“Placental Abruption” – with Dr. Andrei Rebarber

In this episode of Healthful Woman, Dr. Nathan Fox speaks with Dr. Andrei Rebarber regarding placental abruption. This uncommon yet serious pregnancy complication occurs when the placenta partly or totally separates from the inner wall of the uterus before delivery. This can decrease or block the baby’s oxygen and nutrient supply, and cause heavy bleeding in the mother.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health, at all stages of life. I am your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, Dr. Andrei Rebarber, Elvis, welcome back to the podcast. How you doing?

Dr. Rebarber: Hi, Dr. Fox. Pleasure to be here. I don’t think anybody understands why you call me Elvis, but we’ll keep that as a private conversation.

Dr. Fox: Oh, it’s all good. It’s all good.

Dr. Rebarber: Yeah.

Dr. Fox: Well, we are in the same ZIP code, but we’re in different offices. Once again, we’re not podcasting in person. The security forces of MFM Associates wants to keep us separate at all times.

Dr. Rebarber: Exactly.

Dr. Fox: You know?

Dr. Rebarber: For the safety and the welfare of the practice we cannot be in the same location.

Dr. Fox: It’s all good. We do need a Secret Service. That’d be unbelievable.

Dr. Rebarber: Oh, God. No, we don’t. Hopefully not, not in New York City.

Dr. Fox: Not in New York City. All right… No, just because it looks cool. Not because we need protection.

Dr. Rebarber: Yeah.

Dr. Fox: All right, so we’re talking today about placental abruption, also known as abruptio placenta, if you like it in the Latin.

Dr. Rebarber: The Latin.

Dr. Fox: In the Latin. We do a lot of things in the Latin medicine, which somehow stuck. So placental…yeah.

Dr. Rebarber: Yeah. Well [crosstalk 00:01:29.125] is a secret code for doctors, so that way nobody could understand what we were saying, you know?

Dr. Fox: Yeah.

Dr. Rebarber: But now we’ve modernized it, so we try to make it simple for everybody, so we all understand what we’re doing.

Dr. Fox: We do our best. Yeah, so this is something that comes up I guess relatively frequently as either an actual diagnosis, or a possible diagnosis, or a fear of a diagnosis, and I thought it’d be a good topic to cover on the podcast for people, because it’s definitely something that people read about, and have some confusion about. So thank you for joining me. I could not think of someone better to talk with about placental abruption. You are the specialist. Good job.

Dr. Rebarber: Thank you. Yes. I mean, again, I think we see a lot of it in our practice, and a lot of it has to do with the nature of our practice, because we have a higher risk population. It actually is a relatively rare phenomenon that occurs probably under 1% of the time. But you know, again, there are certain risk factors that could predispose toward the development of this, maternal and baby risk factors, and we tend to see them a lot because we end up taking care of a lot of these patients.

Dr. Fox: Yeah.

Dr. Rebarber: So, yeah. I mean, I guess to start out, what is placental abruption?

Dr. Fox: Yes.

Dr. Rebarber: You know, to define it for everybody, it really presents with vaginal bleeding and abdominal pain, but it’s sort of defined as early separation of the placenta, and usually it’s defined as occurring after 20 weeks. We do see bleeding, abdominal pain, and early separation of the placenta before that, but often it’s regarded as sort of a miscarriage, and that’s kind of why it starts at 20 weeks. Preterm labor starts at 20 weeks, abruption of the placenta starts at 20 weeks, the diagnosis of preeclampsia, which is a syndrome of high blood pressure and leg swelling also starts after 20 weeks, in general. So, you know, 20 weeks is kind of a benchmark in obstetrics that we use for a lot of these conditions, and under that, it’s usually defined as either a preexisting condition, like chronic hypertension or preeclampsia, or these others, preterm labor abruption, are related to more so just regarded as a miscarriage, essentially.

