ABRUPTIO PLACENTAE

Premature separation of the placenta from the uterus

1. ABRUPTIO PLACENTA PRESENTED BY : DEEPSHIKHA ASSISTANT PROFESSOR M.M COLLEGE OF NURSING,MULLANA

2. INTRODUCTION Abruptio placenta also called   placental abruption , is where the   placenta  separates from the uterine wall prematurely, usually after the 20th week of gestation, producing hemorrhage. It is a common cause of  bleeding during the second half of pregnancy.

3. DEFINITION Abruptio Placentae ( syn . Accidental haemorrhage , Premature placental separation): It is one form of APH where bleeding occurs due to premature separation of normally situated placenta.

4. TYPES OF ABRUPTIO PLACENTA Revealed - After separation of the placenta, the blood insinuates downwards between the membranes and the deciduas and comes out of the cervical canal to be visible externally.

5. Concealed - The blood collects behind the separated placenta or between the membranes and decidua . Collected blood prevented from coming out of cervix by presenting part which presses on lower segment Blood percolates into amniotic sac after rupturing the membrane

6.   Mixed- part of blood collected inside (concealed) and a part is expelled out (revealed).

7. COUVELAIRE UTERUS ( Utero-placental apoplexy) It is a pathological entity first described by Couvelaire and is met with in association with severe form of concealed abruption placentae . There is massive intravasation of blood into the uterine musculature upto the serous coat. Naked eye features Dark port wine color:patchy and diffused Sub peritoneal petechial hemorrhage Free blood may be present in peritoneal cavity

8. Microscopic appearance: Necrosed uterine muscles in the affected part Blood infiltration between the muscle bundle Blood vessels may show acute degenerative changes Muscular dissociation occurs in middle and outer muscle layer

9. INCIDENCE 1 in 200 deliveries Significant cause of perinatal mortality (15- 20%) and maternal mortality (2- 5%)

10. ETIOLOGICAL FACTORS Advancing age High birth order Hypertension in pregnancy Trauma Sudden uterine decompression Short cord Supine hypotension syndrome Placental anomaly Folic acid deficiency Uterine factor

11. Torsion of the uterus Cocaine abuse Thrombophilias Prior Abruption

12. PATHOGENESIS

13. BLOOD COAGULOPATHY: Blood coagulopathy is due to excess consumption of plasma fibrinogen due to disseminated intravascular coagulation and retroplacental bleeding. There is overt hypofibrinogenemia (<150mg/dl) and elevated levels of fibrin degradation products

14. LABORATORY INVESTIGATIONS REVEALED MIXED Blood: Hb% Low value proportionate Markedly lower, out of proportion to the visible blood loss Coagulation profile Unchanged Variable changes: Clotting time increased(> 6 min) Fibrinogen level-low (<150mg/dl) Platelet count-low Increased thromboplastin time Urine protein May be absent Usually present

15. ULTRASONOGRAPHY

16. DIFFERENTIAL DIAGNOSIS Revealed type -: There may be occasional diagnostic difficulty with placenta previa. Mixed or concealed type- this variety is often confused with: Rupture uterus Rectus sheath haematoma Appendicular or intestinal perforation Twisted ovarian tumour Volvulus Acute hydramnios Tonic uterine contraction

17. E ssential points to diagnose the concealed variety are: Shock out of proportion to external bleeding Unexplained extreme pallor Presence of pre- eclamptic features Uterus is tense, tender and woody hard F.H.S is absent Diminished urinary output Presence of blood coagulation disorder

18. MANAGEMENT PREVENTION: Early detection and effective therapy of preeclampsia Needle puncture during amniocentesis should be under ultrasound guidance Avoidance of trauma - specially forceful external cephalic version under anaesthesia To avoid sudden decompression of the uterus - To avoid supine hypotension Routine administration of folic acid- from the early pregnancy Correction of anaemia during antenatal period so that the patient can withstand blood loss Prompt detection and institution of the therapy to minimise the grave complications namely shock, blood coagulation disorders Renal failure

19. TREATMENT AT HOME The patient is immediately put to bed To assess the blood loss- Inspection of the clothings soaked with blood To note the pulse, blood pressure and degree of anemia Quick but gentle abdominal examination to mark the height of the uterus, to auscultate the fetal heart sound and to note any tenderness of the uterus Vaginal examination must not be done

20. TRANSFER TO THE HOSPITAL Arrangement is made to shift the patient ta an equipped hospital having facilities of blood transfusion, emergency caesarean section and intensive care unit (NICU) “Flying squad” service is ideal for transfer of such type of patients. An intravenous dextrose- saline drip should be started and is kept running during transport. Patient should be accompanied by two or three persons fit for donation of blood, if necessary.

