Placental abruption

Placental abruption is premature separation of placenta from the uterus/ in other words separates before childbirth.

It occurs most commonly around 25 weeks of pregnancy characterized by vaginal bleeding, lower abdominal pain, and dangerously low blood pressure

1. Placental Abruption Prepared by Ms. Jenisha Adhikari BSN

2. Definition Placenta - The  placenta  is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, thermo-regulation, waste elimination, and gas exchange via the mother's blood supply; to fight against internal infection; and to produce hormones which support pregnancy

3. Abruption - the sudden breaking away of a portion from a mass.

4. Introduction Placental abruption  is premature separation of placenta from the uterus/ in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy characterized by vaginal bleeding, lower abdominal pain, and dangerously low blood pressure

5. Incidence It is seen 1-3% of deliveries and accounts for 2 out of 3 cases of ante partum hemorrhage Recurrent rate is about 5-17% after the first episode and about 25% after the second

6. Etiology Maternal hypertension Mulitparity Poor nutrition ; folic acid deficency Decompression of polyhydramnious Short cord Tension of uterus

7. Blunt trauma accidents Fall Domestic voilence Drugs Cocaine Methampathamine

8. Type Revealed Conceled Mixed

9. Revealed the blood comes downward between the membrane and decidua . It occurs at the margin Concealed the blood is collected in between the membrane and decidua , it occurs at the center Mixed in this type, some part of the blood collect inside (concealed and part is expelled out (revealed )

10. Risk factors . History of placental abruption or previous Caesarian section Pre- eclampsia uterine anatomy (e.g. bicornuate uterus) Short umbilical cord

11. Prolonged rupture of membranes (>24 hours) Multiple pregnancy cocaine and tobacco abuse Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk

12. Classification of Placental Abruption Clinical classification is as follows: Class 0 - Asymptomatic Class 1 - Mild (represents approximately 48% of all cases) Class 2 - Moderate (represents approximately 27% of all cases) Class 3 - Severe (represents approximately 24% of all cases)

13. Class 1 characteristics include the following: No vaginal bleeding to mild vaginal bleeding Slightly tender uterus Normal maternal BP and heart rate No coagulopathy No fetal distress

14. Class 2 characteristics include the following: No vaginal bleeding to moderate vaginal bleeding Moderate to severe uterine tenderness with possible tetanic contractions Maternal tachycardia with orthostatic changes in BP and heart rate Fetal distress Hypofibrinogenemia ( ie , 50-250 mg/ dL )

15. Class 3 characteristics include the following: No vaginal bleeding to heavy vaginal bleeding Very painful tetanic uterus Maternal shock Hypofibrinogenemia ( ie , < 150 mg/ dL ) Coagulopathy Fetal death

16. Sign and symptoms It depends on Degree of separation of placenta Speed at which separation occurs Amount of blood concealed inside the uterine cavity

17. Sign and symptom Sign and symptoms Revealed Concealed Vaginal bleeding Usually slight, continious , dark red, rarely sever bleeding Absent, but present in case of mixed Abdominal pain No sever pain but discomfort Acute agonizing pain present shock absent Present ( moderate to severe ) anemia Usually absent Always present Per sbdomen uterus Localized uterine tenderness, fetal presentation are usual FHS is present Tender, tensed, hard with rising fundal height, FHS is not audible, fetal part is not palpable Urinary output normal Usually diminished Vulval inspection Slight to heavy bleeding Bleeding is absent

18. Diagnosis Laboratory test CBC PT BUN/ Creatinine Fibrinogen level Imaging Transvaginsal ultrasonogram Transabdomen ultrasonogram

19. Ultrasound showing placenta abruption

20. Complication Maternal shock blood coagulation disorder, coagulopathy Oliguria or anuria Postpartum hemorrhage due to atont of uterus Puerperal sepsis Fetal Prematurity Anoxia Fetal death

21. Prognosis Nowadays maternal deaths due to placental abruption are rare. The fetal prognosis is worse than the maternal prognosis; approximately 12% of fetuses affected by placental abruption die. 77% of fetuses that die from placental abruption die before birth; the remainder die due to complications of preterm birth Outcomes for the baby also depend on the gestational age.

22. Management Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother is in distress. Blood volume replacement to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed.

23. Vaginal birth is usually preferred over Caesarean section unless there is fetal distress. Caesarean section is contraindicated in cases of disseminated intravascular coagulation. Excessive bleeding from uterus may necessitate hysterectomy.

24. On the basis of severity Mild abruption General treatment and investigation are performed Observe the patient and monitor carefully labor and delivery IV drip start with Ringer lactate, Normal saline DNS and make arrangement for blood transfusion Position the patient in left lateral position

25. Moderate abruption Perform amniotomy and initiate an oxytocin induction after taking general treatment and investigation Vaginal delivery is attempted first If the uterus feels hypertonic during labor or sign of fetal distress appear, delivery immediately by caesarean section Maintain IV fluid Blood transfusion is given

26. Severe abruption with dead fetus Secure intravenous access and obtain sample for investigation Start IV drip, give appropriate IV fluids Catheterize the patient and monitor urine output which should be maintained 30 ml/hr Oxytocin maybe given to induce and sustain labour Destructive operation is done to extract fetus otherwise

27. Severe abruption with live fetus General measure as previous Atleast 4 unit of blood is kept ready after grouping and cross matching CS must be performed if cervix is not dialated and sign of fetal distress is seen Maintain IV fluid, crystalloid, colloids and blood as necessary Monitor vital sign, FHS and urine output every 1-2 hourly as needed

28. Prevention Avoiding tobacco, alcohol and cocaine during pregnancy decreases the risk. Staying away from activities which have a high risk of physical trauma is also important. Women who have high blood pressure or who have had a previous placental abruption and want to conceive must be closely supervised by a doctor.

29. M aintaining a good diet including taking foliated, regular sleep patterns and correction of pregnancy-induced hypertension. It is crucial for women to be made aware of the signs of placental abruption, such as vaginal bleeding, and that if they experience such symptoms they must get into contact with their health care provider/the hospital  without any delay .