But the mechanism…it’s a rather arbitrary cut off, and the mechanism is probably very similar in both, as far as just early separation of the placenta from the wall of the uterus, from the mother.

Dr. Fox: Yeah, I tell people very similarly that the same thing might happen, and if you’re 28 weeks we’re going to call it a placental abruption, and if you’re 14 weeks, we might call it bleeding, and a subchorionic hematoma, or something like that. But technically, it’s the same thing. And when I try to explain to people, like, what does that mean, a premature separation, I mean, in the normal course of events, you know, what typically happens is the placenta is sort of, like, stuck on or latched on to the inside wall of the uterus, and has to be attached there because there’s blood flow coming to it, and that’s how the baby gets nutrients and oxygen and water from the mom, going to the baby. Fine.

And then what normally happens is end of pregnancy, the baby’s delivered, whether that’s vaginally or by C-section, we clamp the cord, we cut the cord, and then sometime thereafter, whether it’s one minute or ten minutes or twenty minutes or whatever it is, the placenta starts to shear off from the wall of the uterus, partially, then completely, and then it comes out. That’s what normally happens.

And basically, a placental abruption is when it happens in reverse order. The placenta starts to shear off either before labor, or in labor, before the baby’s born, and that’s sort of what it is, conceptually. And again, that could happen at the end of pregnancy, it could happen in the middle of the pregnancy, it could happen early in pregnancy, but what we call it sort of depends on how far pregnant she is.

So that’s what happens, essentially.

Dr. Rebarber: Yeah, I mean, it’s interesting. I mean, the placenta itself actually is thought to actually implant in two stages, and that secondary stage, not in the first trimester, but in the early second trimester becomes really critical for it to kind of really attach deeply. The cells of the placenta burrow themselves into the wall of the uterus, and it creates kind of a low-resistance system where blood bathes that area of the placenta where it’s in contact with the maternal circulation. And so by going from a pretty high-resistance system to a low-resistance system, because it actually invades into the wall of the artery, it’s thought that that actually allows for healthy implantation and healthy oxygenation of the placenta. And some of the theories are that you have abnormal implantation during that secondary invasion, during that second stage, and that creates shallow implantation, and makes it more susceptible to abruption.

And so a lot of placental-mediated disorders, so placenta seems to be very central to sort of the long-term health of the pregnancy, and when you have either placental abruption, or poor growth, even associations with stillbirth, preterm labor, they all seem to be associated with this very…and preeclampsia, of course, is associated with a very shallow invasion, poor attachment of the placenta, and that lends itself to these multiple obstetrical complications.

So it seems that the key is in this period of time between sort of 12 to 14, 15 weeks, when the placenta is really establishing its attachment deeply into the maternal circulation.

Dr. Fox: Yeah, and as you said, there’s a lot of overlap between those conditions that are mediated by the placenta, you know? There’s fetal growth restriction, and there’s preeclampsia, and there’s abruption, and the worst case scenario, stillbirth, again, usually preceded by one or all of those other three. And some of the risk factors overlap between them. Having one is a risk factor for the other, having one in a prior pregnancy is a risk factor for the other, meaning there’s something about the placenta not attaching right, whatever that means exactly, that can manifest in many different ways, in different pregnancies.

And one of the other variables is placental abruption is not all or none. Meaning it’s not like the placenta either entirely separates, or doesn’t separate at all. You can have situations where it separates just a small amount, or separates a moderate amount, or separates a severe amount, and those mean different things to us, and they manifest differently.

Dr. Rebarber: Yeah. I mean, so again, if you’ve had bleeding in two trimesters, or you know, hypertension, sometimes, you know, certain medicine that you use, or cocaine use, cigarette smoke, these are all risk factors to develop this implantation problem, we believe, and that is associated with sort of an increased risk for abruption. And what’s interesting is when abruption occurs, there’s sort of bleeding at this interface between the mother’s wall and the placenta, and it could be focal and localized, or what we call a partial abruption, and then you can also have a more massive event, and it shears off more than 50% of the placenta. That could be associated with significant complications for the baby and the mother. And sort of the breakdown of that, most of the time it’s focal, and not so severe, but we do see that ever so often, again, depending on risk factors.

