Abruptio placentae

DR.A.RATHNA ., M.S ( O&G)

II nd YR PG
MMC & RI

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Definition
Abruptio Placentae is the premature separation of the
normally implanted placenta from the uterine wall
after the 20th week of gestation until the 2nd stage of
labor.

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Epidemiology
1/3 of all ante-partum bleeding is due to A P
Incidence ranging from 1 in 75 to 1 in 225 births
AP recurs in 5 to 17% of pregnancies after 1 prior
episode
Up to 25% after 2 prior episodes

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Etiology
Primary cause of A P is uncertain
Several associated conditions identified:
Increase in age & parity: 1.3-1.5%
Pre-eclamsia: 2.1-4%
Chronic hypertension: 1.8-3%
Preterm ruptured membranes: 2.4-4.9%
Multifetal gestation: 2.1%

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Etiology
Cigarette smoking: 1.4-1.9%
Cocaine abuse: NA
Prior abruption: 10-25%
Uterine leiomyoma: NA
Hydromnios: 2%

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Classification
Revealed type: Bleeding is revealed.
Concealed type: No obvious bleeding.
Mixed type: Combination of 1&2 above.
In the concealed type(20%), the hemorrhage is confined
within the uterine cavity, detachment of the placenta may
be complete, and the complications are often severe.
In the revealed type(80%) the blood drains through the
cervix, placental detachment is more likely to be
incomplete, and the complications are fewer and less
severe

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Pathophysiology
Placental abruption initiated by hge into decidua basalis

Haematoma formation

In concealed type blood accumulates &

seeps into myometrium

Couvelaires uterus

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Couvelaires uterus
Also called as Utero-placental apoplexy
First described by Couvelaire in early 1900
Extravasation of blood into uterine musculature &
beneath uterine serosa
Demonstrated only at laparotomy
These myometrial hge interfere with uterine
contraction to produce PPH

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 Couvelaires uterus

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Pathophysiology
Blood gains access to amniotic fluid
through rupture membranes

With disrupted placental site there is reduced

metabolic exchange
Process continues with release
Fetal hypoxia of tissue thromboplastin in
maternal circulation

DIC
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 PRECIPITATIONG FACTORS
PREDISPOSING FACTORS
Smoking
Age
(cigarette,tobacco,cocaine0
Race
Trauma
Previous Placenta Abruption
Chorioamnionitis
Thrombophilia
PIH

Damage in small arterial

vessels in the basal layer of
decidua

Bleedin Splits decidua, leaving

g a thin layer attached
to the placenta
Occult Apparent
 Hematoma
formation

Compression of the
basal layer

Obliteration of the
intervillous space
 Destruction of the
placental tissues

Conceale Impaired
Visible
d exchange of
Bleeding
Bleeding respiratory gases
and nutrients
Blood passes
through the Blood reaches
membranes of the edge of the
amniotic sac placenta
Degrees of Separation:
Grade Criteria
0 No symptoms of separation were apparent from
maternal or fetal signs; the diagnosis that a
slight separation did occur is made after birth,
when the placenta is examined and a segment of
the placenta shows a recent adherent clot on the
maternal surface.
1 Minimal separation, but enough to cause
vaginal bleeding and changes in the maternal
vital signs; no fetal distress or hemorrhagic
shock occurs, however.
Grade Criteria

2 Minimal separation, but enough to cause

vaginal bleeding and changes in the
maternal vital signs; no fetal distress or
hemorrhagic shock occurs, however.

3 Extreme separation; without immediate

interventions, maternal shock and fetal
death will result.
Complications
Maternal:
1. Maternal mortality
2. Hypovolaemic shock
3. Renal failure
4. DIC
5. PPH
6. Rhesus sensitization
7. Complication of massive transfusion

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Complications
Fetal:
1. Fetal death
2. Hypoxic brain injury
3. IUGR
4. Neonatal anemia
5. Congenital malformations (CNS)

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Signs & symptoms
Vaginal bleeding: 78%
Uterine tenderness: 66%
Back pain: 60%
Fetal distress: 22%
Hypertonus: 17%
Fetal demise: 15%

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Diagnosis
Basis of diagnosis consists of :
History & physical examinations
Triad of external bleeding through cervical Os, Uterine
or back pain and fetal distress should be of high
suspicion
Defer digital cervical examinations until PP & VP are
ruled out
Ultrasound limited value but for large abruptions
hypoechoic areas seen underlying placenta

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Ultrasound

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Ultrasound

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Laboratory tests
1. Complete blood cell count
2. Blood type & screen
3. Urine analysis,
4. Liver function tests
5. Renal function tests
6. Prothrombin time/ aPTT
7. Fibrinogen levels
8. FDP Fibrin degradation products

