 Abruptioplacenta

 Abruptio or abaltio placenta and accidental hemorrhage,the letter term being

that commonly used in british medicine ,are used synonymously to describe
this complication.
 Because of it’s comparitivly high mortality and morbidity, premature
separation of the placenta is considered the most serious complication of
pregnancy. Recorded experience from several sorces document the fact that
in the more sever form of premature separation the maternal mortality may
approximate 10 percent. Fortunately,in 85 to 95 percent of the cases only a
relatively small area of the placenta is detached and the clinical course is
comparatively benign. With the present day facilities to treat this
complication,the overall maternal mortality shoud be less than 1 percent.
 The overall incidence is about 1 in 200 deliveries. More and more cases of
placental abruption are being diagnosed in recent year.
 Bleeding is almost maternal but placental tear may cause fetal bleeding.

 Definition
This is a condition of premature separation of normally situated placenta on
the upper uterine segment leading to antepartum haemorrhage.

 Varieties

1. Revealed: Following separation of placenta,the blood insinuate

downward between the membrane and decidua. Ultimately, the
blood comes out of the cervical canal to be visible externally.
This is the commonest type.

2. Concealed: The blood collects behind the separated placenta or

collected in between the membranes and decidua. The collected
blood is prevented from coming out of the cervix by the
presenting part which presses on power segment . At time, the
blood may percolate into the amniotic sac after rupturing the
membranes. In any of the circumstances blood is not visible
outside. This type is rare .
 3. Mixed:In this type ,some part of blood collects inside
(concealed) and a part is expelled out (revealed) usually one
variety predominantes over the other. This is quite common.

 Clinical classification
Dependingupon the degree of placental abruption and its clinical effects,.
Thecases are graded as follows.

 Grade 0: clinical features may be absent . The diagnosis is Made

afterinspection of placenta following delivery.

 Grade 1: vaginal bleeding is slight ,

Uterus: irritable, tenderness may be minimal or absent,
Maternal BP and fibrinogen level unaffected,
FHS is good.
  Grade 2: vaginal bleeding mild and moderate,
Uterine tenderness is always present,
Maternal pulse is high, BP is maintained,
Fibrinogen level may be decreased,
Shock is absent,
Fetaldistrees or even fetal death occurs.
 Grade 3: bleeding is moderate to severe or may be concealed,
Uterinetenderness is marked ,
Shok is pronounced,
Fetal death is the rule
Associated coagulation defect or anuria may complicate.

 Etiology

The prevalence is more with…..

1. High birth order pregnancies with gravida 5and above-three times
more common than first birth.
2. Advancing age of the mother,
3. Poor socio-economic condition,
4. Malnutrition,
5. Smoking.

 Hypertension in pregnancy is the most important predisposing factor. Pre-

eclampsia, gestational hypertension and essential hypertension ,all are
associated with placental abruption.

The association of pre-eclampsia in abruptio placenta varies from 10-50

percent.

The mechanism of the placental separation in pre-eclampsia is:spasm of the

veesels in utero placental bed (decidual spiral artery) leads to anoxic
endothelial damage and than rupture of vessels or extravasation of blood in
the decidua basalis (retroplacental haematoma).

 Trauma:Traumatic separation of placenta usually leads to its margial

separation with escape of blood outside. The trauma may be due to:

 Attempted external cephalic version specially under anaesthesia using

great force
  Road traffic accident or blow on the abdomen
 Needle puncture at amniocentesis.

 Sudden uterine decompression: sudden decompression of uterus leads to

dimished surface area of the uterus adjacent to the placental attachment and
result in separation of placenta. This may occur following-
 Delivery of the first baby of twins,
 Sudden escape of liquor amnii in hydramnios and
 Premature rupture of membranes .

 Supine hypertension syndrome: The weight of the term uterus on the

inferior vena cava and pelvic veins when the patient is in supine position is
thought to raise venous pressure in uterine veins and intervillous space
sufficient to detach the placenta through the mechanism of a retroplacental
hematoma formation.

 Short cord: the placenta may be separated during the second stage of labour
either because of short umbilical cord that pulls the placenta down during the
expulsion of the fetus,or because of strong membrane (delayed rupture): the
delivered membrane pull the placenta .The placenta may be separated
prematurely in twin birth after the delivery of the first foetus.

