PLACENTAL ABRUPTION by Dr. Faiqa Sarwar PGR Obs/Gynea

PLACENTAL ABRUPTION

1. PLACENTAL ABRUPTION Presented by: Dr . Faiqa sarwar Resi d ent Obstetrics & Gynecology Supervised by: S/L Dr. Saima

2. Objective To Emphasize upon the risk assessment and timely Management of APH.

3. PRESENTATION SEQUENCE History Examination Diff er ential Diagnosis Investigations Management Case Discussion

4. PERSONAL PROFILE Name : Aqsa khalid Gravida & Parity : G 2P1 Age : 29 years LMP : 2 th November , 202 3 Gender: Female EDD : 2 7 th August , 202 4 Profession: Housewife Gestational Age : 3 5 weeks Education:Matriculation Admitted: From LR on 24th July 20 24 at 22:30 h ou r s Add r e s s : New Satellite town ,Sargodha

5. P R E SE N TI N G C O M P L A I N T Per Vaginal Bleeding since 30 Minutes

6. HISTORY OF PRESENTING ILLNESS Patient presented to LR at 22:30 hrs with complaint of per vaginal bleeding since 30 minutes which was sudden in onset, continuous,bright red in colour with passage of clots No history of pain abdomen ,per vaginal leaking or trauma . No history of nausea, vomiting, swelling of limbs, periorbital and facial swelling

7. HISTORY OF FIRST TRIMESTER Patient assumed herself to be pregnant following 50 days of missed period History of spontaneous conception She had her first antenatal checkup at 10 weeks of gestation Dating scan was done which was normal She took folic acid supplementation No history of burning micturation , excessive vomiting, fever with rash, per vaginal spotting or bleeding and drug intake Her blood pressure was 110/70 mmHg Routine tests were advised

8. HISTORY OF SECOND TRIMESTER She had no antenatal visit in second trimester Quickening at 5 th month of gestation and continued to percieve fetal movements well Anomaly scan was not done No history of iron or calcium supplementation No record of blood pressure No history of burning micturation , per vaginal discharge, per vaginal spotting or bleeding

9. HISTORY OF THIRD TRIMESTER She had her second antenatal visit at 29 weeks of gestation Fetal movements were perceived well by the mother Her scan showed normal fetal parameters corresponding to gestational age Her baseline tests were within normal limits Iron and calcium supplements advised Her blood pressure was 130/90 mmHg She was asked to maintain blood pressure record No history of per vaginal leaking or bleeding She had no further visit and presented to LR at 35 weeks of gestation with per vaginal bleeding

10. PAST OBSTETRICS HISTORY S# Gender Age MOD Indications Peri-Natal C o m pl i c a t i o n s Vaccine Baby´s Health status 1 B a b y boy 2.5 years El L scs Breech presentation none Yes Alive & H e al t h y 2 Present Pregnancy

11. Past Gynaecological History Past Surgical History Past Medical History Age of Menarche - 14 years Cycle Length - 7/30 days No history of Dysmennohea No history of pap smear No history of use of contraception Previous 1 Lower Segment Caesarian Section Not significant

12. Marital history Transfusion History Family History Married at the age of 22 yrs Non consanguineous marriage Living with husband Not significant Not significant

13. Immunization History Personal History Socio-Economic History Tet a nus One dose given Normal appetite Decreased sleep Normal bowel and bladder habits No history of drug or substance abuse Middle Class Family members - 05 Bread Earner - 01

14. GENERAL PHYSICAL EXAMINATION An x ious Supine Well oriented BP 160 / 100 mmHg Pulse 90 b / m in RR 16 br/min Pallor No Edema Jaundice Clubbing Cyanosis Koi l on y c hia Thyroid appears normal CVS S1 + S2 +no ad d e d s ou n d CNS GCS 15/15 Normal reflexes n Respiratory Bilateral clear on ausculatation

15. ABDOMINAL EXAMINATION Protuberant abdomen, Everted central umbilicus, Linea Nigra, Striae Gravidarium, LSCS scar Inspection SFH : 3 7 cm , Longitudinal Lie, Cephalic Presentation, Persistently Tense Abdomen P a l p a t i o n Bowel Sounds: audible Fetal Heart Sound present Ausculatation Bleeding visualize d with passage of clots P e r s pe c u l um

16. DIFFERENTIAL DIAGNOSIS Placental Abruption Placenta Previa

17. INVESTIGATIONS ULTRASONOGRAPHY : Single alive fetus at 35 weeks ,L/C ,FCA positive Liqour adequate, placenta anterior away from the os Retroplacental collection , low echogenicity between the placenta and uterine wall consistent with placental abruption.

