MANAGEMENT OF ABRUPTIO PLACENTAE

INTRODUCITON
DEFINITION
- It is an antepartum haemorrhage defined as premature separation of part or
the whole of a normally situated placenta from the site of uterine
implantation (upper uterine segment) leading to bleeding from either maternal
or fetal circulation.

EPIDEMIOLOGY
- Nearly 50% of placental abruptions occur at term gestations (defined as ≥37
weeks of gestation).
- Abruptio placentae also occurs in about 1% of all pregnancies throughout the
world.
- The frequency of abruptio placentae in the United States is approximately 1%
- The prevalence of abruption in European countries is 3–6 per 1000
pregnancies, whereas the corresponding data in North America is two-fold
higher (7–12 per 1000 pregnancies)
- The prevalence of abruptio placenta was 1.03%, in a retrospective study carried
out from year 2012 -2016, at Olabisi Onabanjo University Teaching Hospital
Sagamu, Nigeria
-
PATHOPHYSIOLOGY

MANAGEMENT
Biodata
- Age
o Advanced Maternal age
- Parity
o Multiparity
- Gestational age
o ≥ 28 weeks (beyond age of viability)

Presenting Complaints
- +/- Vaginal bleeding
o Vaginal bleeding, in most case (for revealed), OR NO vaginal bleeding
(for concealed)
o Dark red blood
- +/- Abdominal pain (superimposed with abnormal uterine contractions)
o Sudden onset
o Usually constant; but can be intermittent and colicky (like labour pains)
o Can be generalized or felt in lower abdomen
- stms back pain
- Symptoms of shock (due to bleeding) e.g. sweating, dizziness, fainting
- Symptoms of anaemia – same as shock, +/- palpitation, …

Questions to ask to differentiate Abruptio placentae from placentae praevia

o Are you still feeling foetal movement? Or when was the last time you
felt foetal movt?
 Not feeling of fetal movt - - -> Abruptio placentae
 Feeling foetal movt? - - -> Placenta praevia
o Was there any hx of warning bleeding in the past?
 No - - - > Abruptio placentae
 Yes - - -> Placenta praevia

Brief Examination
- General examination
o +/- in painful distress; restless; Pale, weak, cold clammy extremities
o Sanitary Pad or cloth soaked with blood
- Vitals - BP, PR, RR, Spo2
o Normal vitals ____ Mild abruptio
…OR
o Abnormal vitals
 Hypotension, Tachycardia, +/- Tachypnoea, +/- low SPO2
- Brief abdominal examination
o Tense abdomen
o Foetal heart beat present or absent?
- Brief vaginal examination – to see if cervical changes has started & if
membranes are intact
o Remember that abruptio placentae is associated with Preterm &
Precipitous Labour
 Women diagnosed with abruption are at 4–6-fold increased risk
of delivering at preterm gestations. It is believed that release of
thrombin because of decidual-placental hemorrhage (17–19)
and hemosiderin deposition (8, 20)—both commonly found in
the setting of abruption—triggers labor leading to preterm
delivery.

Immediate Intervention
- Call for help
- Secure 2 wide-bore cannula
- Take blood for the following invx:
o urgent PCV,
o GXM of at least 6 pints of blood,
o Clotting profile, Bedside clotting time
- IVF N/S (or R/L) 1-2 Liters, STAT,
- Pass urethral catheter to monitor urine output
o This better helps to monitor CV (cardiovascular) stabilization better
than monitoring BP
- Analgesia
 o Parenteral PCM, if baby’s alive
o NSAIDS (Diclofenac, …) or Opioids (pethidine, pentazocine, …) – if
foetus is dead
- Give supplemental 100% O2
- Perform amniotomy or A.R.M. (artificial rupture of membrane) to:-
o decrease intrauterine pressure,
o extravasation of blood into the myometrium,
o and entry of thromboplastic substances into the circulation
o and to help expedite delivery (of baby & placenta), so that there is
reduction of active blood loss
- Administer Rh immune globulin if the patient is Rh-negative.

Complete history taking

- Assess causes/risk factors
o HTN (first to mention), Severe Pre-eclampsia, Eclampsia
 A known HTNsive? Or was she diagnosed of HTN in index
pregnancy?
o Other Systemic illness e.g. D.M., SLE
o Previous hx of abruptio placentae
o Direct Trauma to the abdomen
 e.g. a blow to the abdomen
o Anything that makes uterine wall hyper-dilatate
 Multiple pregnancy
 Polyhydramnios
 Fibroid
o Short umbilical cord
o Sudden premature rupture of membrane
o Chorioamnionitis
o Low socioeconomic status
o Cocaine use
o Cigarette smoking
- Course
o Gradual or rapid progression of symptoms

Complete Physical examination

- Abdomen
o Tense abdomen; may or may not be Woody hard
o Difficult to determine or count uterine contractions as a result of the
tense or woody hard abdomen
o No foetal parts felt
 But foetal head may be felt, in cephalic presentation
o Foetal heartbeat may or may be heard
 Not heard? - -
 most likely fetal demise …
 or may be due to the woody hard abdomen
- VE -
o Blood-soaked perineum
 o Actively bleeding, with blood pouring out of the vaginal like tap water
o + clot
o +/- Cervical dilation
- NOTE: AVOID DIGITAL OR SPECULUM VAGINAL EXAMINATION , IF UNSURE IF
THE APH IS DUE TO ABRUPTIO OR PRAEVIA

