Dr.

SABIN SHRESTHA
1ST YEAR RESIDENT
DEPARTMENT OF OBS/GYNAE
 CONTENT
• Disease name and synonyms
• Introduction
• Epidemiology
• Etiology
• Pathophysiology
• Classification
• Signs and symptoms
• Diagnosis
• Investigations
• Treatment
• Complications
• Differential diagnosis
 Disease name and synonyms

Pre mature separation of placenta

Accidental hemorrhage
Abruptio placenta
Ablatio placenta
Placenta abruptio
INTRODUCTION
• Placental abruption is premature separation of the normally implanted placenta—
either partially or totally—from its implantation site before delivery.

• Is one of the causes of bleeding during the second half of pregnancy.

• Is a relatively rare but serious complication of pregnancy and placed the well-
being of both mother and fetus at risk.
Epidemiology

• 1/3 of all antepartum bleeding is due to placental abruption

• Incidence ranging from 1 in 75 to 1 in 225 births

• Placental abruption recurs in 5 to 17% of pregnancies after 1 prior episode

• Up to 25% after 2 prior episodes

Etiology
• The exact etiology of placental abruption is unknown.

• Number of factors are associated with its occurrence.

• Risk factors can be thought of in 3 groups:

health history(behaviors and past obstetrical events)
current pregnancy
unexpected trauma.
• Factors that can be identified during the health history that increase the risk of
placental abruption include smoking, cocaine use during pregnancy, maternal age
over 35 years, hypertension, and placental abruption in a prior pregnancy.

• Conditions specific to the current pregnancy which may precipitate placental

abruption are multiple gestation pregnancies, polyhydraminous, preeclampsia,
sudden uterine decompression, and short umbilical cord.

• Trauma to the abdomen such as a motor vehicle accident, fall, or violence

resulting in a blow to the abdomen may lead to placental abruption.
Risk Factor Relative Risk
• Prior abruption 10–188
• Increased age and parity 1.3–2.3
• Preeclampsia 2.1–4.0
• Chronic hypertension 1.8–3.0
• Chorioamnionitis 3.0
• Preterm ruptured membranes 2.4–4.9
• Multi fetal gestation 2–8
• Low birth weight 14.0
• Hydraminous 2–8
• Cigarette smoking 1.4–1.9
• Single umbilical artery 3.4
• Cocaine use NA
• Uterine leiomyoma NA
• Most predictive is abruption in a previous pregnancy.

• Abruption recurs in 19–25% of women who have had two previous pregnancies
complicated by abruption.

• A large observational study from Norway reported a 4.4% incidence of recurrent

abruption.

• First trimester bleeding increases the risk of abruption later in the pregnancy. A
retrospective cohort study from Denmark found that threatened miscarriage
increases the risk of placental abruption from 1.0% to 1.4%.
• A systematic review reported first trimester bleeding to be associated with an
increased risk of placental abruption .When an intrauterine hematoma is identified
on ultrasound scan in the first trimester, the risk of subsequent placental abruption
is increased (RR 5.6)
Varieties
1.Revealed:
• Most common type
Separation of placenta

Blood insinuates downwards between the membrane and decidua

Blood comes out of cervical canal to be visible externally.

2.Concealed type:
• Rare type
• Blood collects behind the separated placenta or collected in between membranes
and decidua
• Collected blood is prevented from coming out of cervix by presenting part
compressing lower segment.
• At times, blood may enter the amniotic sac rupturing the membranes.
3.Mixed type:
• Some part of blood is collected inside and some part is expelled out.
• Usually one variety is predominant over other.
• Quite common.

Bleeding is almost always maternal. But placental tear may cause fetal bleeding.
 Pathophysiology
• The placenta is the fetus’ source of oxygen and nutrients as well as the way the fetus
excretes waste products. Diffusion to and from the maternal circulatory system is
essential to maintaining these life-sustaining functions of the placenta.

• Placental abruption occurs when the maternal vessels tear away from the placenta
and bleeding occurs between the uterine lining and the maternal side of the
placenta.

• As the blood accumulates, it pushes the uterine wall and placenta apart from the
maternal vascular network, the vital functions of the placenta are interrupted.

• If the fetus does not receive enough oxygen and nutrients, it dies.
Risk factors

Hemorrhage into the decidua basalis.

Degeneration and necrosis of the decidua basalis as well as the placenta adjacent.

