ABRUPTIO PLACENTAE

OBJECTIVES
• Develop knowledge regarding abruptio placentae
• Develop positive attitude regarding abruptio placentae
INTRODUCTION
 INCIDENCE
• Approximately 0.4 to 1% of pregnancies are complicated
by placental abruption. The prevalence is lower in the
Nordic countries compared with USA. In developed
countries approximately 10% of all preterm birth 10 to 20%
of all perinatal deaths are caused by placental abruption.
The overall incidence is about 1 in 1000 deliveries.
 DEFINITION
• Abruptio placentae is one form of antepartum
hemorrhage where the bleeding occurs due to premature
srparation of normally situated placenta
 TYPES
• Revealed
• Concealed
• Mixed
• In revealed the blood comes downward between the
membrane and decided. It occurs at the margin
• Concealed the blood is collected in between the
membrane and decidua, it occurs at the center
• Mixed in this type, some part of blood collected and
inside out
 ETIOLOGY

• Etiology:
• High parity pregnencies
• Advancing age
• Poor socioeconomic condition
• Low nutritional state
• Smoking
• Hypertension
• Trauma:
• External cephalic version, especially under anesthesia using
great force
• Road traffic accidents, blunt trauma or blow on the abdomen
• Needle puncture at amniocentesis
• Sudden uterine decompression of uterus:
• Following delivery of the first baby of twin
• Sudden escape of liquor amnii in polyhydramnios
• Premature rupture of membrane
• Short cord
• Supine hypertension syndrome
• Placental anomaly
• Sick placenta
• Folic acid defficiency
• Uterine factor
• Torsion of the uterus
• Cocaine abuse
• Thrombophilias
• Hyperhomocysteinemia
• Couvelaire uterus: it is a pathological entity first described by
couvelaire and is met with association with severe form of
concealed abruptio placentae. There is massive intravasation of
blood into the uterine musculature upto the serous coat.
• Naked eye features:
• The uterus is of dark port wine color which may be patchy or
diffuse
• It tends to occur initially on the cornu before spreading to other
areas, more specially over the placental site
• Subperitoneal petechial hemorrhage are found under the
uterine peritoneum and may extend into broad ligament.
• Microscopic appearance:
• Uterine muscles over the affected area are
necrosed
• There is infiltration of blood and fluid in between
the muscle bundles.
• Changes in other organ:
• In liver : presence of fibrin knots in hepatic
sinusoids
• Kidney : acute cortical necrosis or acute tubular
necrosis, proteinuria
• Blood coagulopathy
 CLINICAL CLASSIFICATION

• Grade 0: clinical features absent. The diagnosis is made after

inspection of placenta following delivery
• Grade 1:
• Veginal bleeding
• Irritable, tenderness of uterus
• Maternal BP and fibrinogen level unaffected
• Fetal heart sound is good
• Grade 2:
• Veginal bleeding mild to moderate
• Uterine tenderness is always present
• Increased maternal pulse
• BP is maintained
• Fibrinogen level may be decreased
• Shock is absent
• Fetal distress or even fetal death occurs
• Grade 3:
• Bleeding is moderate to severe or may be concealed
• Uterine tenderness is marked
• Shock is pronounced
• Fetal death
• Associated coagulation defect or anuria may
complicate
DIAGNOSIS
 DIFFERENTIAL DIAGNOSIS

• Revealed type- placenta previa

• Mixed or concealed type- rupture uterus, rectus
sheath hematoma, appendicular or intestinal
perforation, acute hydramnio, tonic uterine
contraction
 COMPLICATION

• For mother
• For fetus
 FOR MOTHER

• In revealed type – blood loss and death in rare

• In concealed type-
• Hemorrhage
• Shock
• Blood coagulation disorder
• Pituitary failure(sheenhan syndrome)
• Organ damage
• Postpartum hemorrhage
• Pueperal sepsis
• Death
 FE TAL / NE ONATAL

• In revealed type- fetal death

• In concealed type-
• Fetal mortality
• Fetal hypoxia
• Neonatal prematurity
 MANAGEMENT
• Assessment of the cases is to be done as regards:
• Amount of blood loss
• Maturity of the fetus
• Whether the patient is in labor or not
• Presence of any complication
• Type and grade of placental abruption
 EMERGENCY MEASURES