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Maternal Assessment
Signs Symptoms
Increase Abdominal Confusion
girth Abdominal/ back
Board like rigidity pain
Uterine tetany
Cold extremities
Tachypnea, Pallor
Decreased Urine
output
Increase discharges
Fetal Assessment
Signs And Symptoms
 MANAGEMENT
This depends on severity, associated complications,
state of the patient, state of the fetus and the
gestational age.
General management resuscitation.
Specific measures
Immediate delivery
Expectant management
Management of complications.
A IMMEDIATE DELIVERY
Depends on the severity of the abruption, and the state
of the fetus (dead or alive)
i) DEAD FETUS
Aim at vaginal delivery
Needs adequate resuscitation with IV fluids, blood
and plasma.
ARM plus or minus oxytocin (with oxytocin, close
monitoring to avoid over stimulation and uterine
rupture). Where there is the least doubt about the
diagnosis, perform ARM in theatre in case there is
a concomitant placenta praevia.
Delivery should be effected within 6 hrs. If
bleeding continues and progress of labour is slow,
deliver by C/S. Note that C/S is risky in the
presence of DIC. If there is not much blood
available to resuscitate the patient adequately, then
early recourse to C/S may be justifiable.
ii) LIVE FETUS
CS or vaginal delivery. CS offers better chances of
survival for the baby. If vaginal delivery is aimed at,
then there is the need for continuous fetal electronic
monitoring and this may be considered if labour is
well advanced. This is not possible in our
environment.
Fetal distress immediate CS
B EXPECTANT MANAGEMENT
This may be done for very mild cases in which the fetus
is immature. Such cases may develop mild localized
tenderness over the uterus. The ultrasound scan
identifies a small retroplacental clot.
Admit patient
Pain relief
Continuous electronic fetal heart rate monitoring (if
available)
Repeated USS for first few hours to monitor rate of
progression of retroplacental clot.
Monitor fetus subsequently by
Daily fetal kick counts
Twice weekly CTG
Twice weekly ultrasound scan.
If abruption progresses, deliver as soon as
possible.
If abruption does not progress, continue expectant
management till 37 wks and deliver.
C MANAGEMENT OF COMPLICATIONS
Haemorrhagic Shock
The tendency is to underestimate blood loss due
to concealed Abruptio placenta.
The aim of treatment is to restore effective blood
volume and hence tissue perfusion.
This involves the following
Setting up IV line /collecting blood for investigations.
IV fluids colloids/crystalloids.
Oxygen by face-mask.
Monitor of fluid replacement to avoid overload.
Watch out for problems of massive transfusion.
2 DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
More common in severe abruption or massive
haemorrhage. There are three stages based on
laboratory measurements and clinical features
Low grade and compensated.
Uncomplicated, no haemostatic failure
Rampant with haemostatic failure
Treatment Involves
Delivery of the fetus / placenta
Replacement of lost blood and consumed factors; via fresh
whole blood / FFP / Packed cells.
 3. RENAL FAILURE
Caused by hypovolaemic shock and intravascular clotting in
the kidneys from DIC. Types of renal damage are acute
tubular necrosis and acute cortical necrosis.
Treatment entails
Consult to renal physician.
Fluid replacement / renal function monitoring.
Diuretics (manitol 20% and IV frusemide)-Use with caution..
4. PPH
Treatment involves
Adequate blood transfusion
Use of oxytocics ergometrine, oxytocin, syntometrine
and PGF2a
Internal iliac artary ligation or hysterectomy
Rh-sensitisation
Management
Term gestation, hemodynamically stable:
Plan for vaginal delivery with CS for usual indications
Follow serial hematocrit & coagulation studies
Continuous fetal monitoring
Term gestation, hemodynamic instability:
Aggressive fluid resuscitation
Transfuse packed RBC, fresh frozen plasma & platelets as
needed
Maintain Fibrinogen level > 150 mg/deciliter, hematocrit >
25% & platelet over 60000/ L
Urgent CS unless vaginal delivery is imminent

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Management
Preterm gestation hemodynamically stable:
In absence of labor, preterm AP should be followed with
serial USG for fetal growth
Steroids should be given to promote fetal lung maturity
If maternal instability or fetal distress arises delivery
should be performed, if not labor can be induced at
term
Preterm gestation hemodynamically unstable:
Delivery should be performed after appropriate
resuscitation

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Conclusion
Abruptio Placentae is an important cause of fetal and
maternal morbidity and mortality. The etiology is poorly
understood , various management options are however
available.
The principle of initial assessment of the patients
condition and subsequent planned management aimed at
resuscitation and prolongation of pregnancy if possible or
immediate delivery either for fetal or maternal indications.

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