And what’s interesting is that when this abruption event occurs, there’s a chemical called thrombin that gets generated, and that is actually one of the most potent agents that causes uterine contractions. And if you think sort of biology-wise, it makes a lot of sense because at this point, the uterus is basically trying to expel the fetus to save itself from bleeding, essentially. And so the body is built to actually save the mother by generating chemicals that actually induce preterm labor in the setting of an abruption.

Dr. Fox: Yeah and I think that, again, there’s such a wide range of what abruption means, right? When we say someone had an abruption, you know, people think different things, but in our mind, we’re not really sure. It could be a very small amount of bleeding, that has minimal consequences. It could be a huge hemorrhage, which has massive consequences, and everything in between, of course. It could be a lot of these things. And sometimes when we’re talking about risk factors, and placental invasion, and that’s sort of, you know, the kind of abruption that we can sort of understand from a pathophysiologic, sort of chronic setting with recurrence…but occasionally it happens just from something like trauma, in a situation where the placenta was perfectly healthy before.

Dr. Rebarber: Yeah. I mean, certainly motor vehicle accidents are notorious, acceleration, deceleration effects, where you basically create this sort of shearing force on the placenta. But that’s why whenever people do get into car accidents, a lot of times most doctors, even if the mother’s feeling well, wants you to be observed in a hospital setting for a more prolonged period of time because there could be delay in the event, or if it’s very focal or small, we’re not going to be able to see it on ultrasound. So, you know, observation for 24 hours after any kind of trauma to the abdomen or motor vehicle accident is always much safer in a hospital setting, in case this were to occur.

Dr. Fox: Yeah, and there’s different criteria. It’s sort of based on how significant the accident was, based on whether she is or is not contracting, is or is not bleeding, sort of the amount of time one’s going to be monitored, and that ranges from a small amount of time, to up to 24 hours. But again, that really…it depends on the circumstances. But in all those circumstances, we’re going to start with some sort of assessment, by questioning, and symptoms, and then potentially move on to more, I guess, direct observation and monitoring, and the length of time is going to vary.

So the risk factors that we mentioned, we mentioned having hypertension as a risk factor, we mentioned certain substance use, like cocaine or smoking can be a risk factor, we mentioned if the baby is small, if there’s fetal growth restriction, that’s a risk factor. But the biggest risk factor is having it in a previous pregnancy. And why might that be?

Dr. Rebarber: Well, it’s interesting that, you know, if you’ve had a history of abruption, there’s about a 15% recurrence rate. If you were born small for gestational age, or you have a sibling that was born small for gestational age, you have an increased risk for abruption. So what’s interesting is that there probably is some genetic component to this, but we don’t know exactly what that is. And it clearly is not sort of universal. Most people, even if they had an abruption, they don’t have it again. But the recurrence rate is about 15%, and there are risk factors along families, or personal history of that, that may be relevant to sort of your risk.

Dr. Fox: So if someone is experiencing an abruption, what would it look like clinically? I mean, what would either she experience, or what would we see?

Dr. Rebarber: So most of the time, you’re really going to see 80% of the time it comes in patients coming in with abdominal pain and bleeding. That’s sort of your classic presentation. Sometimes what you’ll see is that the uterus doesn’t actually ever relax. The tone of the uterus is firm and rigid, and that may be where there’s a significant amount of blood that’s already extravasated, and you can have sort of constant contraction or pain, not kind of cyclical preterm labor pain. So those are more the severe end, but that’s what you would see.

And then, obviously, depending on the extent of the abruption, patients may have, you know, hypotension, the heart rate of the fetus may be abnormal, in the pattern that’s consistent with a distress situation. And then rarely, it could get even worse, that the mother goes into shock from excessive blood loss.

