Placental Abruption (Accidental hemorrhage)

Placental abruption or Abruptio placenta is one of the causes of antipartum hemorrhage affecting the pregnant woman.

1. 461-465

2. DEFINITION IT IS ONE OF ANTEPARTUM HEMORRHAGE WHERE THE BLEEDING OCCURS DUE TO PREMATURE SEPARATION OF NORMALLY SITUATED PLACENTA .

3. INCIDENCE & SIGNIFICANCE ABOUT 1 IN 200 DELIVERIES PERINATAL MORTALITY 15 TO 20% MATERNAL MORTALITY 2 TO 5 %

4. Risk factors Idiopathic : ( Majority. There is an association with defective trophoblastic invasion, as with pre- eclampsia and intrauterine growth restriction. Direct trauma e.g. RTA and external cephalic version. Multi parity , Advanced age Uterine over distention (as in polyhydramnios and multiple pregnancy ). Sudden decompression of the uterus e.g. after delivery of 1 st twin or release of polyhydramnios . Hypertension . Smoking . Folic acid deficiency .

5. Types :

6. REVEALED THE BLOOD INSINUATES DOWNWARD THE MEMBRANES AND DESIDUA.THE BLOOD COMES OUT THE CERVICAL CANAL TO BE VISIBLE EXTERNALLY.

7. CONCEALED THE BLOOD COLLECT BEHIND THE SEPERATED PLACENTA OR COLLECTED IN BETWEEN THE MEMBRANES.THE COLLECTED BLOOD IS PREVENTED FROM COMING OUT THE CERVIX BY PRESENTING PARTS ON LOWER SEGMENT.

8. MI X ED SOME PARTS OF THE BLOOD COLLECTS INSIDE(CONCEALED) AND A PART IS EXPELLED OUT (REVEALED).

9. Overt Abruptio placenta

10. Conce a led Abruptio placenta

11. PATHOGENESIS premature separation is initiated by haemorrhage into the deciduas basalis. The collected blood (decidual haematoma ) The decidual hematoma may be small and self limited If 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.

12. CLINICAL FEATURES

13. Abruptio placenta Character of bleeding Painful

14. Abruptio placenta Placental Location Normal Not Lower segment

15. Ob-Gyn Key Painful late- trimester bleeding Abruptio placenta

16. REV E ALED MIXED SYMPTOMS ABDOMINAL DISCOMFORT OR PAIN FOLLOWED BY VAGINAL BLEEDING(SLIGHT) ABDOMINAL ACUTE INTENSE PAIN FOLLOWED BY SLIGHT VAGINAL BLEEDING THE PAIN BECOME CONTINUOS BL E EDING CONTINOUS DARK COLOUR (SLIGHT TO MODERATE) CONTINOUS DARK COLOUR OR BLOOD STAINED SEROUS DISCHARGE GENERAL CONDITION PROPORTIONATE TO THE VISIBLE BLOOD LOSS,SHOCK IS USUALLY ABSENT SHOCK MAY BE PRONOUNCED WHICH IS OUT OF PROPORTION TO THE VISIBLE BLOOD LOSS P ALL L OR RELATED WITH VISIBLE BLOOD LOSS SEVERE AND OUT OF PROPORTION TO THE VISIBLE BLEEDING FEATURES OF PREECLAMPSIA ABSENT FREQUENT ASSOCIATION

17. F UTERINE FEEL NORMAL FEEL WITH LOCOLIZED TE N DE R N E S , C ONTR A C TI O NS UTERUS IS TENSE, TENDER &RIGID UTERINE HEIGHT PROPORTIONATE TO GESTATIONAL AGE MAY BE DIS PROPORTIONATE , E N L A R GE D , GLOBULAR FETAL PARTS CAN BE IDENTIFIED EASILLY DIFFICULT TO MAKE OUT FHS USUALLY PRESENT USUALLY ABSENT URINE OUT PUT NOR M AL DIMINISHED

18. DIAGNOSIS MAINLY CLINICAL ,ULTR A SONOGRAPH Y , MRI

19. LABORATORY TEST REVEALED MIXED BLOOD Hb LOW VALUE ,PROPORTIONATE TO THE BLOOD LOSS MARKEDLY ,LOWER ,OUT OF PROPORTION TO THE VISIBLE BLOOD LOSS Coagulation profile Usually unchanged Variable changes: CLOTTING TIME INCREASED(>6MIN) FIBRINOGEN LEVAL – LOW(<150mg/Dl) PLATLET COUNT LOW URINE FOR PROTEIN MAY BE ABSENT USUALLY PRESENT

20. Complications of placental abruption: Maternal complications: Acute Tubular Necrosis DIC. Couvelaire uterus: refers to blood extravasating between the myometrial fibers. Postpartum Hemorrhage Feto-maternal haemorrhage. Maternal mortality Recurrence: 10% After 1st attck, 25% After 2nd attck Fetal complications: Impaired fetal growth and/or hypoxic ischaemic encephalopathy (HIE)…… C.P

21. Couvelaire Uterus( Utero placental apoplexy ) It is a pathological entity in association with sever form of concealed abruption placentae. There is massive intravasation of blood into the uterine musculature up to the serous coat. The condition can only be diagnosed on laprotomy .

22. Couvelaire Uterus

23. MAN A GE M ENT PREVENTION Early detection and effective therapy Needle puncture ( amniocentesis) Avoidance of trauma routine administration of folic acid

24. TREATMENT ASSESSMENT AMOUNT OF BLOOD LOSS MATURITY OF THE FETUS WH E A TH E R TH E P A TIEN T IS IN LAB O UR O R N O T PRESENCE OF ANY COMPLICATION TYPE AND GRADE OF ABRUPTION

25. EMERGENCY MEASURES MANAGEMENT OPTIONS : IMMEDIATE DELIVERY MANAGEMENT OF COMPLICATION EXPECTANT MANAGEMENT BLOOD (HB,COAGULATION PROFILE) RINGER’S SOLUTION D RIP IS STARTED

26. IMMEDIATE DELIVERY THE PATIENT IN LABOUR LABOUR IS ACCELERATED BY LOW RUPTURE OF THE MEMBRAES,OXYTOCIN DRIP MAY BE STARTED TO ACCELERATE LABOUR VAGINAL DELIVEY IS FAVORED IN CASE WITH PLACENTAL ABRUPTION WITH DEAD FETUS DIC is present THE PATIENT NOT IN LABOUR INDUCTION OF THE LABOUR CESAREAN SECTION

27. INDUCTION OF THE LABOUR LABOUR IS QUICKELY COMPLETED ( 4-8HOURS ) RETRO PLACEN TAL CLOT IS EXPELLED SIMULTANEOUSLY WITH DELIVERY OF BABY - OXYTOCIN CESAREAN SECTION INDICATIONS SEVERE ABRUPTION WITH LIVE FETUS & very rapid delivery is needed

28. EXPECTANT MANAGEMENT If BLEEDING IS MILD , No fetal distress , Immature fetus THE GOAL OF THE EXPECTANT MANAGEMENT IS PROLONG THE PREGNANCY WITH HOPE OF IMPROVING MATURITY AND SURVIVAL. PATIENT SHOULD BE MONITER IN THE LABOUR WARD FOR 24-48 Hrs to. FURTHER SEPARATION OF THE PLACENTA MAY CAUSE FETAL DEATH AND MATERNAL COMPLICATION..

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