Rupture of the basal plate forming communication between hematoma and

intervillous space

Fluid and blood percolate into myometrium upto serous coat(couvelaire uterus)

Sometimes serosa splits open and blood enters into peritoneal cavity
 Couvelaire’s uterus

• Also called as Utero-placental apoplexy

• First described by Couvelaire in early 1900s
• Extravasation of blood into uterine musculature & beneath uterine serosa
• Demonstrated only at laparotomy
• These myometrial hemorrhage seldom interfere with uterine contraction and alone
are not indication for hysterectomy.
Grossly

• Uterus is of dark port wine colour-Patchy/Diffuse

• Begin on cornu, specially in placental site than spread to other area.

• Effusion of blood is also seen beneath the tubal serosa, between leaves of broad
ligaments, in the substance of the ovaries and free in the peritoneal cavity.
Microscopic appearance
• The uterine muscles over the affected area are necrosed with infusion of blood and
fluid in between the muscle bundles.

• Most of the muscle dissociation occurs in the middle and outer muscle layers.

• Serosa may split on occasion, to allow blood entry into peritoneal cavity.

• Blood vessels show acute degenerative changes with thrombosis

CLASSIFICATION
• The clinical implications of a placental abruption vary based on the extent of the
separation and the location of the separation. 

• Placental abruption can be complete or partial and marginal or central.

• The classification of placental abruption is based on the following clinical

findings:
Class 0: Asymptomatic

• Discovery of a blood clot on the maternal side of a delivered placenta

• Diagnosis is made retrospectively

Class 1: Mild

• No sign of vaginal bleeding or a small amount of vaginal bleeding.

• Slight uterine tenderness

• Maternal blood pressure and heart rate within normal limit

• No signs of fetal distress

Class 2: Moderate

• No sign of vaginal bleeding to a moderate amount of vaginal bleeding

• Significant uterine tenderness with tetanic contractions

• Change in vital signs: maternal tachycardia, orthostatic changes in blood pressure.

• Evidence of fetal distress

• Clotting profile alteration: hypofibrinogenemia

Class 3: Severe

• No sign of vaginal bleeding to heavy vaginal bleeding

• Tetanic uterus/ board-like consistency on palpation

• Maternal shock

• Clotting profile alteration: hypofibrinogenemia and coagulopathy

• Fetal death
• Classification of 0 or 1 is usually associated with a partial, marginal separation

• classification of 2 or 3 is associated with complete or central separation.

Signs and symptoms

Depends on-
• Degree of separation of placenta.

• Speed at which separation occurs

• Amount of blood concealed inside the uterine cavity

• Vaginal bleeding: 78%

• Uterine tenderness: 66%

• Back pain: 60%

• Fetal distress: 22%

• Hypertonus: 17%

• Fetal demise: 15%

 Mixed(Concealed Features
Parameters Revealed
Predominate)

•Abdominal acute intense

pain
Abdominal discomfort or
followed by slight vaginal
Symptoms pain followed by vaginal
bleeding.
bleeding (usually slight)
•The pain becomes
continuous

Continuous, dark color

Character of Continuous dark color
(usually slight) or blood
bleeding (slight to moderate)
stained serous discharge

•Proportionate to the visible •Shock may be pronounced

General condition blood loss which is out of proportion to
•shock is usually absent. the visible blood loss.

Pallor is usually severe and

Related with the visible
Pallor out of proportion to
blood loss
the visible bleeding
 Proportionate to the May be disproportionately
Uterine height
period of gestation. enlarged and globular.

Normal feel with localized

Uterine feel tenderness, contractions frequent Uterus is tense, tender and rigid
and local amplitude.

Fetal parts Can be identified easily Difficult to make out

FHS Usually present Usually absent

Urine output Normal Usually diminished

2076/12/21 Placental abruptio.UB 31

 DIAGNOSIS
Basis of diagnosis consists of :
• History & physical examinations

• Triad of P/V bleeding, Uterine or back pain and fetal distress should be of high
suspicion.

• Defer digital cervical examinations until Placenta previa & Vasa previa are ruled out

• Ultrasound – limited value but for large abruptions hypoechoic areas seen underlying
placenta.
 History and Physical
• Placental abruption is one of the causes of vaginal bleeding in the second half of
pregnancy.

• History and physical examination are critical to the appropriate management of the

maternal/fetal outcome

• Focused history and physical is critical to differentiate placental abruption and other
causes of vaginal bleeding.

• Because a definitive diagnosis of placental abruption can only be made after birth
when the placenta is examined
• History begins with a review of the prenatal course, especially placental location on
prior sonograms and if there is a history of placental abruption in previous
pregnancies.

• Exploring the woman’s behaviors, specifically whether she smokes or uses cocaine
is a critical component of history.

• Asking about potential trauma, especially in the abdominal area needs to be done in
a tactful and supportive manner and in situations of partner abuse, the woman may
be reluctant to reveal that she sustained trauma to her abdomen.
Most useful mechanism for recognizing the onset of placental abruption is an assessment
of the patient.