Dr. Fox: Right. And then what about in terms of blood tests or ultrasound? Are those routinely part of the diagnosis of a placental abruption?

Dr. Rebarber: So nothing is really what we call diagnostic, and the correlations of blood tests and ultrasound can be poor. Ultrasound really is meant to see large abruptions or tears in the placenta, and so often you may see a retro-placental hematoma or clot, and that could indicate an abruption is occurring, but you really, you can’t always pick up smaller abruptions.

As far as the laboratory issue, classically, people did something called a Kleihauer-Betke test, which was a test that looked for fetal maternal bleeding. So in the setting of abruption, not only do you have mother’s blood bleeding out, but sometimes fetal blood enters the maternal compartment of the maternal circulation because there’s a break in the fetal maternal interface because of the abruption. But it really has a poor correlation, and at the end, it may not be as useful as we thought, so a lot of people don’t really use Kleihauer-Betke that much as either a negative or a positive. Positive may be more helpful, particularly with the clinical presentation, but a negative does not completely rule out an abruption. So therein lies the problem with the K-B test, as we call it, with the Kleihauer-Betke test.

And then, some people use just coagulation factors as a marker, particularly fibrinogen levels dropping and things of that sort, but that’s often just associated with bleeding and blood loss more than specifically abruption.

So there aren’t really great findings, but we do use some of these tools. Most of this is still a clinical diagnosis, based on how patients are presenting, what their history is, and a physical exam. And anytime somebody’s bleeding in the third trimester, unless you actually see a source of bleeding in the lower genital tract system, it’s considered abruption until proven otherwise. So it’s sort of a diagnosis of exclusion.

Dr. Fox: Right. I mean, essentially, if someone comes in bleeding in the third trimester, the things that we’re going to think about, you know, abruption is going to be frequently on the list, a placenta previa, if we haven’t ruled it out before, and we had a podcast on that. Sometimes, as you said, there could be some sort of laceration that could be bleeding, and sometimes people bleed in labor, although the amount that they bleed and why they bleed sort of varies. And so it is, it’s usually a clinical diagnosis. If they’re bleeding, and we can’t see another reason or think of another reason, we usually either call it an abruption, or assume it’s an abruption, or sort of behave as if it’s an abruption, just in case. And I would say that, again, a lot of times, what we do is based on the severity, how much bleeding, whether there’s heart rate abnormalities, and whether she’s contracting or not. But if we don’t find another reason for bleeding, often we’re going to be thinking about abruption, or at least doing all the things we would do for an abruption.

Dr. Rebarber: Yeah. I mean, there are… Like in early labor, you may have spotting or staining, mild bleeding just as the cervix is changing, passing the mucous plug, but that’s very different than when you’re suspecting abruption. A placenta previa, you hope you ruled that out at scans earlier, but that’s a basic, you know, consideration, because if the placenta is covering it… Uterine rupture, people have described the uterus rupture as somebody who is trying for labor, with feedback that they’ll have vaginal bleeding, but those are more rare conditions. And again, it’s sort of a diagnosis of exclusion. You’ve got to think of everything else, and then go down this road.

Dr. Fox: Yeah. I think one of the very difficult situations is in the situation of a placental abruption when there isn’t bleeding. Because if someone has contractions, and they’re not bleeding, it’d be very difficult to know they’re having an abruption unless the bleeding is so significant and concealed that you could see it on ultrasound, which is, as you said, unusual, or that it changes their other blood test parameters, which is, again, unusual that it would remain concealed. And I guess, probably the only way to know best is if there’s contractions with significant heart rate changes in the baby to sort of diagnose an abruption, as opposed to just contractions, preterm contractions, preterm labor without clinical bleeding. It’s a very difficult diagnosis to make if there isn’t bleeding.

