Premature separation of a normally situated placenta after the 24th week of pregnancy and before delivery of the foetus.
0.5-1%.
Unknown, but the following factors may be associated with: Hypertensive disorders of pregnancy (30%) due to spasm and degenerative changes in the decidual arterioles. Trauma as during external version. Sudden drop of intrauterine pressure as rupture of membranes in polyhydramnios. Folate deficiency and may be vitamin C,K, or E deficiency. Passive congestion of the uterus due to pressure of the gravid uterus on the inferior vena cava. Torsion of the uterus. Smoking.Separation of the placenta results in formation of a retroplacental haematoma and its extension leads to more separation of the adjacent placental tissue (concealed haemorrhage). Ultimately the blood reaches the placental margin and tracks between the membranes and uterine wall to escape from the cervix (revealed haemorrhage).
The presence of concealed and revealed haemorrhage together called mixed variety. Thus the three varieties are actually different presentations to one process. If separation of the membranes does not occur, there is progressive disruption of the placental tissue and intravasation of blood through the myometrium even up to the peritoneal coat resulting in Couvelaire’s uterus.
Thromboplastin-like substances are released from the damaged placental site and passed to the maternal circulation initiating the process of disseminated intravascular coagulopathy (DIC). Acute renal failure may result from renal ischaemia caused by: hypovolaemia, reflex spasm of the renal vessels due to sudden distension of the uterus, occlusion of the glomerular capillaries by microthrombi from DIC, and /or kidney pathology caused by hypertensive states of pregnancy.
Early stage of renal ischaemia causes renal tubular necrosis which is reversible. Later on, irreversible cortical necrosis occurs.
Postpartum haemorrhage is common as the result of: uterine damage, uterine atony, coagulation failure (DIC), anaemia, inhibition of myometrial activity by fibrinogen degradation products (FDP) present in DIC, and Sheehan’s syndrome: severe antepartum and / or postpartum haemorrhage leads to necrosis of the anterior pituitary.
Symptoms Acute constant severe abdominal pain which may be localised or diffuse. Dark vaginal bleeding results from escape of blood from the retroplacental haematoma. Cessation of foetal movement is common.
Signs A.General examination: Shock is usually present and may be marked and not proportionate to the amount of visible bleeding due to: concealed and/ or revealed haemorrhage, overdistension of the uterus and damage of the myometrium causing neurogenic shock. Blood pressure is; subnormal due to haemorrhage, normal due to falling from previous hypertension or high due to slight bleeding in hypertensive patient. Tachycardia.
(B) Abdominal examination: Uterus is large for date and increasing gradually in size due to retained blood. Uterus is very tender and hard (board-like). Foetal parts are difficult to be felt. FHS may be absent due to foetal death in severe cases or distressed in mild cases.
(C) Vaginal examination: Done under the same precautions in placenta praevia may reveal: Vaginal bleeding which is dark as it is retained for some time before escape. If the cervix is dilated the placenta is not felt.
Other causes of antepartum haemorrhage. Other causes of acute abdomen.
Ultrasound: detects normally sited placenta with retroplacental haematoma that may dissect the placental margin. Tests for DIC.There is no treatment to stop placental abruption or reattach the placenta. Depend on: Severity of condition. Gestational age. maternal condition. Fetal condition. Associated complications.
The main principles of treatment in obvious cases of placental abruption are: 1. Early delivery. 2. Adequate blood transfusion. 3. Adequate analgesia. 4. Detailed monitoring of maternal condition. 5. Assessment of fetal condition.
At homeThe same as in placenta praevia.At hospitalAs placenta praevia regarding:Assessment of the patient’s condition, general and abdominal examination and resuscitation. Blood volume preservation. Ultrasonography.
According to this principle the patient need: Admission to hospital. Insert 2 large bore IV canula and infusion with normal saline, ringer lactate, blood, fresh frozen plasma. Send blood for cross match of 4 units of blood, and send for Hb and coagulation studies.
Urinary catheter to monitor U.O.P.(urinary out put ) hourly. Input and output chart. C.V.P.measurment and strict fluid balance. Early delivery is vital.
Patient with abruptio placenta has to be delivered and usually there is no place for conservative treatment. Amniotomy + oxytocin if: bleeding is not severe, vertex presentation, the cervix is partially dilated. adequate pelvis with no soft tissue obstruction,
Advantages of amniotomy: It reduces the intrauterine tension, intravasation of blood between myometrial muscles and its damage. Reduces the pain and shock. Reduces the incidence of renal failure. Stimulates the onset of labour and improves uterine contractions pattern.
Caesarean section is indicated in: Severe haemorrhage whether the foetus is dead or alive. Living foetus and labour is expected to be longer than 6 hours e.g. closed cervix. Foetal distress. Failure of progress after amniotomy + oxytocin. Other indications for C.S. as contracted pelvis, malpresentations and elderly primigravida.
The patient is more liable for postpartum haemorrhage so oxytocin is continued after delivery of the foetus, methergin is given with delivery of the shoulders if there is no hypertension with continuous massage of the uterus.
A.Effects on the mother 1.Hypovolemic shock. 2.DIC (Disseminated Intravasculer Coagulopathy) which mean hypofibrinogenemia, decrease platlet, increase FDP (Fibrin Degradation Product). triggered by tissue thromboplastin.
3.Acute renal failure Which occur due to A. Hypovolemia. B. Hypotension. C. DIC (microthrombi in kidneys).
4.post-partum haemorrhage (ppH) Which occur due to: A. Coagulation failure. B. Poorly contracting couvelair uterus. C. Predisposing factors for antepartum haemorrhage (APH) as polyhydramnios, multiple pregnancy.
5.Feto-maternal haemorrhage:6.It can lead to sensitization of mother especially if Rh –ve mother. So all mother who are Rh-ve should have Kleihaure test to quantify size of transfer and appropriate dose of anti-D immunoglobin.7.Maternal mortality due to complication.8.recurrence of abruptio placentae 10%
1.increase in perinatal mortality and the increase depend on: Size of abruption. Interval to delivery. Gestational age at delivery. Other associated factors. 2.IUGR (Intra Uterine Growth Restriction) in few cases which treated conservatively.
Placenta Praevia
Marginal HaemorrhageAbruptio Placentae
(I) History: Bleeding
- Painless, causeless, recurrent. - Usually starts slight in amount.
- Associated with abdominal pain. - A cause may be detected. - Usually starts severe in amount.
(II) Examination: 1) General
- The degree of shock is proportionate to the amount of blood loss. - Hypertension usually not present.
- The degree of shock may be out of proportion to amount of blood loss. - Hypertension usually present.
(2) Abdominal - Uterus - Foetus - FHS
- No tenderness or hardness. - Easily felt. - Usually normal.
- Tender, hard. - Not easily felt. - Absent or distressed.
(3) Vaginal (with the precautions) - Bleeding - Placenta
- Bright red. - Can be felt
- Dark red. - Not felt.
(III) Investigations - Urine - Blood - Ultrasound for placenta
- Normal. - Normal. - In lower segment.
- Normal. - Normal. - In upper segment.
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