Table Of Contents
Abruptio placentae
Abruptio placentae is premature separation of the placenta from the uterus. Abruption is difficult to pick up through ultrasound, but it is still done to rule out placenta and vasa previa. The preferable mode of delivery in case of abruption is vaginal delivery, since caesarean delivery may be prevented by disseminated intravascular coagulopathy (DIC). If caesarean delivery is preferred it should be perfomed immediately before clottign factors are depleted.
Abruption is relatively uncommon, and is not easy to treat. Abruption accounts for 30% of cases of antepartum hemorrhage. It occrs in 1% of pregnancies and fetal mortality ranges from 20 – 40%.
Types of bleeding in abruption
| Bleeding | Description |
|---|---|
| Concealed (20%) | Minimal per vaginal bleeding. This form is more dangerous |
| Revealed/Apparent(80%) | Bleeding is appreciated, usually with partial detachment of the placenta from the uterus. |
Grading of placental abruption
| Grade | Description |
|---|---|
| Grade 1 | Retrospective diagnosis |
| Grade 2 | Abruption and live fetus |
| Grade 3 | Dead fetus |
| Grade 3A | No coagulopathy |
| Grade 3B | With coagulopathy |
- Risk factors
- Hypertension
- Pre-eclampsia
- Blunt force trauma to the abdomen (avulses the placenta)
- Cocaine use (causes vasoconstriction)
- Previous abruption
- Multiple pregnancy
- Previous caesarean delivery
- Thrombophilia
- Smoking
- Signs and symptoms
- Painful late pregnancy bleeding
- Firm “woody-hard” and tender uterus
- Pain between contractions
- Signs of shock – tachycardia, hypotension, tachypnoea, confusion or drowsiness, loss of consciousness
- Fetal bradycardia
- Late decelerations
- Couvelier uterus (bluish, enlarged and hard uterus due to blood in the myometrium)
- Retroplacental blood clot and sloughing
- Investigations
- Complete blood count
- Group and crossmatch
- Coagulation panel
- Renal funciton test and Electrolytes
- Liver function tests
- Ultrasound: to exclude placenta previa
- Principles of Treatment of abruption
- Resuscitaiton and Replace blood loss
- Deliver without delay (preferrably vaginal)
- Investigate for and prevent post-partum hemorrhage, DIC, and renal failure
Treatment of abruption
| Scenario | Treatment |
|---|---|
| Preterm and stable (no active bleeding) | Admit for observation |
| Treatment if term and stable (no active bleeding) | Vaginal delivery |
| Severe abruption | Emergency caesarean delivery |
- Indications for Caesarean delivery in abruption
- Previous caesarean delivery
- Failure to progress despite AROM, Oxytocin and traction
- Bleeding to death with normal clotting factors
- Live foetus > 2kg with signs of distress
- Transverse lie (vaginal delivery is impossible!)
- Management of Intraoperative bleeding
- Intrauterine balloon tamponade
- Hemostatic sutures (B-lynch, Hayman)
- Devascularization
- Hysterectomy (last resort)
- Complications of abruptio placentae
- Disseminated Intravascular coagulation: abruption causes release of tissue factor
- CBC with peripheral blood film show thrombocytopenia, schistocytes and helmet cells
- PT and PTT: prolonged
- D-dimer: High
- Fibrinogen: low or normal
- Maternal renal failure
- Maternal shock
- Amniotic fluid embolism
- Fetal distress (due to uteroplacental insufficiency)
- Intrauterine growth restriction
- Stillbirth
- Preterm delivery
- Postpartum hemorrhage (especially with a couvelier uterus in concealed hemorrhage)
- Death
- Maternal demise (0.5-5%)
- Fetal demise (35-80%)
- Disseminated Intravascular coagulation: abruption causes release of tissue factor
