Abruptio Placenta I.

Definition Placental abruption (also known as abruptio placentae) is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies worldwide. Placental abruption is a significant contributor to maternal mortality worldwide; early and skilled medical intervention is needed to ensure a good outcome, and this is not available in many parts of the world. Treatment depends on how serious the abruption is and how far along the woman is in her pregnancy. Placental abruption has effects on both mother and fetus. The effects on the mother depend primarily on the severity of the abruption, while the effects on the fetus depend on both its severity and the gestational age at which it occurs. The heart rate of the fetus can be associated with the severity. Abruptio placentae is defined as the premature separation of the placenta from the uterus. Patients with abruptio placentae, also called placental abruption, typically present with bleeding, uterine contractions, and fetal distress. A significant cause of third-trimester bleeding associated with fetal and maternal morbidity and mortality, placental abruption must be considered whenever bleeding is encountered in the second half of pregnancy. Placental abruption (abruptio placentae) is an uncommon yet serious complication of pregnancy. The placenta is a structure that develops in the uterus during pregnancy to nourish the growing baby. If the placenta peels away from the inner wall of the uterus before delivery either partially or completely it's known as placental abruption. Placental abruption can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother. Placental abruption often happens suddenly. Left untreated, placental abruption puts both mother and baby in jeopardy.

II. Causes The exact cause of a placental abruption may be hard to determine. Direct causes are rare, but include:

Injury to the belly area (abdomen) from a fall, hit to the abdomen, or automobile accident Sudden loss of uterine volume (can occur with rapid loss of amniotic fluid or after a first twin is delivered)

III. Signs and Symptoms Placental abruption is most likely in the last 12 weeks before birth. Classic signs and symptoms of placental abruption include:

Vaginal bleeding Abdominal pain Back pain Uterine tenderness Rapid uterine contractions, often coming one right after another

Abdominal pain and back pain often begin suddenly. The amount of vaginal bleeding can vary greatly, and doesn't necessarily correspond to how much of the placenta has separated from the inner wall of the uterus. It's even possible to have a severe placental abruption and no visible bleeding, if the blood becomes trapped inside the uterus by the placenta. In some cases, placental abruption develops slowly. If this happens, you might notice light, intermittent vaginal bleeding. Your baby might not grow as quickly as expected, and you might have low amniotic fluid (oligohydramnios) or other complications. IV. Clinical Manifestations

Class 0: asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta. Class 1: (covert/mild separation/mild abruption placentae) mild and represents approximately 48% of all cases. Characteristics include the following: o No vaginal bleeding to mild vaginal bleeding o Slightly tender uterus o Normal maternal BP and heart rate o No coagulopathy o No fetal distress Class 2: (overt/moderate separation/moderate abruption placentae) moderate and represent approximately 27% of all cases. Characteristics include the following: o No vaginal bleeding to moderate vaginal bleeding o Moderate-to-severe uterine tenderness with possible tetanic contractions o Maternal tachycardia with orthostatic changes in BP and heart rate o Fetal distress o Hypofibrinogenemia (i.e., 50250 mg/dL) Class 3: (placental prolapsed/severe separation/severe abruption placentae) severe and represents approximately 24% of all cases. Characteristics include the following: o No vaginal bleeding to heavy vaginal bleeding o Very painful tetanic uterus o Maternal shock

o o o

Hypofibrinogenemia (i.e., <150 mg/dL) Coagulopathy Fetal death

V. Risk Factors Various factors can increase the risk of placental abruption, including:

Previous placental abruption. If you've experienced placental abruption before, you're at higher risk of experiencing it again. High blood pressure. High blood pressure whether chronic or as a result of pregnancy increases the risk of placental abruption. Abdominal trauma. Trauma to your abdomen such as from a fall or other type of blow to the abdomen makes placental abruption more likely. Substance abuse. Placental abruption is more common in women who smoke or use cocaine during pregnancy. Premature rupture of the membranes. During pregnancy, the baby is surrounded and cushioned by a fluid-filled membrane called the amniotic sac. The risk of placental abruption increases if the sac leaks or breaks before labor begins. Blood-clotting disorders. Any condition that impairs your blood's ability to clot increases the risk of placental abruption. Multiple pregnancy. If you're carrying more than one baby, the delivery of the first baby can cause changes in the uterus that trigger placental abruption before the other baby or babies are delivered. Maternal age. Placental abruption is more common in older women, especially after age 40.

