by the administration of crystalloid fluids during resuscitation.

Fibrinogen Pregnancy is associated with hyperfibrinogenemia; therefore, modestly depressed fibrinogen

levels may represent significant coagulopathy. A fibrinogen level of less than 200 mg/dL suggests that the patient has a severe abruption.

The goal should be to keep the fibrinogen level above 100 mg/dL, which can be accomplished via transfusion of fresh frozen plasma or cryoprecipitate, as necessary.

Prothrombin time/activated partial thromboplastin time Some form of DIC is present in up to 20% of patients with severe abruptions. Because many of these patients may require cesarean delivery, knowing a patient's coagulation

status is imperative. Blood urea nitrogen/creatinine

The hypovolemic condition brought on by a significant abruption also affects renal function. The condition usually self-corrects without significant residual dysfunction if fluid resuscitation

is timely and adequate.

Kleihauer-Betke test Findings help detect fetal red blood cells in the maternal circulation. If the abruption is significant, inadvertent transfusion of fetal blood into the maternal circulation

may occur. In women who are Rh-negative, this fetal-to-maternal transfusion may lead to isoimmunization of the mother to Rh factor. Kleihauer-Betke test findings help determine the volume of fetal blood transfused into the maternal circulation.

All patients who are D-negative should receive Rho (D) immune globulin (RhoGAM) after

significant trauma. Kleihauer-Betke test findings may help determine the appropriate dosage of Rho (D) immune globulin in cases of significant fetal-maternal hemorrhage.

Blood type: The patient should have her blood typed and at least 2 units of packed red blood cells crossmatched in the event she requires a transfusion.

Rh type: The blood Rh type is important to determine because patients who are Rh-negative require Rh immune globulin in order to prevent isoimmunization, which could affect future pregnancies.

Thrombophilia workup While this is not of immediate concern or helpful in stabilizing the acute event, patients with an

early or severe abruption may be tested for genetic thrombophilias given their possible association with this complication.

Laboratory studies should evaluate for the following: Factor V Leiden mutation Prothrombin gene (A20210) mutation Antithrombin III deficiency Protein C and protein S deficiencies Fasting homocysteine level Anticardiolipin antibodies Activated protein C resistance

Imaging Studies Ultrasonography

Ultrasonography is a readily available and important imaging modality for assessing bleeding in pregnancy.

The quality and sensitivity of ultrasonography in detecting placental abruptions has improved significantly; however, it is not a sensitive modality for this purpose—findings are positive in only 25% of cases confirmed at delivery and the negative predictive value is low at around 50%.

In addition, there does not appear to be any clinical difference in presentation between women who have an abruption seen on ultrasound and those who do not.

Ultrasonographic studies help to quickly diagnose placenta previa as the etiology of bleeding, if present.

Placental abruption shows as a retroplacental clot on an ultrasound image, but not all abruptions are ultrasonographically detectable.

In the acute phase, a hemorrhage is generally hyperechoic, or even isoechoic, compared with the placenta; a hemorrhage does not become hypoechoic for nearly a week.

Ultrasonography can help exclude other causes of third-trimester bleeding. Possible findings consistent with an abruption include (1) retroplacental clot (ie, hyperechoic to isoechoic in the acute phase, changing to hypoechoic within a wk), (2) concealed hemorrhage, or (3) expanding hemorrhage.

Other Tests Nonstress test

External fetal monitors often reveal fetal distress, as evidenced by late decelerations, fetal bradycardia, or decreased beat-to-beat variability.

An increase in the uterine resting tone may also be noticed, along with frequent contractions that may progress to uterine hyperstimulation.

Biophysical profile A biophysical profile (BPP) can be used to help evaluate patients with chronic abruptions who

are being managed conservatively.

A BPP score less than 6 (maximum of 10) may be an early sign of fetal compromise. A modified BPP (nonstress test with amniotic fluid index) is sometimes used for monitoring in

this situation.Procedures:Any procedures that may be required (ie, continuous monitoring of the fetal heart rate tracing, vaginal delivery, cesarean section) will be dictated by both the gestational age and the overall status of the fetus. This is discussed in more detail below.Histologic FindingsAfter delivery of the placenta, a retroplacental clot may be noted. Another possible finding involves extravasation of blood into the myometrium, which produces a purple discoloration of the uterine serosa. This phenomenon is known as a Couvelaire uterus.

MEDICAL MANAGEMENT:Inpatient admission is required if abruptio placentae is considered likely.

