Antepartum Haemorrhage: Abruptio Placenta

Brief discussion about Antepartum haemorrhage

1. ABRUPTIO PLACENTA DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

2. DEFINITION It is one form of antepartum hemorrhage where the bleeding occurs due to premature separation of normally situated placenta. Bleeding is almost always maternal. But placental tear may cause fetal bleeding. Incidence and significance The overall incidence is about 1 in 200 deliveries. Depending on the extent (partial or complete) and intensity of placental separation, it is a significant cause of perinatal mortality (15–20%) and maternal mortality (2–5%).

3. TYPES (1) Revealed : Following separation of the placenta, the blood insinuates downwards between the membranes and the decidua. Ultimately, the blood comes out of the cervical canal to be visible externally. This is the most common 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 the lower segment. At times, 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 the blood collects inside (concealed) and a part is expelled out (revealed). Usually one variety predominates over the other. This is quite common.

4. ETIOLOGY ( RISK FACTORS) (a) high birth order pregnancies with parity >5 (b) advancing age of the mother (c) poor socio-economic condition (d) malnutrition (e) Smoking (f) Hypertension in pregnancy (g) Trauma (h) Sudden uterine decompression ( i ) Short cord (j)Supine hypotension syndrome (k) Placental anomaly (l) Tortion of uterus, cocaine (m) Thrombophilias

5. PATHOGENESIS Premature placental separation is initiated by hemorrhage into the decidua basalis.( decidual hematoma)  Degeneration and necrosis of the decidua basalis as well as the placenta adjacent to it. Rupture of the basal plate may also occur, thus communicating the hematoma with the intervillous space. Retro placental hematoma If a major spiral artery ruptures, a big hematoma is formed  As the uterus remains distended by the conceptus , it fails to contract and therefore fails to compress the torn bleeding points. It has to be remembered that absence of rhythmic  uterine contractions plays a significant role for the blood  to remain concealed.

6. FEATURES The features of retroplacental hematoma are: (a) Depression found on the maternal surface of the placenta with a clot which may be found firmly attached to the areas (b) Areas of infarction with varying degree of organization

7. COUVELAIRE UTERUS It is a pathological entity in association with severe form of concealed abruptio placentae. There is massive intravasation of blood into the uterine musculature upto the serous coat. The condition can only be diagnosed on laparotomy. Naked eye features : The uterus is of dark port win e color which may be patchy or diffuse. It tends to occur initially on the cornua before spreading to other areas, more specially over the placental site. Subperitoneal petechial hemorrhages are found under the uterine peritoneum and may extend into the broad ligament. There may be free blood in the peritoneal cavity or broad ligament hematoma. Microscopic appearance : The uterine muscles over the affected area are necrosed and there is infiltration of blood and fluid in between the muscle bundles. Most of the muscular dissociation occurs in the middle and outer muscle layers. The serosa may split on occasions, to allow the blood to enter the peritoneal cavity. The blood vessels show acute degenerative changes with thrombosis

8. CLASSIFICATION Grade—0: Clinical features may be absent. The diagnosis is made after inspection of placenta following delivery. Grade—1 (40%): ( i ) vaginal bleeding is slight (ii) uterus: irritable, tenderness may be minimal or absent (iii) maternal BP and fibrinogen levels unaffected (iv) FHS is good. Grade—2 (45%): ( i ) vaginal bleeding mild to moderate (ii) uterine tenderness is always present (iii) maternal pulse ↑, BP is maintained (iv) fibrinogen level may be decreased (v) shock is absent (vi) fetal distress or even fetal death occurs. Grade—3 (15%): ( i ) bleeding is moderate to severe or may be concealed (ii) uterine tenderness is marked (iii) shock is pronounced (iv) fetal death is the rule (v) associated coagulation defect or anuria may complicate.

9. CLINICAL FEATURES DIAGNOSIS- USG, MRI

10. DIFFERENTIAL DIAGNOSIS

11. PROGNOSIS: The prognosis of the mother and the baby depends on the clinical types (revealed, mixed or purely concealed), degree of placental separation, the interval between the separation of the placenta and delivery of the baby and the efficacy of treatment.

12. COMPLICATIONS MATERNAL Revealed type— maternal risk is proportionate to the visible blood loss Concealed variety— The following complications may occur either singly or in combination. (1) Hemorrhage which is either totally concealed inside the uterus or more commonly part is revealed outside. There may be intraperitoneal or broad ligament hematoma. (2) Shock may be out of proportion to the blood loss. Release of thromboplastin into the maternal circulation results in DIC or there may be amniotic fluid embolism. (3) Blood coagulation disorders (4) Oliguria and anuria due to—(a) hypovolemia (b) serotonin liberated from the damaged uterine muscle producing renal ischemia (c) acute tubular necrosis.(d) renal failure (5) Postpartum hemorrhage due to — (a) atony of the uterus and (b) increase in serum FDP (6) Puerperal sepsis.

13. FETAL Revealed type:- the fetal death is to the extent of 25–30%. Concealed type:- the fetal death is appreciably high, ranging from 50% to 100%. The deaths are due to prematurity and anoxia due to placental separation. With same degree of placental separation, the fetus is put to more risk in abruptio placentae than in placenta previa . This is due to the presence of preexisting placental pathology with poor functional reserve in former in contrast to an almost normal placental functions in the latter.

14. MANAGEMENT Prevention: The prevention aims at— (1)Elimination of the known factors likely to produce placental separation. (2) Correction of anemia during antenatal period so that the patient can withstand blood loss. (3) Prompt detection and institution of the therapy to minimize the grave complications namely shock, blood coagulation disorders and renal failure. Prevention of known risk factors  Early detection and effective therapy of preeclampsia and other hypertensive disorders of pregnancy.  Needle puncture during amniocentesis should be under ultrasound guidance.  Avoidance of trauma—specially forceful external cephalic version under anesthesia.  To avoid sudden decompression of the uterus— in acute or chronic hydramnios , amniocentesis is preferable to artificial rupture of the membranes.  To avoid supine hypotension the patient is advised to lie in the left lateral position in the later months of pregnancy.  Routine administration of folic acid from the early pregnancy

15. MANAGEMENT OF COMPLICATIONS 1)Hypovolemia - Irrespective of the patient’s general condition, atleast one liter of blood transfusion should be the minimum when the diagnosis is made. The best guide to monitor the patient is the use of central venous pressure (CVP) , which is maintained at 10 cm of water. Hematocrit should be at least 30% and urinary output ≥ 30 mL/h. 2)DIC— Release of tissue thromboplastin in placental abruption causes consumptive coagulopathy .Diagnosis is based on the coagulation profile assessment. Treatment is to restore the hematologic deficiency (fibrinogen level > 150 mg/dL), 1 unit (500 mL) of fresh blood contains 0.5 mg of fibrinogen and raises the fibrinogen level by 12.5 mg/dL. Platelet count increases by 10,000–15,000/cu mm to replenish the volume deficit 3)Feto-maternal hemorrhage - common with traumatic variety of placental abruption. To combat feto -maternal hemorrhage 300 mcg of anti-D immunoglobulin is administered to all Rh-negative women.

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