ABRUPTIO

PLACENTAE
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Dr.C.H.CHANG
MBBS ( MANG )
FRCOG ( LOND )
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ABRUPTIO
PLACENTAE
DEFINATION

! Premature separation of
the normally located
placenta after 20 weeks
of gestation, prior to the
birth of the infant ie 2nd
stage of labour.
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PATHOPHYSIOLOGY / TYPES

! Placental separation
at Decidua Basalis

! REVEALED or

! CONCEALED
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PATHOPHYSIOLOGY
HISTOLOGICAL LEVEL

Rupture of Maternal vessels at Decidua

Basalis

Rarely at Feto placental vessels

Arterial rupture : high press : extensive :

Central dissection: CONCEALED Life
threatening

Venous : low press : usually at periphery :

typically marginal : REVEALED : self
limiting and repeated. IUGR
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PATHOPHYSIOLOGY ( cont )

! Decidual bleeding leads to release of thromboplastin

! Generation of THROMBIN

! Thrombin : potent uterine stimulant – contractions, hypertonus

: release of inflammatory agents like cystokine

: Triggers coagulation pathway - DIVC

: Intravascular fibrin deposition – tissue injury, organ

damage

Affects fetomaternal perfusion leading to fetal hypoxia

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COMPLICATIONS OF ABRUPTION
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COUVELAIRE’S
UTERUS
! Blood seeps through the
myometrium, serosal
surface

! Uterus bruised and Flaccid

! APH – PPH

Couvelaire’s uterus = Uterine

apoplexy ie unconscious,
incapacitated !
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Incidence & Aetiology

! Incidence : About 1 % of Pregnancies

! Fetal Perinatal Mortality about 15 %

! Aetiology : Unknown

! but may be related to chronic placental disease as

! predisposing factors include HPT, smoking

! : Trauma – MVA

! - Sudden overstretching, decompression of uterus eg

! following delivery of first twin, polyhydramnois

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RISK
FACTORS
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CLINICAL FEATURES
Symptoms

! Abrupt Vaginal bleeding in 80%. ( 20 % concealed )

! Usually dark colour. viz fresh red blood in pl. praevia, vasa praevia

! Abdominal pain and / backache

! Uterine contractions

! Preterm labour
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CLINICAL FEATURES
SIGNS
! Uterine contractions

! Uterine tenderness / woody hard

! Fetal distress / IUD

! Signs of hypovolemia , shock

! Signs of DIVC : bleeding from venepuncture sites

! In cases of concealed hgge, the degree of shock is out of

proportion to the amount of bleeding
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DIFFERENTIAL DIAGNOSIS
APH

! Uterine Rupture

! Preterm labour
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Vasa Praevia
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CLASSIFICATION
( severity of abruptio )
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INVESTIGATIONS

! DIAGNOSIS of Abruptio
Placenta is CLINICAL

! ULTRASOUND may show

retroplacental clot.
Exclude placenta praevia

! CTG : Fetal distress

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LAB INVESTIGATIONS
( DIVC ) Consumption Coagulopathy
20 % of cases
! BOTH COAGULATION & FIBRINOLYSIS AT SAME TIME

! Blood group : Rhesus

! Hb, Platelet

! Prothrombin time, Activated partial thromboplastin time

! Fibrinogen, Fibrin / Fibrinogen degradation product

! D – Dimer : measures clot that is breaking down

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Coagulation Pathway
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DIVC lab tests
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MANAGEMENT

! ASSESS SEVERITY

! FETAL CONDITION

! ULTRASOUND AND LAB TESTS

! STABILIZATION OF MOTHER : large bore canula

! : treatment of hypovolemic shock

! : correction of DIVC

! CLOSE MONITOR OF MOTHER & FETUS

! RH – ve mother KLEIHAUER test : quantify the size of fetomat hgge.

! : Appropriate dose of Anti D

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MANAGEMENT ( cont )
! Depends on SEVERITY OF ABRUPTION & GESTATION & FETAL CONDITION

! Term Gestation, Hemodynamically stable

! Plan for vaginal delivery, LSCS for any other Obst complications

! Continous fetal monitoring

! Term Gestation, Hemodynamically unstable

! Resustication

! Correction of DIVC

! Urgent LSCS unless delivery imminent

! If fetus is dead, aim for vaginal delivery

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MANAGEMENT ( Cont )

! Preterm gestation, Hemodynamically stable

! In the absence of labour, conservative with follow up with serial

USG and tests of fetal well being

! Steroids to promote lung maturity, anticipate delivery

! Delivery once reaches Term

! Preterm gestation, Hemodynamically unstable

! Delivery should be performed after appropriate resuscitation

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MANAGEMENT ( Cont )

! Anticipate PPH : active management of 3rd stage

! Controlled Cord Traction

! Syntometrine, other uterotonics

! Oxytocin infusion

! Couvelaire’s uterus during LSCS : anticipate and consent for

! caesarean hysterectomy
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MANAGEMENT
CORRECTION OF HYPOVOLEMIC SHOCK & DIVC

! Airway, breathing, oxygen, IV access, Left lateral tilt

! Crystalloids – Hartmann’s solution ( up to 2 L )

! Colloids – albumin, voluven ( hydroxyethyl starch ) : up to 1 – 2 L

! Blood & Blood products

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Crystalloids
vs Colloids
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BLOOD &
BLOOD
PRODUCTS
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TARGET OF FLUID RESUSCITATION

Ensure adequate end organ perfusion

1. Urine output > 0.5ml / kg / hour

2. Mean arterial blood pressure ( MAP ) > 65 mmHg.

MAP is the average pressure in pt’s arteries during one cardiac cycle.

It is a better indicator of perfusion to vital organs than systolic pressure

3. CVP > 4 mmHg ( normal 2 – 6 mmHg )

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TARGET OF BLOOD / PRODUCTS
TRANSFUSION

! Hb > 8.0 g/dl

! Platelet count > 75,000 / micro L

! Prothrombin time < 1.5 x mean control

! activated Prothrombin time < 1.5 x mean control

! Fibrinogen > 1.0 g/l

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KEY POINTS
! ABRUPTIO PLACENTA : a major obstetric complication which threatens the life of
mother and fetus

! In CONCEALED ABRUPTION, the degree of shock is out of proportion to the degree of

bleeding

! In severe cases, there is usually signs of fetal distress or IUD

! DIVC is a major complication

! In a major abruption, the treatment is stabilization of mother, correction of DIVC,

delivery. Fetal well being is a concern.

! In minor, chronic abruptions, monitor fetal growth, steroids and delivery once baby
reaches Term
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References

! UptoDate : Abruptio placentae

! Antepartum hemorrhage Green – Top Guideline No 63 Nov 2011

! Obstetrics Today : Prof Sachithanantham, Dr. Kavitha Nagandla

! Handbook of Obstetric Emergencies : OGSM