• Palpation of the uterus:

Uterus is palpated for tenderness, consistency, and frequency and duration of uterine
contractions, if present.

The tense or ‘woody’ feel to the uterus on abdominal palpation indicates a significant
abruption.

Soft, non-tender uterus may suggest a lower genital tract cause or bleeding from placenta
or vasa previa
.
Speculum examination
• Vaginal area is inspected for the presence of bleeding.
• If bleeding is present, the quantity and characteristic of the blood, as well as the
presence of clots, is evaluated.
• Absence of vaginal bleeding does not eliminate the diagnosis of placental abruption
• A speculum examination can be useful to identify cervical dilatation or visualize a
lower genital tract cause for the APH.
• In a prospective observational study of 564 women presenting with APH, 521
(92.4%) underwent an admission speculum examination; 389 women (69%) had a
normal cervix, 120 (21%) had cervical ectropion and 12 (2%) had a dilated cervix.
• If the woman presents with a clinically suspicious cervix she should be referred for
colposcopic evaluation
• Digital examination of the cervix should be delayed until a sonogram is
obtained for placental location and to rule out a placenta previa.

• Evaluation of vital signs to detect tachycardia or hypotension, which may be

indicators of a concealed hemorrhage are taken.

• Evaluation of fetal well-being:

Begin with auscultation of fetal heart sounds and ask about fetal movement,
specifically recent changes in activity patterns.
Continuous electronic fetal monitoring is initiated to identify prolonged
bradycardia, decreased variability, and the presence of late decelerations.
INVESTIGATIONS

Maternal investigation:
• Blood specimens such as a complete blood count (CBC), fibrinogen, clotting profile,
and type and RH may be collected. These laboratory values will not aid in the
diagnosis of placental abruption but will provide baseline data against which to
evaluate the patient’s condition over time.

• The Kleihauer test should be performed in rhesus D (RhD)-negative women to

quantify fetomaternal haemorrhage (FMH) in order to gauge the dose of anti-D
immunoglobulin (anti-D Ig) required.
 Mixed
Parameters Revealed
(Concealed Feature Predominate)

Low value proportionate Markedly lower, out of proportion to

Blood: Hb%
to the blood loss the visible blood loss

Variable changes:
•Clotting time increased (> 6 min)
•Fibrinogen level-low (< 150mg/dL)
Coagulation profile Usually unchanged
•Platelet count-low
•↑ partial thromboplastin time
•↑ FDP and D-dimer

Urine for protein May be absent Usually present

Ultrasound scan:
• Scan should be performed to confirm or exclude placenta previa if the placental
site is not already known.
• Is well established in determining placental location and in the diagnosis of
placenta previa.
• The sensitivity of ultrasound for the detection of retroplacental clot (abruption) is
poor.
• Glantz reported the sensitivity, specificity, and positive and negative predictive
values of ultrasonography for placental abruption to be 24%, 96%, 88% and 53%
respectively. Thus, ultrasonography will fail to detect three-quarters of cases of
abruption. However, when the ultrasound suggests an abruption, the likelihood that
there is an abruption is high
Fetal investigation
• An assessment of the fetal heart rate should be performed, usually with a
cardiotocograph (CTG) in women presenting with APH once the mother is stable
or resuscitation has commenced, to aid decision making on the mode of delivery.

• In one study, the fetal heart-rate pattern (CTG) was abnormal in 69% of women
presenting with placental abruption.

• Ultrasound should be carried out to establish fetal heart pulsation if fetal viability
cannot be detected using external auscultation to exclude an intrauterine fetal
death
TREATMENT
• Onset of placental abruption is often unexpected, sudden, and intense and requires
immediate treatment.
• Pre-hospital care for the patient with a suspected placental abruption requires
advanced life support and transport to a hospital with a full-service obstetrical unit
and a neonatal intensive care unit.
• Following arrival at the hospital, intravenous (IV) fluids and supplemental oxygen
as well as continuous maternal and fetal monitoring should be done
• Treatment will vary based on the data collected during the assessment, the
gestation of the pregnancy, and the degree of distress being experienced by the
woman and/or the fetus
Prevention
• The prevention aims at—
(1) Elimination of the known factors likely to produce placental separation.
(2) Correction of anemia during antenatal period so that the patient can withstand
blood loss.
(3) Prompt detection and institution of the therapy to minimize complications like
shock, blood coagulation disorders and renal failure.
Prevention of known factors likely to cause placental separation are
Early detection and effective therapy of preeclampsia and other hypertensive disorders of
pregnancy.

 Needle puncture during amniocentesis should be under ultrasound guidance.