Procedures Begin continuous external fetal monitoring for both the fetal heart rate and contractions. Obtain intravenous access using 2 large-bore intravenous lines. Institute crystalloid fluid resuscitation for the patient. Type and crossmatch blood. Begin a transfusion if the patient is hemodynamically unstable after fluid resuscitation. Correct coagulopathy, if present. Administer Rh immune globulin if the patient is Rh-negative.

Vaginal delivery This is the preferred method of delivery for a fetus that has died secondary to placental

abruption. The ability of the patient to undergo vaginal delivery depends on her remaining

hemodynamically stable. Delivery is usually rapid in these patients secondary to increased uterine tone and contractions.

MedicationTocolysis is considered controversial in the management of placental abruption and is considered only in

patients (1) who are hemodynamically stable, (2) in whom no evidence of fetal jeopardy exists, and (3) in whom a preterm fetus may benefit from corticosteroids or delay of delivery.

Even in patients meeting these criteria, consultation with an MFM specialist is important. Tocolysis must be undertaken with caution because maternal or fetal distress can develop rapidly. In general, either magnesium sulfate or nifedipine (but not both) is used for tocolysis and beta-sympathomimetic agents are avoided, as the latter may cause significant undesirable cardiovascular effects, such as tachycardia, which may mask clinical signs of blood loss in these patients.

TocolyticsMay allow for effective administration of glucocorticoids to the preterm fetus to accelerate fetal lung maturation. In chronic abruption, may also help delay delivery to a gestational age when complications of prematurity are less severe.

Nifedipine (Adalat, Procardia)A calcium channel blocker. The theory behind use as tocolytic is that by blocking influx of calcium into uterine muscle cells, it will decrease contractions, which are dependent on calcium.Dosing

Interactions Contraindications Precautions

AdultLoading dose: 10 mg PO q20min for up to 4 dosesMaintenance dose: 10 mg PO q4-6 hInteraction:Coadministration with magnesium sulfate has potential to act in a synergistic manner with nifedipine and enhance the hypotensive effects; fentanyl and alcohol may increase hypotensive effects; calcium channel blocker may increase cyclosporine levels; H2 blockers (cimetidine), erythromycin, nafcillin, and azole antifungals may increase toxicity (avoid combination or monitor closely); carbamazepine may reduce bioavailability (avoid this combination); rifampin may decrease levels (monitor and adjust dose of calcium channel blocker)

Contraindication:Hypersensitivity to nifedipine; evidence of an acute myocardial infarction Pregnancy:C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetusPrecautions:Potential side effects include hypotension, dizziness, nausea, pulmonary edema, reflex tachycardia; may cause lower extremity edema; allergic hepatitis have occurred but is rare

Magnesium sulfateDOC for tocolysis in patients with placental abruption.

Dosing Interactions Contraindications Precautions

AdultInitial dose: 4-6 g IV bolus over 20 minMaintenance dose: 2-4 g/h IV, titrated prn to suppress contractionsPediatricNot established

Dosing Interactions Contraindications Precautions

Interaction:Concurrent use with nifedipine may cause hypotension and neuromuscular blockade; may increase neuromuscular blockade noted with aminoglycosides and potentiate neuromuscular blockade produced by tubocurarine, vecuronium, and succinylcholine; may increase CNS effects and toxicity of CNS depressants and betamethasone and cardiotoxicity of ritodrinProecautions:Adverse effects include flushing, blurry vision, headaches, and nausea; more serious adverse effects, observed only at toxic levels, include pulmonary edema, respiratory depression, cardiac arrest, maternal tetany, and profound hypotension; to reverse effects, calcium gluconate (1 g slow IV push) may be administered

SURGICAL MANAGEMENT:Cesarean delivery

Cesarean delivery is often necessary for both fetal and maternal stabilization. While cesarean delivery facilitates rapid delivery and direct access to the uterus and its

vasculature, it can be complicated by the patient's coagulation status. Because of this, a vertical skin incision, which has been associated with less blood loss, is often used when the patient appears to have DIC.

The type of uterine incision is dictated by the gestational age of the fetus, with a vertical or classic uterine incision often being necessary in the preterm patient.

If hemorrhage cannot be controlled after delivery, a cesarean hysterectomy may be required to save the patient's life.

Before proceeding to hysterectomy, other procedures, including correction of coagulopathy, ligation of the uterine artery, administration of uterotonics (if atony is present), packing of the uterus, and other techniques to control hemorrhage, may be attempted.

