A serious pregnancy complication in which the placenta detaches from the womb (uterus).
Placental abruption occurs when the placenta detaches from the inner wall of the womb before delivery. The condition can deprive the baby of oxygen and nutrients.
Symptoms include vaginal bleeding, stomach pain and back pain in the last 12 weeks of pregnancy.
Depending on the degree of placental separation and how close the baby is to full-term, treatment may include bed rest or a Caesarean (C-section).
2. PLACENTAL ABRUPTION
•It is one form of antepartum hemorrhage
where the bleeding occurs due to
premature separation of normally situated
placenta.
3. TYPES OF ABRUPTION
depending upon the extent and region of separation.
• A complete abruption occurs when the entire placenta
separates.
• A partial abruption exists when part of the placenta
separates from the uterine wall.
•A marginal abruption occurs when the separation is limited
to the edge of the placenta
4. VARIETIES
•(1) Revealed : Following
separation of the placenta,
the blood insinuates
downwards between the
membranes and the decidua.
Ultimately, the blood comes
out of the cervical canal to be
visible externally. This is the
commonest type.
5. • (2) Concealed : The blood collects behind the
separated placenta or collected in between the
membranes and decidua. The collected blood is
prevented from coming out of the cervix by the
presenting part which presses on the lower
segment.
6. (3) Mixed :
•In this type, some part of
the blood collects inside
(concealed) and a part is
expelled out (revealed).
•Usually one variety
predominates over the
other. This is quite
common.
7. RISK FACTORS
1)The prevalence is more with
•(a) high birth order pregnancies with gravida 5
and above — three times more common than in
first birth
•(b) advancing age of the mother
•(c) poor socio-economic condition
•(d) malnutrition
•(e) smoking (vaso-spasm).
8. 2)Hypertension in pregnancy
• Pre-eclampsia, gestational hypertension and essential hypertension, all are
associated with placental abruption.
•The mechanism of the placental separation in pre-
eclampsia is : Spasm of the vessels in the utero
placental bed (decidual spiral artery) → anoxic
endothelial damage → rupture of vessels or
extravasation of blood in the decidua basalis
(retroplacental hematoma).
9. 3)Trauma:
Traumatic separation of the placenta usually leads to
its marginal separation with escape of blood outside.
The trauma may be due to:
(i) Attempted external cephalic version specially
under anaesthesia using great force
(ii) Road traffic accidents or blow on the
abdomen
(iii) Needle puncture at amniocentesis.
10. 4) Sudden uterine decompression:
Sudden decompression of the uterus leads to
diminished surface area of the uterus adjacent to the
placental attachment and results in separation of the
placenta.
This may occur following—
(a)delivery of the first baby of twins
(b) sudden escape of liquor amnii in hydramnios and
(c) premature rupture of membranes.
11. 5) Short cord, either relative or absolute, can
bring about placental separation during labor
by mechanical pull.
6) Supine hypotension syndrome: In this
condition which occurs in pregnancy there is
passive engorgement of the uterine and
placental vessels resulting in rupture and
extravasation of the blood.
7) Placental anomaly: Circumvallate placenta
8) Sick placenta: Poor placentation,
9) Folic acid deficiency
12. 10) Uterine factor: Placenta implanted over a septum (Septate
Uterus) or a submucous fibroid.
11) Torsion of the uterus leads to increased venous pressure
and rupture of the veins with separation of the placenta.
12)Cocaine abuse is associated with increased risk of transient
hypertension, vasospasm and placental abruption.
13)Thrombophilias inherited or acquired have been associated
with increased risk of placental infarcts or abruption.
14)Prior abruption: Risk of recurrence for a woman with
previous abruption varies between 5 to 17%.
13.
14. CLINICAL CLASSIFICATION: Depending upon the degree of placental
abruption and its clinical effects
Grade—0:
• Clinical features
may be absent.
• The diagnosis is
made after
inspection of
placenta
following
delivery.
Grade—1 (40%):
• (i) Vaginal
bleeding is slight
• (ii)Uterus:irritable,
tenderness may
be minimal or
absent
• (iii) Maternal BP
and fibrinogen
levels unaffected
• (iv) FHS is good.
(i) Vaginal bleeding
mild to moderate
(ii) Uterine
tenderness is always
present
(iii) Maternal pulse ↑,
BP is maintained
(iv) Fibrinogen level
may be decreased
(v) Shock is absent
(vi) Fetal distress or
even fetal death
occurs.
Grade—2 (45%):
(i) Bleeding is
moderate to severe
or may be concealed
(ii) Uterine
tenderness is
marked
(iii) Shock is
pronounced
(iv) Fetal death is
the rule
(v) Associated
coagulation defect
or anuria may
complicate.