Dr. Rebarber: Yep. And a certain percentage, like one-third of them actually occur in labor itself. So some will occur antepartum, where they’ll occur before you go into labor, but in labor it gets even more challenging, as far as there’s a cervical change, is it bleeding, but do you continue with the labor, do you continue with emergency C-section? So again, some of it could be quite challenging to manage when you’re in labor and abrupting, versus not in labor. But that’s when the placenta is most challenged, because as the uterus starts to contract, it generates a lot of force against the placenta, and so it’s not uncommon to see that occur in labor, particularly in the setting of a damaged placenta. If somebody’s been chronically smoking, or potentially a small baby that wasn’t growing well, with a damaged placenta, that abruption is not uncommon in a labor setting, where things were stable before.

Dr. Fox: And I think just for our listeners, the reason it matters if the placenta separates early, it tends to be two things happen. Number one, when the placenta separates, there’s bleeding, and now this bleeding is maternal bleeding. It’s not typically the baby’s blood, it’s the mother’s blood. So if there’s a lot of bleeding, that’s unsafe to the mother, obviously. And number two, if she’s preterm, the bleeding, as you said, can lead to contractions, can lead to premature labor, and premature birth.

So like, problem number one is the fact that it causes bleeding. But problem number two is even regardless of the bleeding, if the placenta is separating, the portion of the placenta, whatever amount of the placenta has separated from the uterus, it’s no longer functional. It can’t do what it’s supposed to do, which is transfer nutrients back and forth. And so if a third of the placenta is separated, not only do you have bleeding from it, but now you’re missing, so to speak, one-third of your placenta from doing the job. And that’s why we frequently see fetal heart rate changes if they’re in labor, or if it’s a chronic situation, the babies might not grow as well.

And so it’s sort of a twofold process, and then on top of it, it could also…having any bleeding can sort of lead to further abruption, and can just make the whole process worse.

Dr. Rebarber: Yep.

Dr. Fox: All right, so when someone has an abruption, and all these things can happen, what do we do when we see them?

Dr. Rebarber: Well, a couple of things. You first have to you have to… You have two patients, so you have to make an assessment of both patients. So the first patient, is the mother stable or unstable? And then, after you make that assessment, then you make the assessment is the fetus alive and stable, or not stable? So you can have an unstable mother, with a demised fetus, and you can have a stable mother, with a live fetus. And so you really want to assess on that spectrum what each of your patients are doing. And once you’ve decided that the fetus is alive, you will then assess how reassuring is its status to still stay and remain inside the uterine environment? And all that depends also on what tools you have, based on the gestational age.

So in general, if we suspect abruption under 34 weeks, we generally will try to keep the pregnancy going longer, if things are stable, and the fetus is stable to stay inside. After about 34 weeks with abruption, most people will deliver, and certainly after 36 weeks, if abruption is suspected, 99% of people will just deliver at that point, we recommend delivery. And in that delivery, it doesn’t mean C-section. Sometimes we have to induce people, but that doesn’t mean…and vaginal delivery is definitely preferable to the patient, if possible. But once there’s evidence of abruption, there can be a higher risk for a more massive abruption in labor, if you labor somebody with an abruption. So close monitoring, having anesthesia available readily, and patients being aware they do have a higher chance for a C-section because the abruption can expand in labor. But that’s kind of how I approach it.

Dr. Fox: Right. So if they’re…so let’s break it down. If they’re, let’s say…well, let’s start with someone who’s premature, right, the under 34 weeks, and we’ll say we’re talking about…let’s talk about the third trimester, so the baby’s potentially viable. So let’s say after 24-ish weeks, 23-ish weeks, whatever it is, depends on the circumstances, ’til about 34 weeks, if we suspect an abruption, obviously at any point if the mother is unstable, then essentially you don’t have a choice. You have to do a delivery, you have to sort of, you know, remove the placenta, and sort of make sure that she’s okay. Fortunately, that’s not so common. But if she’s unstable, there really isn’t an option to try to continue the pregnancy.

