PA AND PP

The third subsidiary hospital

of Zhengzhou University
Guan Yichun
 PA and PP
 PA(Placenta Abruption)
 PP(Placenta Previa)

 They are all the main causes of the

third trimester bleeding
 Placenta Abruption
 PA(Placenta Abruption) : after 20 weeks’
gestation age or at term, the normally
implanted placenta prematurely
separated from the uterine wall,partially
or completely .
 It may cause maternal hemorrhagic shock
,and result in maternal and fetal
mortality.Once the diagnosis
obtianed,the patient should be managed
as soon as possible .
 Epidemiology

 incidence varies from 1 in 86 to 1 in 206

births.

 5-17% after an episode in one previous

pregnancy

 25% after episodes in two previous

pregancies.
 Etiology
 many causes are not apparent
 maternal hypertension, preeclampsia-
eclampsia,chronic renal disease,cociane use
and tobacco use . Placenta abruption history.
 Abdominal trauma
 Rapidly contraction of overdistened uterus

such as rupture of menbrane with

polyhydramnios or delivery of one infant in a
multiple gestation.
 Pathophysiology
 several mechanism are thought to
be important .
 one is local vascular injury ,
another is an abrupt rise in uterine
venous pressure → result in vacular
rupture into the decidua basalis
 Pathology
 Decidua basalis
hemorrhage→hematoma behind the
placenta→placenta partial or
complete separation from uterine
wall
1.In early stage, retroplacental hematoma is small(no
clinical symptoms) →disease may be discovered, when
placenta is examined after labor

2.when hematoma expands →disrupt more vessels

→more separation,reaches the margin of placenta
→the blood may dissect the membranes from the
uterine wall
→appear externally →revealed abruption
→completely retained in the uterus →concealed
abruption (more dangerous)
 Classification
1. Revealed abruption (external
hemorrhage)
bleeding between the membrane and
uterus→escape through the cervix
→appears externally
2. Concealed abruption (internal
hemorrhage)
the blood doesn't escape externally
→retain
between the detached placenta and the
uterus
→concealed abruption
2.Uteroplacental apoplexy
Definition:
In some severe cases ,the wide spread blood
infiltrates the uterine wall,and disrupt the
uterine muscle bundles and arrive the
uterine serosa . we call it uteroplacental
apoplexy,also call it Couvelaire uterus. It can
be demonstrated at C.S . There are purple
eccbymosis on the surface of uterus,
especially near the site of the placenta
attachment.
 2.Uteroplacental apoplexy
 It is a indurated organ that all but loses
its power of contraction.Rarely,Couvelaire
uterus may lead to uterine atony and
massive hemorrhage,which
necessitates aggressive measures such
as selective arterial embolization or
cesarean hysterectomy to control the
bleeding .
 3.Consumptive
coagulopathy
Placenta abruption →consumptive coagulopathy →DIC
→formation of microembolus in vessels of important
organs (such as kidney 、 lungs) →organal dysfunction
 Clinical features
Mild type
(1)revealed abruption or discovered during
delivery
(2)area of abruption ＜ 1/3
(3)with or without abdominal pain 、 no back
pain
(4)not prominent anemia ,without shock
(5)uterus is soft 、 mild tenderness.the size is
proportional to the pregnant weeks.
(6)fetal position and fetal heart sound is clear
Severe type
(1)massive hemorrhage( revealed or
concealed )→ hemorrhagic shock or DIC
(2)area of abruption >1/3
(3)sudden persist abdominal pain 、 back
pain.
(4)with anemia. the degree isn’t proportional
to the amount of external bleeding.
(5)the uterus is plate-like hard .fundus is
elevated highly than that of pregnant weeks.
(6)the fetal position and heartsound isn’t
clear.
(7)if the area >1/2 →fetal distress →fetal
heart sound may disappear.
 Accessory examination
1.Lab tests: blood routine 、 Urine routine
test for consumptive
coagulopathy (TT 、 APTT 、 3p
text)
2.ultrasonography
The significant findings include:
Retroplacental hematoma
The placenta is thicker than normal size
The chorial plate is convex to the amniotic cavity
 Diagnosis
 Clinical feature
 Abdominal pain
 Ultrasonography reveals hypoechioc
area between placenta and uterine
wall
 Labor test manifest hemorrhage or
coagulation failure.At the same time
determine the blood type and
crossmatch.
 Management
1.Correct shock
2.Terminated pregnancy in time
3.Management of postpartum hemorrhage
4.Treatment of consumptive coagulation
5.Prevention of Renal Failure
6.Careful observation during the management
7.Other supporting therapies Anemia
Infection
 1.Vaginal delivery
Indications: Delivered woman with good general
conditions or first delivery woman with mild type
abruption
Benefits (1)Vaginal delivery can avoid the
incisions of abdomen and uterus
(2)with vaginal delivery →vessles may be
contracted sufficiently →serious
hemorrhage can be avoided
Method (1)Artificial rupture of the membrane
(2)use of oxytocin
(3)carefully observe FHR 、 NST 、 maternal
hypertention
 2.C.S
Indications (1)severe type patient .especially first
delivery woman
(2)mild type with intrauterine fetal distress
(3)no progress after amniotomy
(4)the condition of patient is worse
Method:control postpartum hemorrhage
(1)use oxytocin and soft massotheraphy
(2)fresh blood transfusion
(3)ligation of internal iliac
(4)hysterectomy