VI. Prognosis If the bleeding continues, fetal and maternal distress may develop. Fetal and maternal death may occur if appropriate interventions are not undertaken. The severity of fetal distress correlates with the degree of placental separation. In nearcomplete or complete abruption, fetal death is inevitable unless an immediate cesarian delivery is performed. If an abruption occurs, the risk of perinatal mortality is reported as 119 per 1,000 people in the United States, but this can depend on the extent of the abruption and the gestational age of the fetus. This rate is higher in patients with a significant smoking history. Currently, placental abruption is responsible for approximately 6% of maternal deaths. Morbidity associated with abruption placentae

Fetal morbidity is caused by the insult of the abruption itself and by issues related to prematurity when early delivery is required to alleviate maternal or fetal distress. Maternal morbidity may include the following: o Transfusion-related morbidity o Classic cesarean delivery with need for repeat cesarean deliveries

Hysterectomy

Cesarean delivery

Cesarean delivery is often necessary if the patient is far from her delivery date or if significant fetal compromise develops. If significant placental separation is present, the fetal heart rate tracing typically shows evidence of fetal decelerations and even persistent fetal bradycardia. A cesarean delivery may be complicated by infection, additional hemorrhage, the need for transfusion of blood products, injury of the maternal bowel or bladder, and/or hysterectomy for uncontrollable hemorrhage. In rare cases, death occurs. Hemorrhage / coagulopathy

Disseminated intravascular coagulation (DIC) may occur as a sequela of placental abruption. Patients with a placental abruption are at higher risk of developing a coagulopathic state than those with placenta previa. The coagulopathy must be corrected to ensure adequate hemostasis in the case of a cesarean delivery.\ Prematurity

Delivery is required in cases of severe abruption or when significant fetal or maternal distress occurs, even in the setting of profound prematurity. In some cases, immediate delivery is the only option, even before the administration of corticosteroid therapy in these premature infants. All other problems and complications associated with a premature infant are also possible. Recurrence

The risk of recurrence of abruptio placentae is reportedly 4-12%. If the patient has abruptio placentae in 2 consecutive pregnancies, the risk of recurrence rises to 25%. If the abruption is severe and results in the death of the fetus, the risk of a recurrent abruption and fetal demise is 7%. VII. Exams and tests Tests may include: Abdominal ultrasound Complete blood count Fetal monitoring Fibrinogen level Partial thromboplastin time Pelvic exam Platelet count Prothrombin time Vaginal ultrasound

VIII. Management Management of these pregnancies is determined on a case-by-case basis, and will depend upon the severity of the abruption, the gestational age, and maternal and fetal status. Any patient who presents with even slight bleeding from placental separation is at risk of developing sudden severe abruption. Therefore, all of these patients should be monitored and undergo continuous fetal heart rate assessment until their status is clear. o monitoring of maternal vital signs, fetal heart rate (FHR), uterine contractions and vaginal bleeding o likelihood of vaginal delivery depends on the degree and timing of separation in labor o cesarean delivery indicated for moderate to severe placental separation o evaluation of maternal laboratory values o F & E replacement therapy; blood transfusion o Emotional support Mild abruption placentae

If placental separation is minor, vaginal bleeding is light, and your fetus is not in distress, you may be observed in the hospital for several hours or several days. For the remainder of your pregnancy, you'll probably be advised to avoid strenuous activities and you and your fetus will need to be monitored regularly. If you are in preterm labor, the separation is minor, and you are far from your due date, you may be given tocolytic medicine to stop labor. Moderate to severe abruption placentae

If placental separation is moderate to severe, or if it causes a life-threatening condition called disseminated intravascular coagulation (DIC), rapid delivery is almost always necessary. Although vaginal delivery is sometimes possible, the need for rapid delivery increases the likelihood of a cesarean (C-section). In rare cases of heavy bleeding that won't stop, the uterus is surgically removed (hysterectomy). Depending how much blood you have lost and whether you have disseminated intravascular coagulation, you may need a transfusion of blood or blood-clotting products, such as platelets. How well your baby does after a placental abruption depends on how prematurely he or she is delivered and how well the placenta was able to circulate blood oxygen and nutrients to the fetus before delivery. Following delivery, it may be necessary to remain close to a health center able to care for premature infants. A sick or premature newborn can receive the best treatment possible in a neonatal intensive care unit, or NICU. Care in the NICU can last days or weeks, depending on the baby's level of maturity, the extent of the baby's problems, and the amount of care needed. Treatment for premature infants can be provided by a neonatologist, a doctor who specializes in the care of newborns.

