Abruptio placenta clinical features

Abruptio placenta clinical features

1. ABRUPTIO PLACENTA Anantha Chaitanya J Final Year MBBS BGS GIMS 1

2. Overview Couvelaire Uterus. Pathological Changes In Other Organs. Clinical Classification. Clinical Features . Ultrasonographic Localization. Differential Diagnosis. Complications. 2

3. Couvelaire Uterus Aka Uteroplacental Apoplexy . First described by Alexandre Couvelaire . Associated with Severe form of Concealed Abruptio Placenta. Massive intravasation of blood into uterine musculature upto serous coat. Can only be diagnosed on laparotomy . NOTE : Myometrial Hematoma rarely interferes with uterine contractions following delivery. Therefore, presence of Couvelaire uterus observed during C-section is NOT AN INDICATION FOR HYSTERECTOMY . 3

4. Couvelaire Uterus 4 Gross Uterus is d ark port wine colour which maybe patchy/diffuse. Initially over cornu , spreads over placental site. Sub peritoneal petechial haemorrhage under uterine peritoneum and may extend into broad ligament. Free blood in peritoneal cavity or broad ligament hematoma . Microscopy Uterine muscles over affected areas are necrosed with infiltration of blood and fluid between muscle bundles. Mostly in middle and outer muscle layers. On occasions, serosa splits and blood enters peritoneal cavity. Blood vessels show acute degenerative changes with thrombosis .

5. Couvelaire Uterus 5

6. Pathological Changes In Other Organs Liver : Changes of Pre-eclampsia. Fibrin knots in Hepatic Sinusoids. Kidney : Acute cortical/tubular necrosis [Massive haemorrhage  intrarenal vasospasm]. Shock proteinuria due to renal anoxia [ Disappears 2 days post delivery , unlike in pre-eclampsia]. Blood : Coagulopathy [Excess consumption of plasma fibrinogen due to DIC and retroplacental bleeding]. Overt hyperfibrinogenaemia(< 150mg/dL), elevated FDP and D-dimer. 6

7. Clinical Classification 7 Grade 0 Grade 1 Grade 2 Grade 3 Incidence - 40% 45% 15% Vaginal Bleeding None. None to mild. None to moderate. None to severe. Uterine tenderness None. Slight. Moderate. Severe. Maternal Hemodynamics Stable. Normal HR and BP. Tachycardia & Orthostatic hypotension. Hypovolemic Shock HR>120/min & SBP<80mmHg. Hyperfibrinogenaemia None. None. Mild(>150mg/dL ). Severe(<150mg/dL ). Coagulation Profile Normal. Normal. Mild abnormality. Frank Coagulopathy. Fetal Status Reassuring. Reassuring. Fetal distress/ death. Fetal death.

8. Clinical Features Depends on : Degree of separation. Speed at which separation occurs. Amount of blood concealed in uterine cavity. Diagnosis : Mainly Clinical. USG/MRI maybe helpful. 8

9. Clinical Features 9 Clinical Features Revealed Mixed (Concealed predominant) Symptoms Abdominal discomfort followed by vaginal bleeding. Acute abdominal intense pain followed by slight vaginal bleeding. Character Of Bleeding Continuous dark colour. Continuous blood stained serous discharge. General Condition Proportionate to visible blood loss. Disproportionate shock usually present. Uterine Height Proportionate to Gestational Age. Disproportionately enlarged. Uterus Feel Normal with local tenderness. Tense, tender and rigid. Fetal Parts Easily identified. Difficult. FHS Usually p resent. Absent. Urine Output Usually normal . Diminished.

10. Clinical Features-Laboratory Tests 10 Laboratory Tests Revealed Mixed (Concealed predominant) Hb% Low value, proportionate to blood loss. Markedly lower, out of proportion to the visible blood loss. Coagulation Profile Unchanged. Variable changes. Urine For Protein May be absent. Usually present.

11. Clinical Features-Ultrasonography Early haemorrhage is hypo or isoechoic. Acute haemorrhage is often confused with fibroid or thick placenta. Negative findings do not exclude abruption. 11

12. Ultrasonographic Localization 12

13. Differential Diagnosis 13

14. Differential Diagnosis Essential Features to diagnose concealed type : Shock out of proportion of external bleeding. Unexplained extreme pallor. Presence of pre-eclamptic features. Uterus is tense, tender and woody hard. FHS absent. Diminished urinary output. Presence of blood coagulation disorder. 14

15. Differential Diagnosis-Placenta Previa and Abruptio Placenta 15 Clinical Features Placenta Previa Abruptio Placenta Nature of bleeding a)Painless, apparently causeless and recurrent. b)Bleeding always revealed. a)Painful, continuous, often attributed to pre-eclampsia or trauma. b)Revealed/concealed/mixed. Character of blood Bright Red. Dark coloured. General condition and anaemia Proportionate to blood loss. Out of proportion to visible blood loss in concealed/mixed. Features of Pre-eclampsia Not relevant Present in one third cases.

16. Differential Diagnosis-Placenta Previa and Abruptio Placenta 16 Abdominal Examination Placenta Previa Abruptio Placenta Height of uterus Proportional to gestational age. Maybe disproportionately enlarged in concealed type. Feel of uterus Soft and relaxed. Tense, tender and rigid. Malpresentation Common. Head is high floating. Uncommon. Head may be engaged. FHS Usually present. Usually absent. Vaginal Examination Placenta felt on lower segment. Placenta not felt in lower segment. Blood cots not to be confused with placenta. USG Placenta in lower segment. Placenta in upper segment.

17. Complications 17

18. Bibliography DC Dutta’s Textbook Of Obstetrics, 8 th Edition . Williams Obstetrics, 24 th Edition. 18

19. Thank You 19