ICU: If the patient is hemodynamically unstable, either before or after delivery, invasive monitoring in an ICU may be required.

Consultations

Maternal-fetal medicine specialist If a mild abruption is diagnosed or the diagnosis is questionable, a maternal-fetal medicine

(MFM) specialist should be consulted. In the case of a preterm fetus in which tocolysis is considered likely, consulting an MFM

specialist may be prudent. Pediatricians or neonatal intensive care specialists should be consulted if the fetus is considered viable,

usually at 24 weeks' gestation, and delivery is anticipated.

Diet

The patient should be restricted to nothing by mouth (NPO) if emergent delivery is a possibility.

Activity

Preterm patients diagnosed with a chronic abruption may be started on a modified bedrest regimen and monitored closely for any signs of maternal or fetal distress that could necessitate delivery. Again, consultation with MFM specialists is advised for conservative management of abruptio placentae.

Further Inpatient Care

Admit the patient for testing and possible delivery.

Inpatient & Outpatient Medications

Prenatal vitamins Iron supplements Stool softeners if the patient is hemodynamically stable and is kept in an inpatient setting for monitoring

Transfer

Transfer to an ICU may be necessary, before or after delivery, if shock develops that requires invasive central monitoring or if operative complications are encountered.

Transfer to a facility with a neonatal ICU is needed if the fetus is preterm and appropriate facilities are

not available. This should be accomplished after delivery if delivery is required to stabilize the mother.

Deterrence/Prevention

Elimination of correctable risk factors can decrease the risk of recurrence in subsequent pregnancies. Two of the most notable correctable factors are smoking and cocaine abuse. Education about the risks of

these behaviors and about cessation or rehabilitation programs may help prevent future abruptions. If a patient was abused, preventing further abuse is an important consideration. Because of the potential association with thrombophilias, a patient found to have a thrombophilia who

had a severe or early abruption, especially with death of the fetus, is usually treated with heparin anticoagulation therapy during the following pregnancy and for 6 weeks' postpartum, though, at present, little evidence has demonstrated that this measure decreases the risk of recurrence.

Complications

Fetal Death Issues related to prematurity

Maternal Death Transfusion-related morbidity Classic cesarean delivery with need for repeat cesarean deliveries Hysterectomy

NURSING IMPLICATION:

Nursing implications are listed below.

(1) Implement all nursing measures for a patient on complete bed rest.

(2) Monitor peri-pads for amount and character of vaginal bleeding.

(3) Be knowledgeable of local laws which support legal abortions.

(4) Refer questions of legal abortions to immediate supervisor so further counseling can be offered to the mother.

(5) Assess the mother's emotional and spiritual needs.

Nursing Management:1. Continuous evaluate maternal and fetal physiologic status, particularly:

Vital Signs Bleeding Electronic fetal and maternal monitoring tracings Signs of shock – rapid pulse, cold and moist skin, decrease in blood pressure Decreasing urine output Never perform a vaginal or rectal examination or take any action that would stimulate

uterine activity. 2. Asses the need for immediate delivery. If the client is in active labor and bleeding cannot be stopped

with bed rest, emergency cesarean delivery may be indicated. 3. Provide appropriate management.

On admission, place the woman on bed rest in a lateral position to prevent pressure on the vena

cava. Insert a large gauge intravenous catheter into a large vein for fluid replacement. Obtain a blood

sample for fibrinogen level. Monitor the FHR externally and measure maternal vital signs every 5 to 15 minutes. Administer

oxygen to the mother by mask. Prepare for cesarean section, which is the method of choice for the birth

4. Provide client and family teaching. 5. Address emotional and psychosocial needs. Outcome for the mother and fetus depends on the extent of

the separation, amount of fetal hypoxia and amount of bleeding.

PROGNOSIS:The prognosis for cases of placental abruption varies, depending on the severity of the abruption. The risk of death for the mother ranges up to 5%, usually due to severe blood loss, heart failure, and kidney failure. In cases of severe abruption, 50-80% of all fetuses die. Among those who survive, nearly half will have lifelong problems due to oxygen deprivation in the uterus and premature birth.

The risk of recurrence of abruptio placentae is reportedly 4-12%. If the patient has abruptio placentae in 2 consecutive pregnancies, the risk of recurrence rises to 25%.

If the abruption was severe and resulted in the death of the fetus, the risk of a recurrent abruption and fetal demise is 7%.

Reference:

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