Avoidance of trauma—specially forceful external cephalic version under anesthesia.

To avoid sudden decompression of the uterus— in acute or chronic hydramnios, amniocentesis is
preferable to artificial rupture of the membranes.

To avoid supine hypotension the patient is advised to lie in the left lateral position in the later
months of pregnancy.

Routine administration of folic acid from the early pregnancy — of doubtful value.
• AT HOME:
Patient should be shifted to an equipped maternity unit as early as possible

• IN THE HOSPITAL:
Assessment of the case is to be done as regards:
(a) amount of blood loss
(b) maturity of the fetus and
(c) whether the patient is in labor or not
(d) presence of any complication
(e) type and grade of placental abruption
• Emergency measures:
(i) blood is sent for hemoglobin and hematocrit estimation, coagulation profile and
blood grouping and urine for detection of protein

(ii) Ringer’s solution drip is started with a wide bore cannula and arrangement for
blood transfusion is made for resuscitation.

• Close monitoring of maternal and fetal condition is done

Management options are:
(a) immediate delivery
(b) management of complications if there is any
(c) expectant management (rare).
Immediate delivery:
• The patient is in labor

• The patient is not in labor

The patient is in labor:
• The labor is accelerated by low rupture of the membranes.
• Rupture of the membranes with escape of liquor amnii accelerates labor and it
increases the uterine tone also.
• Oxytocin drip may be started to accelerate labor when needed.

Vaginal delivery is favored in cases with:

(i) limited placental abruption
(ii) FHR tracing is reassuring
(iii) facilities for continuous (electronic) fetal monitoring is available
(iv) placental abruption with a dead fetus.
The patient is not in labor:
(i) Bleeding continues
(ii) > Grade I abruption
• Delivery either by
(A) induction of labor
(B) cesarean section
 Cesarean section:
Indications are :
(a) severe abruption with live fetus
b) amniotomy could not be done
(c) amniotomy failed to control bleeding
(d) amniotomy failed to arrest the process of abruption (rising fundal height)
(e) appearance of adverse features (fetal distress, falling fibrinogen level, oliguria).
COMPLICATIONS
A)Maternal
• Anemia
• Infection
• Maternal shock
• Renal tubular necrosis
• Consumptive coagulopathy
• Post partum hemorrhage
• Prolong hospital stay
• Complications od blood transfusion
• Recurrence(4-12%)
• Hysterectomy
B)Fetal complications
• Fetal hypoxia
• Prematurity
• Growth restriction
• Central Nervous System anomalies
• Fetal death
DIFFERENTIAL DIAGNOSIS
• Placenta previa
• Vasa previa
• Infection
• Lower genital tract lesion
• Bloody show
Abruptio VS Placenta previa
• Onset of symptoms is sudden and intense for placental abruption but quiet and
insidious for placenta previa
• Bleeding may be visible or concealed with placental abruption and is external and
visible with placenta previa
• Degree of anemia or shock is greater than the visible blood loss in placental
abruption and is equal to the blood loss in placenta previa.
• Pain is intense and acute in placental abruption and is unrelated to placenta previa.
• Uterine tone is firm and board-like in placental abruption and soft and relaxed in
placenta previa.
Enhancing Healthcare Team Outcomes

It is a serious complication of pregnancy and is best managed by an interprofessional team of

healthcare professionals.
Nurse should be aware of this condition and immediately admit and notify on duty doctor
While the patient is being resuscitated, the obstetrician should be called ASAP.
Immediate transfer to an ICU setting is highly recommended and blood should be crossed
and typed in case needed.
Placental abruption is a true obstetric emergency and requires collaboration between the
anesthesiologist and a radiologist.
Operating room nurses should be informed of the patient so that they have the room
prepared.
In case the fetus is premature, the neonatal ICU team should be notified.
Only with a team approach can the morbidity and mortality of this disorder be lowered
References
• WILLIAMS obstetrics 25TH EDITION
• DUTTA OBSTETRICS-9th edition
• https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg63/
• https://www.ncbi.nlm.nih.gov/books/NBK482335/
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2009;116:693–699.
• Kennare R, Heard A, Chan A. Substance use during pregnancy: risk factors and
obstetric and perinatal outcomes in South Australia. ANZJOG 2005;45:220–5.
• Lykke JA, Dideriksen KL, Lidegaard O, Langhoff-Roos J. Firsttrimester vaginal
bleeding and complications later in pregnancy. Obstet Gynecol 2010;115:935–44.
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RG, Exalto N; ESHRE Special Interest Group for Early Pregnancy (SIGEP).
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complications: a review. Hum Reprod Update 2009;15:409–21
• Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment
of placental abruption. J Ultrasound Med 2002;21:837–40.