PLACENTAL ABRUPTION
General Consideration:
• Definition: Premature separation of the placenta from its site of implantation from 24
weeks of gestation until delivery of baby.
• Incidence;
-
0.4-2%
GRADING:
• Grade 0: Separation not apparent until placenta examined > delivery.
• Grade 1: minimal - causes vaginal bleeding & alterations in maternal VS.
• Grade 2: moderate - + signs of fetal distress. Uterus tense & painful when
palpated.
• Grade 3: extreme (total) separation. Maternal shock/fetal death if immediate
intervention not done.
Etiology:
•
Uncertain (primary cause).
•
Risk factors:
1. Increased age and parity.
2. Vascular diseases: preeclampsia, chronic hypertension, renal disease.
3. Mechanical factors: trauma, intercourse, polyhydramnios.
4. Supine hypotensive syndrome.
5. Smoking, cocaine use, uterine myoma
Pathology:
• Main change: hemorrhage into the decidua basalis → decidua splits → decidural
hematoma → separation, compression, destruction of the placenta adjacent to it.
• Types: revealed abruption, concealed abruption, mixed type
Manifestation:
• Vaginal bleeding companied with abdominal pain.
-
Mild type: abruption ≤ 1/3, apparent vaginal bleeding.
-
Severe type: abruption > 1/3, large retroplacental hematoma, vaginal bleeding
companied by persistent abdominal pain, tenderness on the uterus, change of fetal
heart rate. shock and renal failure.
Examination:
Abdominal examination:
•
Tender tense uterus (woody hard).
•
The fetus is difficult to palpate.
•
Fetus may be dead , in distress or unafected (size-location of abruption)
Diagnosis:
• Sign and Symptom:
-
Vaginal bleeding.
-
Uterine tenderness or back pain.
-
Fetal distress.
-
High frequency contractions.
-
Idiopathic preterm labor.
-
Dead fetus.
•
Ultrasonography:
-
Position of placenta, severity of abruption, survival of fetus.
-
Signs: retro placental hematoma.
-
Negative findings do not exclude placental abruption
Complications:
• DIC.
• Hypovolemic shock.
• Amnionic fluid embolism.
• Acute renal failure.
• Fetomaternal haemorrhage.
• Perinatal mortality.
• Fetal growth restriction.
Treatment:
• Treatment will vary depending upon gestational age and the status of mother and
fetus.
• Treatment of hypovolemic shock: intensive transfusion with blood.
• Assessment of fetus.
• Termination of pregnancy: CS or Vaginal delivery.