Grade—3 (15%):
15. CLINICAL MANIFESTATION
Clinical manifestation mild moderate severe
Per vaginal bleeding No overt per vaginal
bleeding
Moderate vagnal
bleeding
Massive vaginal
bleeding
Rigid abdomen Present Present Present
Blood pressure Decreased Decreased Decreased
Pulse Tachycardia Tachycardia Tachycardia
Accute abdominal pain Present Present Present
Shock Not May/may not Present
Uteroplacental
insufficiancy
present present Markedly present
18. MANAGEMENT OF ABRUPTIO PLACENTAE
•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 and
•(3) prompt detection and institution of the therapy
to minimise the grave complications namely shock,
blood coagulation disorders and renal failure.
19. Prevention
• • Early detection and effective therapy of pre-eclampsia 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.
20. AT HOME:
• The patient is to be treated as outlined in placenta previa and arrangement
should be made to shift
• the patient 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 (usually labor
starts)
(d) presence of any complication and
(e) type and grade of placental abruption
21. • Management options
(a) Immediate delivery
(b) Management of complications if there is any
(c) Expectant management (rare).
•Definitive treatment (immediate delivery):
• The patient is in labor: Most patients are in labor following a term pregnancy: 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 reassuring
(iii) Facilities for continuous (electronic) fetal monitoring is available
(iv) Prospect of vaginal delivery is soon or
(v) Placental abruption with a dead fetus.
22. The patient is not in labor:
(i) Bleeding continues
(ii) > Grade I abruption
Delivery either by
(A) Induction of labor or
(B) Cesarean section.
Indications are :
(a) Severe abruption with live fetus
(b) Amniotomy could not be done (unfavorable cervix)
(c) Prospect of immediate vaginal delivery despite amniotomy is remote
(d) Amniotomy failed to control bleeding
(e) Amniotomy failed to arrest the process of abruption (rising fundal height)
(f) Appearance of adverse features (fetal distress, falling fibrinogen level, oliguria).
23. DIGNOSIS
• Clinical grounds of painful
vaginal bleeding in association
with uterine tenderness &
hyperactivity
• USG demonstrate retro
placental clots & to exclude
placenta preavia
• Abruption may occur in the
absence of US findings.
• In some cases the diagnosis
may be only made by
inspection of placenta after 3rd
stage of labour
MANAGEMENT
• Careful maternal haemodynamic monitoring
• Fetal monitoring
• fluid administration
• Serial evaluation of the haematocrit &
coagulation profile
• Expectant management
(preterm patients with less severe
abruptions an minimal bleeding)
• Delivery of the fetus
• Vaginal (ARM & oxytocin)
fetal death
mild to mod abruption with no fetal
distress or CI
• Cesarean
fetal distress
24. COMPLICATIONs
MATERNAL
• 1. Maternal mortality 1%
• 2. Recurrence of APH in 10% & ↑to 25% after 2nd
episodes
• 3. Hypovolemic shock -concealed
• 4. Acute renal failure- ATN
• 5. DIC- Abruption is the most common cause of
coagulopathy in pregnancy
low plt and fibrinogen, prolonged PT/a PTT
• 6. PPH -coagulation failure /Couvelaire uterus-Rarely,
blood penetrates the uteru to such an extent that the
serosa becomes blue or purple in colour.
• 7. Feto-maternal haemorrhage lead to severe Rh
sensitization in Rh
• negative mother
• - A Kleihauer-Betke or similar test is essential
FETAL
• 1. Perinatal mortality:
• 4.5 % - 60% depending on
• neonatal facilities & closely
• related to the gestational age &
associated complication like HTN &
growth restriction
• 2. IUGR due to presence of
maternal hypertension & pre
eclampsia
• 3. Neonatal anemia
26. Clinical features PLACENTA PREVIA ABRUPTIO PLACENTAE
• nature of bleeding
• character of blood
• general condition and anemia
• features of preeclampsia
•Bleeding (duration)
• painless -causeless and recurrent,
always revealed
•bright red
• proportionate to visible blood loss
-------
Often ceases within 1-2 hrs
• painful, cont.
revealed/concealed
•dark coloured out of proportion in
concealed or mixed present in one
third cases
Continuous
Abdominal examination
• height of the uterus
• feel of uterus
• malpresentation
• FHS
•DIC
•Associated history
• proportionate
• soft and relaxed
• common, head is high floating
•Present
•Normal
•rare
• disproportionate (concealed)
• tense, tender and rigid
---------------
• absent in concealed.
TC then BC, Loss of
variability, Decelerations,
IUFD
Severe
•Trauma, hypertension
Multiple gestation
Polyhydramnios
Placentography US placenta in lower
segment
Placentography US placenta in lower segment Placenta in upper segment
Vaginal examination Placenta felt on the lower segment Placenta not felt