21. IN THE HOSPITAL: Assessment of the case is to be done as regards: Amount of blood loss Maturity of the fetus Whether patient is in labour or not Presence of any complication Type and grade of placental abruption

22. DEFINITIVE TREATMENT- REVEALED TYPE Patient in labour :labour accelerated by low rupture of membranes , oxytocin drips to be started to accelerate labour Patient not in labour : A. pregnancy 37 weeks or more then induction of labour is done by low ruptue of membranes b. Indication for caesarean section: fetal distress , amniotomy could not be done or failed. Pregnancy < 37 weeks : bleeding moderate to severe( low rupture of membrane , oxytocin drip is started), bleeding slight or stopped( put on conservative treatment)

23. Mixed or concealed type Blood samples are taken To correct hypovolemia Artificial rupture of membranes Vaginal delivery Caesarean section – indicated in two extreme cases 1. early – unfavourable cervix, where speedy delivery is not possible Late – progress of labour delayed in spite of amniotony and oxytocin

24. COMPLICATIONS

25. NURSING MANAGEMENT Assessment: Assess for signs of shock, especially when heavy  bleeding  occurs. Assess if the  bleeding  is external or internal. Monitor contractions if separation occurs during  labor . Obtain baseline vital signs. Assess for the time the  bleeding  began, the amount and kind of  bleeding , and interventions done when bleeding occurred if it started before admission. Assess for the quality of pain.

26. NURSING DIAGNOSIS Ineffective tissue perfusion related to excessive blood loss as evidenced by altered blood pressure from the baseline Risk for shock related to internal and external bleeding as evidenced by vaginal bleeding Acute pain related to sudden separation of placenta as evidenced by Sharp, stabbing pain high in the uterine fundal part Fluid volume deficit related to bleeding during premature placental separation.

27. SUMMARY Definition of Abruptio Placenta Types Incidence and sigificance Etiology Pathogenesis Clinical classification Clinical features Diagnostic evaluation Differential diagnosis Management

28. CONCLUSION Abruption placenta is a obstetrical and medical emergency which should be treated promptly to prevent maternal and neonatal mortality. We envisage need for mass information regarding the importance of antenatal maternal care and improvement in nutritional status, which may reduce the frequency of maternal and fetal morbidity and mortality associated with abruption placenta

29. RESEARCH ABSTRACT Retrospective study of risk factors and maternal and fetal outcome in patients with abruptio placentae Introduction: Abruptio placentae (AP) which is a major cause of maternal morbidity and perinatal mortality globally is of serious concern in the developing world. Study was retrospectively analyzed for the AP cases and evaluated its impact on fetal and maternal outcomes.

30. Materials and Methods: The present study was undertaken from September 2007-August 2009 at a tertiary care center attached to medical college; patients of AP were selected from all cases with minimum of 28 weeks of gestation, presenting with antepartum hemorrhage. Patients underwent complete obstetrical investigations and were managed according to maternal and fetal condition. Results: 4.4% incidence rate of AP was documented accounting for 318 cases during the study period. Most of cases were unbooked , with an average age of 34.5 years (range, 18-44) and nearly two-third of the patients were from lower socioeconomic class. Anemia was observed in 96% of patients, with 3.5 and 68% incidence of maternal and fetal mortality, respectively.

31. Conclusion: It is observed a higher than expected frequency of AP and neonatal mortality in study population, which is of major concern. To envisage need for mass information regarding the importance of antenatal maternal care and improvement in nutritional status, which may reduce the frequency of maternal and fetal morbidity and mortality associated with AP.