Dr. Rebarber: Yeah.

Dr. Fox: Good. Agreed.

Dr. Rebarber: Agreed.

Dr. Fox: Right, agreed. If she’s stable, then you have to sort of assume or assess if the baby’s okay or not. And if the baby’s okay, and the mother’s okay, like you said, we’ll do our best to prolong the pregnancy as much as we can. And number two, during that time period, there’s things that we do, and we’ve mentioned this on other podcasts related to preterm birth, or PPROM, or whatever it is, things like giving steroids, things like giving magnesium potentially, again based on the circumstances, to prepare for a possible or likely preterm or premature birth. And so we might do those things, and then watch her very closely, and the baby very closely. Because again, she could get worse, the baby could get worse, and if either of those happen, then generally, you can’t continue to watch expectantly. So that’s in the preterm period.

Dr. Rebarber: And we also do an assessment of the fetus in the sense of the actual weight, the amount of fluid that’s around the baby, just in case delivery were to happen. Growth restriction or poor growth can often be associated with the placenta that’s abrupting, mother’s blood pressure, and certain labs because preeclampsia can occur at a higher rate in the setting of an abruption, or may be the cause for the abruption. So you want to assess for some of these other conditions that often come along, or pregnancy-related risks associated with abruption.

Dr. Fox: Now, does she have to be in the hospital for this whole time, under 34 weeks?

Dr. Rebarber: We would recommend at least a 72 to 96-hour period of observation, and then once things are stable, depending on the risk factors, determine if outpatient management can be done, knowing that they are at pretty significant risk of recurrent abruption in the same pregnancy. Also, you want to assess how far do patients live from a hospital setting, and make sure they’re reliable enough that if they were to have a recurrence, how quickly they can get to a place that could deliver a baby, particularly a premature baby. So you really want to take it on a case-by-case basis. Most of the time, patients, when the course is self-limited, a partial focal region of an abruption and everything else is stable, and we’ve got about three four days under our belt, and everything is not…it’s stable, and nothing has recurred, those are the patients we have managed as outpatient.

Dr. Fox: Right. It’s not exactly the same, but there’s a lot of similarities for someone who has bleeding with the placenta previa. And generally, you know, sometimes it’s, you know, heavy bleeding, or on and off bleeding that never stops, in which case it’s very hard to manage as an outpatient. And sometimes they get a bleed, and it stops, and then they don’t bleed for two or three days, and then it’s an individualized decision, if that’s someone who’s safe to go home or not. Again, it’s totally individualized because it depends on so many variables, but that’s frequently sort of the decision process that’s made.

Now, after 34 weeks, it’s almost similar, like, whether to deliver right away, or whether to wait a little bit more, again, often depends on the exact circumstance. Have they been bleeding on and off the whole pregnancy, has it just happened once? Is it heavy, is it light, did it stop, you know? And so that’s why there is, like you said, some variation about whether someone’s going to be delivered at 34 or 35. But if someone’s bleeding, and we think there’s an abruption, very unusual that you’re going to wait too long, and so, you know, at 36-plus, or 37 weeks, or something in that range, pretty much everyone’s going to get delivered, just because the benefit of waiting goes down. But there’s always a risk of waiting, and it probably goes up as you get closer to term, but also the benefit seems to go down, because the baby’s already, you know, full term at that point.

Dr. Rebarber: Yeah. I mean, that’s why I think, you know, you really have to gauge the patient, their situation, their clinical history. For example, if they’ve had two abruptions, they’re likely for recurrence for an abruption is at least, like, 25%, 30%. So, you know, if somebody has a history of abruption, and now is abrupting in their second pregnancy, and you find yourself at 34 weeks, 35 weeks, it just doesn’t make a lot of sense to wait on somebody with that history, particularly if it was a severe abruption. Whereas if somebody has the first time, and she’s pretty low risk, and it was just self-limited, and it was very light, and it’s better now, and you know, everything is reassuring about the mother and fetal status, it just may make a lot of sense to kind of consider waiting until 37 weeks, and then just deliver at that point.