Future pregnancy

After having one placental abruption, you have an increased risk of developing another during a future pregnancy. After two or more, you have a 1-in-4 risk of having another. Although there are no specific treatment guidelines for preventing another placental abruption, you and your health professional can take some steps to reduce your risk. o Avoid high-risk factors such as drug use, cigarette smoking, or untreated high blood pressure (140/90 mm Hg or higher). o Experts recommend you take 0.4 mg (400 mcg) to 0.8 mg (800 mcg) of folic acid every day. o See your health professional regularly throughout your pregnancy. IX. Anatomy and Physiology Most species have 2 sexes: male and female. Each sex has its own unique reproductive system. They are different in shape and structure, but both are specifically designed to produce, nourish, and transport either the egg or sperm. Unlike the male, the human female has a reproductive system located entirely in the pelvis. The external part of the female reproductive organs is called the vulva, which means covering. Located between the legs, the vulva covers the opening to the vagina and other reproductive organs located inside the body. The fleshy area located just above the top of the vaginal opening is called the mons pubis. Two pairs of skin flaps called the labia (which means lips) surround the vaginal opening. The clitoris, a small sensory organ, is located toward the front of the vulva where the folds of the labia join. Between the labia are openings to the urethra (the canal that carries urine from the bladder to the outside of the body) and vagina. Once girls become sexually mature, the outer labia and the mons pubis are covered by pubic hair. A female's internal reproductive organs are the vagina, uterus, fallopian tubes, and ovaries. The vagina is a muscular, hollow tube that extends from the vaginal opening to the uterus. The vagina is about 3 to 5 inches (8 to 12 centimeters) long in a grown woman. Because it has muscular walls, it can expand and contract. This ability to become wider or narrower allows the vagina to accommodate something as slim as a tampon and as wide as a baby. The vagina's muscular walls are lined with mucous membranes, which keep it protected and moist. The vagina serves 3 purposes: It's where the penis is inserted during sexual intercourse, and it's also the pathway that a baby takes out of a woman's body during childbirth, called the birth canal, and it provides the route for the menstrual blood (the period) to leave the body from the uterus. A thin sheet of tissue with 1 or more holes in it called the hymen partially covers the opening of the vagina. Hymens are often different from person to person. Most women find their hymens have stretched or torn after their first sexual experience, and the hymen may bleed a little (this usually causes little, if any, pain). Some women who have had sex don't have much of a change in their hymens, though. The vagina connects with the uterus, or womb, at the cervix (which means neck). The cervix has strong, thick walls. The opening of the cervix is very small (no wider than a straw),

which is why a tampon can never get lost inside a girl's body. During childbirth, the cervix can expand to allow a baby to pass. The uterus is shaped like an upside-down pear, with a thick lining and muscular walls - in fact, the uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. When a woman isn't pregnant, the uterus is only about 3 inches (7.5 centimeters) long and 2 inches (5 centimeters) wide. At the upper corners of the uterus, the fallopian tubes connect the uterus to the ovaries. The ovaries are 2 oval-shaped organs that lie to the upper right and left of the uterus. They produce, store, and release eggs into the fallopian tubes in the process called ovulation. Each ovary measures about 1 1/2 to 2 inches (4 to 5 centimeters) in a grown woman. There are 2 fallopian tubes, each attached to a side of the uterus. The fallopian tubes are about 4 inches (10 centimeters) long and about as wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed area wraps around the ovary but doesn't completely attach to it. When an egg pops out of an ovary, it enters the fallopian tube. Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down the narrow passageway toward the uterus. The ovaries are also part of the endocrine system because they produce female sex hormones such as estrogen and progesterone. Anatomy of the uterine/placental compartment at the time of birth. o The cotyledons of the maternal surface of the placenta extend into the decidua basalis, which forms a natural cleavage plane between the placenta and the uterine wall. o There are interlacing uterine muscle bundles, consisting of tiny myofibrils, around the branches of the uterine arteries that run through the wall of the uterus to the placental area. o The placental site is usually located on either the anterior or the posterior uterine wall. o The amniotic membranes are adhered to the inner wall of the uterus except where the placenta is located.

X. Pathophysiology