1

PLACENTAL PREVIA AND

ABRUPTION
KOOMSON KOFI KAMAL
 2

PLACENTAL ABRUPTION
• It is also known as abruptio placentae

• It is the premature separation of the placenta

from the uterus.

• Can occur any time after the 20th week of

pregnancy till birth.

• Only about 1% of all pregnant women will

experience placental abruption.
 3

What is it?
• The placenta is part of the baby’s life support
system.

• Placental expulsion begins as a physiological

separation from the wall of the uterus.

• When the placenta separates from the uterine lining

before labour, then we have placental abruption.

• Placental abruption can only be truly diagnosed

after birth when the placenta can be examined.
 4

CAUSES OF PLACENTAL ABRUPTION

• Maternal hypertension • Alcohol consumption
and preeclampsia • Cigarette smoking
• Maternal trauma • Fibromyoma
• Cocaine use • Previous placental
• Sudden abruption
decompression of the • Maternal ages 35
uterus years and above and
• Chorioamnionitis below 20 years.
 5

SYMPTOMS OF PLACENTAL ABRUPTION

• Vaginal bleeding

• Abdominal or back pain and uterine tenderness

• Fetal distress

• Abnormal uterine contractions

• Idiopathic premature labour

• Fetal death
 6

CLASSIFICATION
• Extent of separation (partial vs complete/total)

• Location of separation (marginal vs central)

• Clinical characteristics (class 0, 1, 2 and 3)

• Presence and extent of bleeding
• Maternal BP and heart rate
• Fetal distress or death
• Uterine tenderness and presence of contractions
• Presence of coagulopathy
 7

• CLASS 0
Diagnosis by finding an organized blood clot or a
depressed area on a delivered placenta.

• CLASS 1
No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No foetal distress
 8
CLASS 2 CLASS 3
• No vaginal bleeding to • No vaginal bleeding to
moderate vaginal heavy vaginal bleeding
bleeding.
• Moderate to severe • Very painful tetanic

uterine tenderness, uterus

with possible tetanic
• Maternal shock
contractions
• Maternal tachycardia,
• Hypofibrinogenemia (<
with orthostatic
150 mg/dL)
changes in BP and
heart rate.
• Coagulopathy
• Fetal distress
• Hypofribrinogenmia
• Fetal death
(50-250 mg/dL)
 9

DIRECT COMPLICATIONS
MATERNAL FETAL
• Hemorrhagic shock
• Hypoxia

• Coagulopathy/
disseminated • Anemia
intravascular coagulation
• Growth retardation
• Uterine rupture

• Renal failure
• CNS anomalies

• Ischemic necrosis of distal • Fetal death

organs such as hepatic,
adrenal, pituitary.
 10

INDIRECT COMPLICATIONS
• Indirect maternal and fetal complications include
issues related to
1. Caesarean delivery (with need for repeat
caesarean deliveries)
2. Hemorrhage/coagulopathy and transfusion-
related morbidity
3. Prematurity
 11

LABORATORY STUDIES
• No laboratory studies definitive for placental abruption

1. Complete blood count

1. Hemoglobin
2. hematocrit
3. Platelets

2. Fibrinogen study
1. Fibrinogen (less than 200 mg/dL)
2. Fibrin/ fibrinogen degradation products

3. Prothrombin time (PT)/ activated partial thromboplastin

time (aPTT)

4. Blood urea nitrogen/ creatinine study

 12

ULTRASONOGRAPHY
• Ultrasonography is not very useful in diagnosing
placental abruptiuon and normal ultrasonographic
findings do not exclude the condition.