 Sick placenta, cocaine abuse and prior abruption are also create placental
abruption.

 Pathology

 In mildcases(revealed type):A small blood clot can be adherent to the

maternal surface of the placenta and on separation of the clot,the area is
found to be depressed in placental maternal surface.

 In severe concealed type ( couvelaire uterus) :First described by

couvelaire,1912 the retroplacental clot is large one,over and above,there are
muscular and vascular injuryes in the uterine wall especially at the site of
placental attachment.

There are haemorrhagic infiltration from capillaries in the uterine

musculature,oedema on the serous surface, sometimes,free blood can be
found in the peritoneal covering of the uterus,and necrosis in the muscles and
also ecchymcses.this condition leads to uterine distension and atony.
 However ,the condition seldom interferes with uterine contractions to produce
sever PPH.

Thisy be further associated with haemorrhage in other sites,e.g.,broad

ligaments , fallopian tube , ovary ,liver , gastric mucosa ,suprarenals
,endocardium.

Diagnosis of cauvalaire uterus is made on laparotomy. Treatment is same as

concealed abruptio placenta.

Appearance of placenta following deliveryCouvelaire uterus

Clinical features of abruptio placenta

 Theinical features depend on: degree of separation of placenta,Speed at

which separation occurs and amount of blood concealed inside the uterine
cavity.but they may be very deceptive in posteriorly implanted placenta. The
clinical features of revealed and mixed varity are given in tabulated form.

Revealed Mixed
(Concealed features
predominant)
 Revealed Mixed
(Concealed features
predominant)

Symptoms:. Abdominal discomfort or Abdominal acute intense

pain follwed by vaginal pain follwed by slight
bleeding (usually sight) vaginal bleeding.the pain
become continues.
Character of bleeding: Continuous dark colour Continuous ,dark colour
(Slight to moderate) (usually slight )or blood
stained serous
discharge.

Pallor: Related with the visible Pallor is usually severe

blood loss and out of proportion to
the visible bleeding

General conditions: Proportionate to the Shock may be

visible blood loss ,shock pronounced which is out
is usually absent of proportion to the
visible blood loss
Feature of pre May be absent
eclampsia: Frequent association
Proportionate to the May be
Uterine height: period of gestation disproportionately
enlarged and globular

Uterine feel: Normal feel with localised Uterus is tense ,tender

tenderness, contractions and rigid
frequent and local
amplitude

Fetal part: Can be identified easily Difficult to make out

FHS: Usually present Usually absent

Urine output: Normal Usually diminished

Laboratory:

Blood:HB% Low value proportionate Markedly lower,oit of

to the blood loss proportion to the visible
blood loss
Coagulation profile: Usually unchanged Variable changes:

Cloting time
increased(>6min)

Fibrinogen level
low(<150mg/dl)
 Revealed Mixed
(Concealed features
predominant)

Platelet count low

Increased partial
thromboplastin time

Increased FDP and

D-dimer

Urine for protein: May be absent Usually present

 Diagnosis
 Mainly clinical . Ultrasonography or MRI may be helpful.

 Ultrasonography:Early haemorrhage is hyperchoic or isechoic. Acute

haemorrhage is often confused with a fibroid,or a thick placenta.however,ever
negative finding with USG examination do not exclude placental abruption.

 The essential point to arrive at the diagnosis of the concealed variety

type:.

Shock out of proportion to external bleeding,Unexplained extreme pallor,

Presence of pre eclamptic features,Uterus is tense,tender and woody hard,.
FHS is absent,.
Diminished urinary output,.
Presence of coagulation disorders.

 Differential diagnosis:

1. Revealed type:there may be occasional diagnostic difficulty with

placeta previa.
2. Mixed or concealed type: This variety is often confused with rupture
uterus, rectus sheth haematoma, appendicular or intestinal
 perforation,twisted ovarian tumour,volvulus,acute hydramnios and tonic
uterine contraction.

 Prognosis
The prognosis of the mother and the baby Depends on the clinical type , degree of
placental separation,the interval between the separation of the placenta and delivery
of the baby and the efficacy of treatment.