But either way, we would deliver them…we wouldn’t wait. If they had evidence of an abruption at some point in the pregnancy, and you did expect to manage it with them, and now they got to 37, 38 weeks, you wouldn’t really want to go past 38 weeks with them, or 39. I generally deliver between 37 and 38 weeks in these cases, because of their risk of recurrent abruption in their next pregnancy, even if everything is stable.

Dr. Fox: Right. So what would you do for someone, let’s say they come to you in the beginning of pregnancy, and they say, “Last pregnancy I had a placental abruption, I was in and out of the hospital, and I ended up delivering at 34 weeks,” or whatever their story is, but it was an abruption. Either you know about it because you took care of her, or her story and her history is pretty obvious that that is what it was, what would you do in the next pregnancy that you wouldn’t, let’s say, normally do?

Dr. Rebarber: So, you know, there really has…no proven measure has been described that basically reduces the risk of recurrent abruption. Having said that, I mean, there are modifiable risk factors, like particularly smoking cigarettes, or cocaine use, that are modifiable, and that may decrease the risk. Poorly controlled hypertension [inaudible 00:28:40] diabetes, I mean again, you want to control medical conditions. And then, possibly certain, you know, obstructive conditions in the uterus, like let’s say a submucous myoma, if there’s a fibroid that’s actually impinging into the uterine cavity, and the placenta happens to implant on that fibroid in the uterine cavity, there’s some data that there may be an increased association of abruption. So removing the fibroid, knowing that it’s there might be helpful if somebody has a history of this situation.

Outside of that, there isn’t that much people do. I do like to look at the placenta pathology, and I want to see what the baby’s weight was. You want to get a better sense of how that pregnancy went otherwise. If there are signs of poor placentation, or damaged placenta, some people have sent clotting workup. A clotting workup particularly includes, you know, really the antiphospholipid antibodies, most people are not sending a genetic thrombophilia, but just the acquired thrombophilia. So particularly preterm abruptions, there are some, depending on the placenta and the fetal growth, that may send antiphospholipid antibodies, but that’s about it.

And then treatment-wise, some people have considered using baby aspirin, though trials have not shown clear benefit to that.

Dr. Fox: And then, how do you monitor them in the pregnancy, assuming you didn’t find a cause, and everything seems to be otherwise okay?

Dr. Rebarber: Yeah, I mean, in general, we tend to see these patients more frequently.

Dr. Fox: Closely. Yeah.

Dr. Rebarber: Exactly. They want to be seen every other week, often just to check the heartbeat, make sure things are going well. We do ultrasounds to check growth every four weeks, starting at around 20 weeks or so. And then outside of that, maybe what we call continual testing, or surveillance, which either includes something called a non-stress test, or it could be a biophysical profile. Some people use one, some people use another. The non-stress test is actually where they put the baby on a monitor, and follow the heart rate, and measure contractions. The biophysical profile is a test that looks at fetal wellbeing by using an ultrasound, which looks at four parameters of fetal wellbeing, the amniotic fluid, fetal movement tone, and fetal breathing, with your parameters of good fetal oxygenation.

So people will start that weekly, around 32 weeks, though again, there’s a lot of variation on when to start that, depending on the timing of the abruption, and the severity of it. More severe abruptions, particularly ones that resulted in neonatal demise, have a higher recurrence rate, and we tend to actually start surveillance and weekly visits two weeks prior to when the abruption occurred. But again, it all varies based on gestational age, and the clinical picture.

Dr. Fox: All good. All right, Andrei covered the abruption. Thank you.

Dr. Rebarber: Yeah, we did good? All done?

Dr. Fox: We did good. All done. You can go back to work now.

Dr. Rebarber: Okay. Thank you.

Dr. Fox: Thanks for coming on.

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