Bedside investigation
- Bedside clotting time
- Bedside obstetrics USS, if available
o The hallmark of diagnosis of AP is Abdominal USS;
o Hematoma is seen as hypoechoic or hyperechoic lesion between the
placenta and uterine wall
o
- CTG
o should be performed in women above 26 weeks gestation to assess fetal
wellbeing. Abruption can result in fetal hypoxia and abnormalities of
the fetal heart rate pattern. Under 26 weeks handheld doppler or USS
should be performed to assess for a fetal heartbeat.
Monitoring
- FHR
- Maternal Vitals
- Urine output

Classify the Abruptio, Clinically

- Class 1 (Mild abruptio placentae)
o No sign of vaginal bleeding or a small amount of vaginal bleeding.
o Slight uterine tenderness
o Maternal BP and PR are WNL
o Live foetus with NO distress
o < 500ml of blood loss
o No coagulopathy i.e. Fibrinogen > 250mg/dl
- Class 2 (Moderate abruptio placentae)
o No vaginal bleeding to moderate vaginal bleeding
o Moderate to severe uterine tenderness, with possible tetanic
contractions
o Maternal tachycardia, with orthostatic changes in BP and heart rate
o Fetal distress
o 500 to < 1000ml of blood loss
o Hypofibrinogenemia (ie, 150-250 mg/dL)
- Class 3 (Severe abruptio placentae) divided into 3A (without DIC) & 3B (with
DIC)
o No vaginal bleeding to heavy vaginal bleeding
o Very painful tetanic uterus
o Maternal shock; i.e. Hypotension, Tachycardia
o Fetal death
 o > 1000mls of blood loss
o Hypofibrinogenemia (ie, < 150 mg/dL)
- NOTE; there is a Class 0 abruptio placentae : Asymptomatic
o Discovery of a blood clot on the maternal side of a delivered placenta
o Diagnosis is made retrospectively
- NOTE - Classification of 0 or 1 is usually associated with a partial, marginal
separation, whereas classification of 2 or 3 is associated with complete or
central separation

CONTINUATION OF TREATMENT
- Expedite blood transfusion, where needed/available
o If the woman is in shock or with symptomatic anaemia, it is better to
ensure blood is available before commencing definitive tx or plans to
deliver the baby
o It is preferrable to transfuse with fresh whole blood, esp in moderate &
severe abruptio, because mother is losing not only red cells but also
plasma (which contains clotting factors & platelets)
-
- Definitive treatment depends on the severity of the abruptio,
o For Mild abruptio placentae
 < 36 weeks –
 admit for bedrest & observe closely for 24-48hrs,
 steroids (e.g. IV dexamethasone 12mg 12hrly x 24hrs)
 treat risk factors,
 no tocolysis,
 gestational age determines delivery
 > 36 weeks –
 admit,
 then IOL or ARM (if cervix is 4cm dilated & above) after
confirming foetus is in cephalic presentation
o for haemorrhage at term without maternal or
fetal compromise, induction of labour is usually
recommended to avoid further bleeding.
o ARM done to
 Decrease Intrauterine pressure
 Cause release of endogenous
prostaglandins
 to expedite delivery
o when doing ARM, control the flow of amniotic
fluid, with your fingers, to prevent sudden
decompression of uterus because such action will
lead to further shearing of the placental
membranes
o Moderate abruptio placentae
 Steroid (e.g. IV dexamethasone 12mg stat), if EGA < 34wks
 Do EMCS (since the foetus is alive & you want to prevent
development of DIC/coagulopathy)
o Severe abruptio placentae (i.e. foetus is dead)
 Without DIC
  Cervix not favourable,
o IOL for vaginal delivery
 OR
o Do EMCS with Fresh whole blood (to prevent
patient from progressing to DIC)
 Cervix favourable
o Do A.R.M, +/- Augmentation, to achieve vaginal
delivery
 Actually do A.R.M. then wait for 1-2hrs
before augmentation
 With DIC (in 30% of severe abruptio placentae)
 The best treatment for DIC as a complication of placental
abruption is immediate delivery [MEDSCAPE]
 First treat the DIC via transfusion of fresh whole blood
 Then deliver baby either vaginally or via C/S, preferably
via vaginal delivery
o NOTE: for the EMCS
 a vertical skin incision is used on the abdomen because it is
assoc. with less blood loss & is often used when the patient
appears to have DIC.
 The type of uterine incision is dictated by the gestational age of
the fetus, with a vertical or classic uterine incision often being
necessary in the preterm patient.
 If hemorrhage cannot be controlled after delivery, a cesarean
hysterectomy may be required to save the patient's life.
 Before proceeding to hysterectomy, other procedures,
including correction of coagulopathy, ligation of the
uterine artery, administration of uterotonics (if atony is
present), packing of the uterus, and other techniques to
control hemorrhage, may be attempted.
o In all cases, anti-D should be administered within 72 hours of the onset
of bleeding if the woman is rhesus D negative.
-

Post delivery care

- Transfuse blood

Prevention
- Treat or prevent risk factors
o Treat maternal hypertension.
 Note that although hypertensive conditions increase the risk of
placental abruption, they do not appear to increase the rate of
recurrence of placental abruption in subsequent pregnancies.
o Prevent maternal trauma/domestic violence.
o Prevent smoking and substance abuse.
o Diagnose placental abruption at an early stage in high-risk groups (eg,
maternal hypertension, maternal trauma, association with domestic
 violence, smoking habit, substance abuse, advanced maternal age,
premature ruptured membranes, uterine fibromyomas, amniocentesis).
o Elective induction of labour from 37wks GA, for women with hx of
recurrent of abruptio placentae, or women at risk of recurrence