 Complication
Maternal: revealed type has no maternal death while concealed type carries
mortality of 2.5-6.4 percent concealed reported from various centres in the country.
The factor responsible are as follow.
a) Shock due to haemorrhage and injury to the uterus.
b) Haemorrhage- antepartum , intrapartum and
postpartum
c) Sepsis,
d) Uterine rupture in couvelaire uterus
e) Coagulation defect (5 percent),
f) Anuria, partial pitutary necrosis may develop as a
sequela.
Maternal complication rise when haemorrhage delivery interval in concealed type
riaes more than 10 hours.
Foetal risk:the foetal mortality in revealed type goes about 25percent but in
concealed type it is 100 percent . The chief factor for foetal mortality are prematurity
and anoxia due to separation of the placenta.

 Treatment
At home: the patient is to be treated as outlined in placenta previa and
arrangement shoud be made to shift the patient to an equipped maternity unit as
early as possible.

In the hospital:assessment of the case is to be done as regards:

a. Amount of blood loss,
b. Maturity of the fetus,
c. Whether the patient is in labour or not (ussually labour start)
d. Presence of any complication and
e. Type and grade of placental abruption.
Emergency measures:

i. Blood is sent for haemoglobin and haematocrit estimation, coagulation profile

(fibrinogen level,FDP , prothrombin time , activated partial thromboplastin time
and platelet), ABO and Rh grouping and urine for detection of protein
ii. Ringer’s solutions drip is started with a wide bore cannula and arrangement
for blood transfusion is made for resuscitation.close monitoring of maternal
and fetal condition is done.

Management options are:

a) Immediate delivery.
b) Management of complication if there is any
c) Expectant management (rare).

Immediate delivery:
The patient is in labour : most patients are in labour following a term pregnancy: the
labour is accelerated by low rupture of the membranes. Rupture of the membranes
with escape of liquor amnii accelerates labour and it increases the uterus tone
also.oxytocin drip may be started to accelerate labour when needed.

 Vaginal delivery is favoured in case with :

i. Limited placental abruption
ii. FHR tracing is reassuring
iii. Facilities for continuous fetal monitoring is available
iv. Prospect of vaginal delivery is soon or
v. Placental abruption with a dead fetus.

 The advantages of amniotomy are:

a. Initiates myometrial contraction and labour process
b. Expedites delivery
c. Better compression of spiral artery to arrest haemorrhage
d. Reduces entry of thromboplastin into maternal circulation and thereby
e. Reduces the risk of renal cortical necrosis and DIC

The patient is not in labour:bleedingcontinuous,>grade 1 abruption : delivery either

by induction of labour or caesarean section.
Inducton of labour is done by low rupture of membranes.oxotocin may be added
to expedite delivery. Labour ussually starts soon in majority of cases and delivery is
completed quickly.placenta with varying amount of retro placental clot is expelled
most often simultaneously with the delivery of baby ing.oxitocin10IU IV or IM or
ing.methargin0.2mgIV is given with the delivery of baby to minimise postpartum
blood loss.oxytocics should be used to improve the uterine tone along with along
with blood transfusion.

Caeserian section: indication are:

a. Severe abruption with live fetus
b. Amniotomy could not be done (unfeverable cervix)
c. Prospect of immediate vaginal delivery despite amniotomy is remote
d. Amniotomy failed to control bleeding
e. Amniotomy failed to arrest the process of abruption (rising fundal height)
f. Appearance of adverse features (fetal distrees, falling fibrinogen level,oliguria)

Anaesthesia during caesarean section: regional anaesthesia is generally avoided

when there is significant haemorrhage. This is to avoid profound and persistent
hypotension.
References

1) D.C.Datta's textbook of obstetrics Including perinatology and

contraception ,
Edited by Hiralal Konar,
Seventh edition.

2) A textbook of obestratics and neonatology by professor c.s.dhawn and

recepient of Dr.B.C.Roy ,
Tenth edition.

3) Textbook of obestratics and neonatology revised sixteen edition ,2004

By professor Dr C .S.Dawn.

4) Management of high -risk pregnancy and intensive care of the

neonate.BABSON-BENSON-PERNOLL-BENDA.
Third edition.

5) Textbook of obstetrics.
By V.I. Bodyazhina,.
First published 1983, revised from the 1980 Russian edition,second
printing 1987.