18. LABORATORY INVESTIGATIONS Hb% 10.6 g/dL Hep B/C Negative Platelets 268 x10³/μL Blood Grouping O- ve WBCs 1 .0 x 10³/μL Urea 2.83mmol/L Uric acid 217mmol/L Creatinine 59μmol/L PT 1 4 /14 UA +1 PTTK 3 4 /34 BSR 4.3 Urine for protein N ill

19. CTG

20. FINAL DIAGNOSIS Pregnancy Induced Hypertension with Placental Abruption

21. EMERGENCY MANAGEMENT NPO 2 wide bore IV lines Blood Samples I V F l u i d s Catheterization &Pla t el e t s R C C s High Risk Consent Shifted for EmLSCS

22. PROCEDURE AND INTRA OP FINDINGS Under ASM abdomen opened Couvelaire uterus Uterus opened via previous scar Blood mixed liqour drained Baby girl delivered as cephalic with poor APGAR Cord blood saved > 50% placental abruption Uterus stitched in two layers Hemostasis secured with extra haemostatic sutures Abdomen closed in reverse order EBL 800-1000ml Patient had intraoperative generalized tonic clonic fits for which ABC maintained , IV diazepam and IV MgSO4 loading dose given

23. POST – OPERATIVE RECOVERY Shifted to ITC post-operatively Patient was vitally stable BP 130/90mmHg, pulse 89/min, RR 16 bpm and afebrile . Maintenance dose of MgSO4 1g/hr started Call to medicine attended and anti hypertensive started Strict record of UOP,RR, reflexes IV antibiotics, IV analgesia and IV fluids advised All baseline investigations were repeated which came within normal limits Cord blood was O+ve , Inj. Anti D given Oral sips allowed in the evening Foleys catheter was removed on 2 nd post op day Encouraged mobilization Patient was stable, stitch line healthy, Discharged on 3 rd POD

24. PLACENTAL ABRUPTION Premature Separation of the normally implanted placenta from the uterine wall after the 20th week of gestation until the second stage of labour

25. A E T I OLOG Y Primary ( I diopathic ) Secondary ( R ecognized associations) Prior Abru p t ion : 1 - 25% Preterm Ruptured Membranes : 2.4-4.9% Pregnancy Induced Hypertension : 2.1-4% Smoking & Drug Abuse : 1.4-1.9% I n c r ea s e in Age & Pari t y : 1 . 3 -1- 5% Fetal Abnormality Trauma

26. CLINICAL CLASSIFICATION Revealed C o n cea l e d Mixed

27. Classification According to History & Investigations Grade Assymptomatic Incidental retroplacental clots Grade 1 Mild vaginal bleeding No maternal or fetal compromise Grade 2 M ild to moderate vaginal bleeding Fetal distress, No maternal Shock Grade 3 Fetal distress or IUD , Maternal Shock Marked uterine Tenderness

28. P R E V A L E N C E 0.66% ( 0. 6 to 1. 2 %) of all Pregnancies. Recurrent Abruptions incidence is 4.4 %.(RCOG 2011) Two previous pregnancies with placental abruption. Incidence is 19-25 %.(RCOG 2011)

29. PATHOPHYSIOLOGY Rupture of spiral arteries Bleeding in de c idua basalis Hematoma formation R OM Blo o d A c c e s s to amniotic fluid Disrupted placental site Reduced m e t abolic e x c h an g e Fetal hypoxia Release of tissue t hro m bopl a s t in D I C M O D S I U D & M a t ern al Death

30. COUVELAIRE´S UTERUS In case of severe abruption extravasation of blood into myometrium

31. CLINICAL CHARACTERISTICS Vaginal bleeding Uterine tenderness Hypertonic uterus Nonreassuring fetal heart rate pattern Fetal demise

32. D I A G N O S I S Based on History & Clinical Examination External bleeding through cervical OS Uterine Tenderness or Backache Fetal Distress Laboratory investigation

33. ULTRASONOGRAPHY

34. Management of APH Women with grade 1 or mild placental abruption No signs of maternal or fetal distress Managed conservatively Women with grade 3 or 4 placental abruption Signs of maternal or fetal distress Emergency delivery

35. M A N A G E M E N T TERM GESTATION HEMODYNAMIC STABLE TERM GESTATION HEMODYNAMIC UNSTABLE Left lateral and ABC Aggressive resu s ciation with IV fluids Maintain IV line, 2 IV bore RCCs transfusion FVC, U&E, LFTs, Clotting Profile, BG&CM FFPs transfusión Maternal Assessment Platelets transfusión Fetal Assessment Maintain Fibrinogen > 150mg/dl MDT Maintain Hematocrit > 25% Counseling and Debriefing. Urgent LSCS unless imminent vaginal delivery

36. C O M P L I C A T I O N S Maternal Fetal PPH Hypoxic Brain Injury Hypovolemic Shock IUGR AKI Prematurity DIC Ne o na t a l A n e m i a Maternal Mortality Fetal Demise

37. TAKE HOME MESSAGE High level of suspicion when observing : APH in pregnancy . Emphasize the importance of Immediate intervention and timely delivery to enhance the outcome of both the mother and the fetus.

38. REFERENCES RCOG (2011) Antepartum hemorrhage , Greentop guideline NO. 63