ABRUPTIO PLACENTA

OBG B UNIT

Definition
A seperation of placenta from site of its implantation before delivery.(latin-rendering placenta as under).

Incidence
Range of 0.52% - 1.29%.Increases with increased gestational age. Perinatal mortality- 119/1000 live births Vs 8.2/1000 due to other causes.

ETIOLOGY
MATERNAL HYPERTENSION. PROM. CIGARETTE SMOKING,COCAINE ABUSE. THROMBOPHILIAS. SUDDEN UTERINE DECOMPRESSION (polyhydramnios). EXTERNAL TRAUMA. UTERINE LEIOMYOMA. PRIOR ABRUPTION.

RISK FACTORS
RISK FACTORS increased age n parity preeclapmsia chronic hypertension
PROM

multifetal gestation hydramnios chronic smoking thrombophilias cocaine abuse prior abruption uterine leiomyoma

RELATIVE RISK 1.3-1.5 2.1-4.0 1.8-3.0 2.4-4.9 2.1 2.0 1.4-1.9 3-7 NA 10-25 NA

PATHOLOGY
Haemorrhage into decidua basalis decidua splits leaving a thin layer adherent to myometrium decidual haematoma separation,compression & destruction of placenta.

PATHOLOGY
Decidual spiral artery rupture retroplacental haematoma the area of separaton becomes more extensive upto margin uterus unable to contract blood dissects membrane from utrine wall & escapes out or remains concealed

Pathological classification

REVEALED

CONCEALED

CONCEALED

Causes of concealed haemorrhage

Effusion of blood behind placenta but margin adherent. Placenta separeted but membrane still retain their attachment. Blood gains access through amniotic cavity. Fetal head closely applied to lower segment that prevents blood escape.

CLINICAL FEATURES
Vaginal bleeding 78% utrine tenderness 66% fetal distress 60% preterm labour 22% high frequency of contraction 17% hypertonus 17% dead fetus 15%

CLINICAL CLASSIFICATION
GRADE 1- not recognised clinically & diagnosed by retroplacental clots after delivery. GRADE 2-intermediate,classical signs present but fetus still alive. GRADE 3-severe, fetus is dead. 3a-without coagulopathy. 3b-with coagulopathy.

DIFFERENTIAL DIAGNOSIS
WITH VAGINAL BLEED placenta praevia,

uterine rupture, vasa praevia.

WITHOUT VAGINAL BLEED rectus sheath haematoma, retro peritoneal haemorrhage, rupture of appendicular abcess, acute degeneration or torsion of uterine fibroid.

COMPLICATION
Hypovolemic shock. Acute renal failure. DIC. Couvelaire uterus.

Couvelaire uterus

MANAGEMENT OF ABRUPTIO
ROLE OF IMAGING Poor sensitivity When clot visualized,PPV high

IUD with abruption

Blood for grouping,crossmatching Hb%,PCV DIC Profile LFT,RFT Urine routine

 Replace blood loss

Correct coagulopathy

Deliver the baby

Evaluation and replacement of blood loss

Aggressive correction despite normal vitals & Hct Insert CVP catheter,Foleys catheter Transfuse packed cells Expand volume with RL/NS 1 FFP after every 4U packed cells Maintain PCV 30%,urine O/P of 30 ml/hr

Management of coagulopathy
Normal values of DIC profile
Fibrinogen PT PTT Platelet count D-dimer FDP -150 to 600 mg/dl -11 to 16 sec -22 to 37 sec -1.2 to 3.5 lak/ cmm - <0.5 mg/l - <10 microgram/dl

 Clot retraction test- For function of platelets Clot lysis- Gross measure of fibrinolytic system Transfuse 10-20 U of cryoppt if fibrinogen <100 mg/dl Transfuse platelets if count <40,000

Termination of pregnancy
Vaginal delivery unless no CI Early amniotomy Oxytocin infusion Time for obtaining delivery upto 24 hrs

Live fetus but in distress

Emer LSCS Evaluate hemostatic system Speed of delivery important

Live fetus ,FHS normal

Induce and allow for vaginal delivery Continuous CTG If CTG abnormal,LSCS

Expectant Mx in preterm
Only in mild cases To await lung maturity Hospital stay a must