• Ultrasonography helps to determine the location

of the placenta in order to exclude placenta
previa
 13

PREVENTION
• Treat maternal hypertension

• Prevent maternal trauma and domestic violence

• Prevent smoking and alcohol intake as well as substance

abuse.
 14

MANAGEMENT
VAGINAL DELIVERY CAESAREAN DELIVERY
• Preferred method if fetus • Facilitates rapid delivery
has died secondary to and gives direct access
placental abruption. to the uterus and its
vasculature.
• Depends on her
remaining • Can be complicated by
hemodynamically stable. the patient’s coagulation
status.
• Delivery is usally rapid
secondary to increased
uterine tone and
contractions.
 15

OTHER PROCEDURES
• Correction of the coagulopathy

• Ligation of the uterine artery

• Administration of uterotonics (if atony is present)

• Packing of the uterus

• Caesarean hysterectomy (last resort)

• In instances where significant bleeding ensues,

rapid replacement of blood products is a priority.
 16

PLACENTAL PRRIVEA
• Placenta previa is a condition that classically
presents as painless vaginal bleeding secondary
to abnormal placentation near or covering the
cervical os.

• The diagnosis is commonly made earlier in

pregnancy.
 17

What is it?
• Placental implantation is initiated by the embryo
adhering in the lower uterus.

• Developing placenta may cover the cervical os,

however defective decidual vasculariastion occurs
over the cervix.

• Bleeding is in association with the development of

the lower uterine segment in the third trimester.
 18

What is it?
• The area gradually thins in preparation for the
onset of labour.

• This leads to bleeding at the implantation site

because the uterus is unable to contract
adequately.

• Thrombin release from the bleeding sites

promotes uterine contractions and leads to a
cycle of bleeding-contractions-placental
separation-bleeding.
 19

CAUSES OF PLACENTAL ABRUPTION

• Maternal ages 35 • Previous uterine
years surgery, uterine insult
• Infertility treatment or injury
• Multiparity • Previoius caesaren
• Multiple gestation section
• Short interpregnacy • Previous abortion

interval • Previous placenta

• Smoking previa
• Cocaine use
 20

SYMPTOMS OF PLACENTAL ABRUPTION

• The classic presentation of placenta previa is
painless, bright reed vaginal bleeding that
often stops spontaneously and then recurs with
labour.

• Placenta previa often leads to preterm delivery.

• Profuse hemorrhage

• Hypotension

• Tachycardia
 21

CLASSIFICATION
• Two main types depending on the extent of covering the
cervix
1. Complete previa
2. Marginal previa
 22

COMPLICATIONS
MATERNAL FETAL
• Hemorrhage • Abnormal fetal
presentation
• Placental abruption
• Fetal Anemia
• Postpartum
endometritis • Intrauterine Growth
retardation
• Increased PPH and
hysterectomy • Low birth weight

• Fetal death
 23

PHYSICAL EXAMINATION
• Pregnant women beyond the first trimester with
vaginal bleeding
• Digital examination of the vagina is absolutely
contraindicated until placenta previa is excluded.

• Findings on examination, include:

1. Profuse hemorrhage
2. Hypotension
3. Tachycardia
4. Soft and non-tender uterus
5. Normal fetal heart tones usually
 24

LABORATORY STUDIES
1. Complete blood count
1. Hemoglobin
2. hematocrit
3. Platelets

2. Fibrinogen study
1. Fibrinogen
2. Fibrin/ fibrinogen degradation/split products

3. Prothrombin time (PT)/ activated partial

thromboplastin time (aPTT)
 25

ULTRASONOGRAPHY
• Ultrasonographic evaluation of the fetus is
valuable in identifying:

1. Current gestational age and weight

2. Potential congenital anomalies
3. Malpresentation
4. Evidence for fetal growth restriction

• Transvaginal and transabdominal ultrasonography

 26

TRANSVAGINAL TRANSABDOMINAL

• Gold standard for the • Simple, precise and

diagnosis of placenta safe
previa.
• Less accurate with
• Accurate, cost- false-positive and
effective and well false-negative rates
tolerated. as 7% and 8%
resectively
 27

MANAGEMENT
• Medical intervention: pharmacological agenys to
help resolve uterine atony, the main cause of
hemorrhage post-delivery.

• Surgical intervention
• Oversewing the placental implantation site
• Ligation of the uterine artery
• Administration of uterotonics (if atony is present)
• Packing of the uterus
• Caesarean hysterectomy (last resort)
• In instances where significant bleeding ensues,
rapid replacement of blood products is a priority.
 28

THANK YOU