• Blood test for hemoglobin and hematocrit estimation,

coagulation profile, ABO and Rh grouping and urine for
detection of protein
• Ringer‘s solution and blood transfusion
• Management options are-
• Immediate delivery
• Management of complication if present
• Expectant management
 DEFINITIVE TREATMENT
(IMMEDIATE DELIVERY)

•
Patient in labor
• Patient is not in labor
 PATIENT IS IN LABOR

•
ARM +/- oxytocin
• ↓
• Veginal delivery
•
↓
• Oxytocin to be continued
• Veginal delivery is favored in case with:
• Limited placental abruption
• FHR tracing is reassuring
• Facilities for continuous fetal monitoring available
• Prospect of veginal delivery is soon
• Placental abruption with a dead fetus
 ADVANTAGES OF AMNIOTOMY

• Initiates myometrial contraction and labor process

• Expedites delivery
• Better compression of spiral artery to arrest hemorrhage
• Reduces the risk of renal cortical necrosis
 THE PATIENT IS NOT IN LABOR

• If patient’s bleeding continues and grade

1abruption then delivery either by
• Induction of labor
• Caesarean section
 INDUCTION OF LABOR

• Induction of labor is done by low rupture of membranes

• Oxytocin may be added to expedite delivery
• Inj oxytocin 10 IU IV (slow)or IM or inj methergine
0.2mg iv is given to minimize postpartum blood loss
• Oxytocices should be used to improve the uterine tone
along with blood transfusion
 CAESAREAN SECTION

• Indication are:
• Severe abruption with live and viable fetus
• Appearance of adverse features (fetal distress, falling fibrinogen
level, oliguria)
• Amniotomy could not be done
• Amniotomy failed to arrest the process of abruption
• Amniotomy failed to control bleeding
 EXPECTANT MANAGEMENT
• Expectant management is considered where:bleeding is slight
and has stopped, fetus with reactive CTG and remote from term
• The goal is to prolong the pregnancy with the hope of improving
fetal maturity and survival. Continuous electronic fetal
monitoring is maintained
• Patient should be observed in the labor room for 24to 48hr
• Betamethasone is given and also Mgso4
 MANAGEMENT OF
COMPLICATION

• Irrespective of the patients general condition at least 1L of blood

transfusion should be the minimum when the diagnosis of
concealed type is made
• Monitoring:CVP should be maintained at 10cm of water,
hematocrit should be at least 30% and urinary output more than
30ml/hr
• DIC : 1unit of fresh blood raises the blood volume and fibrinogen
level approx, 12.5mg/100ml
 PREVENTION
• The prevention aims at:
• Elimination of the known factors likely to reduce placental separation
• Correction of anemia during antenatal period so that the patient can
withstand blood loss
• Promt detection and institution of the therapy to minimize the grave
complication namely shock, blood coagulation disorder and renal
failure
• Prevention of known risk factors:
• Early detection and effective therapy
• Needle puncture
• Avoidance of trauma
• To avoid Sudden decompression of the uterus
• To avoid supine hypotension
• Routine administration of folic acid
 NURSING MANAGEMENT

• Pain related to bleeding from premature separation of placenta as evidenced by

pain score, facial expression
• Decreased cardiac output related to hemorrhage, veginal bleeding as evidenced
by bradycardia, hypotension, ECG changes, pallor, restlessness
• Fluid volume deficit related to excessive blood loss as evidenced by dry lips,
increased thirst, increased HR , decreased BP
• Altered uteroplacental tissue perfusion related to excessive bleeding secondary
to abruptio placentae as evidenced by veginal bleeding, uterine contraction and
uterine pain
• Knowledge deficit related to treatment and progress of the disease as evidenced
by patient’s verbalization, anxious look
PROGNOSIS
CONCLUSION
 BIBLIOGRAPHY
• Dutta DC. DC Dutta’s Textbook of obstetrics including perinatology and
contraception, 10th edition;jaypee brothers medical publishers;EMCA
house, 23/23-B , Ansari road, Daryaganj, New Delhi, India;2023.p-, 239-
244
• Reeder, Martin, Koniak-Graffin.Maternity Nursing, 19th edition;wolter
kluwer pvt Ltd;Nee Delhi, India;2014.p-538-542
• https://www.mayoclinic.org/diseases-conditions/placental
abruption/symptoms cause/syc-20376458