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Abruptio plancentae

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  • 1. Abruptio Plancentae Dr Dambo D T Department of Obstetrics & Gynaecology
  • 2. Introduction
    • Abruptio Placentae:- Is the complete or partial separation of a normally situated placenta from its uterine site after the 28 th week of gestation until the 2 nd stage of labour.
    • It normally occurs in the 3 rd trimester of pregnancy, although the process may occur earlier in pregnancy.
    • Abruptio Placenta is classified into 3 types:-
      • Revealed type: Bleeding is revealed.
      • Concealed type: no obvious bleeding.
      • Mixed type : combination of 1&2 above.
  • 3.
    • In the concealed type(20%), the hemorrhage is confined within the uterine cavity, detachment of the placenta may be complete, and the complications are often severe.
    • In the revealed type(80%) the blood drains through the cervix, placental detachment is more likely to be incomplete, and the complications are fewer and less severe
  • 4. Incidence
    • This has been documented in Britain as between 0.5%-2% of pregnancies, but varies depending on the criteria used for diagnosis. Where the diagnosis is based on histological examination of the placenta the incidence has been reported to be as high as 4%. From the annual report of 2003 the incidence in UPTH is 1.5%.
  • 5. Aetiology
    • The aetiology are often difficult to ascertain, although there are risk factors.
    • Hypertensive states most consistent risk factor.
    • Trauma:
    • - Ritual abdominal massage by birth attendants
    • - RTA
    • High parity (AP is independent of age, it occurs in older women because of high parity.)
    • Prolonged preterm rupture of membrane.
    • Sudden decompression of the uterus that accompany spontaneous or artificial rupture of membranes when there is polyhydramnios.
    • Multiple gestation.
    • Submucous uterine fibroid.
    • Cigarette smoking.
    • Cocaine, the heat stable smokable cocaine alkaloid.
    • Short cord.
    • Folic acid deficiency.
    • Chorio-amnionitis
  • 6. Pathophysiology
    • Spontaneous rupture of the placental bed blood vessels. Leads to haematoma formation. In the concealed type the haematoma accumulates, causing increasing pressure and separation of the placenta. Some blood might dissect into the myometrium causing COUVELAIRE uterus
    • The blood may also rupture through the membranes and gain access to the amniotic fluid. With the disrupted placental site, there is reduced metabolic exchange resulting in fetal hypoxia and probable death. The process might continue with the release of tissue Thromboplastin into the maternal circulation causing Disseminated Intravascular Coagulopathy.
  • 7. MANAGEMENT
    • HISTORY --Vaginal bleeding usually dark and non-clothing. However bleeding may be absent. --Abdominal pain This increase in severity --Back pain -Absence of fetal movement -Symptoms of shock Restlessness, sweating dizziness
    • -Some may present with no symptoms.
  • 8.
    • PHYSICAL EXAMINATION:
    • Signs of shock
    • Faintness and collapse may occur
    • Pallor
    • Cold clammy extremities
    • Pulse Normal or tachycardia
    • Blood Pressure:- normal or hypotension
    • Abdomen
    • The uterus may be larger than gestation. A tender uterus, describe as woody hard. it does not relax. Fetal parts are difficult to palpate. The fetal heart rate may or may not audible. Vaginal examination is not done if the diagnosis is in doubt.
    • If placenta praevia is ruled out, then vaginal examination will show evidence of bleeding in the reveal type. The cervical os may be dilated if the patient is in labour, or closed if not in labour.
  • 9.
    • INVESTIGATIONS
    • Full blood count +differentials Electrolytes, urea ,creatinine & uric acid
    • Urine for urinalysis &m/c/s
    • Group & crossmatch at least 4 units of blood
    • Coagulation profile
      • platelet count
      • clotting time
      • prothrombin time
      • active partial prothrombin time
      • fibrin degradation products
      • Fibrinogen level
      • thrombin level
  • 10.
      • Abruptio plancenta is divided into 3 grades according to clinical and laboratory findings. They are
      • Grade 1 or mild slight vaginal bleeding minimal uterine irritability
        • normal BP & HR
        • normal FHR
      • Grade 2 or Moderate External vaginal bleeding may be or not present.
        • No signs of maternal shock.
        • Signs of fetal distress are present
  • 11.
        • Grade 3 or Severe External vaginal bleeding may or may not present. Marked uterine tetany
        • Persistent abdominal pain.
        • Fetal demise present.
        • Coagulopathy may become evident in 30% of cases.
  • 12.
      • TREATMENT Principles of mx include 1)Resuscitation 2)Immediate delivery 3)Expectant mx
  • 13.
    • Resuscitation No delay, prompt action, to prevent maternal and if possible perinatal mortality
    • General assessment
    • Wide bore cannula to give IV fluids and transfusion.
    • Catheterize
    • Oxygen by face mask if needed.
    • Bedside clotting time & ward urinalysis
    • Other investigations
  • 14.
    • Grade 3 Severe
    • No contraindication to vaginal delivery.
    • If in labour,
      • amniotomy
      • augement labour with oxytocin
      • transfuse when necessary
      • active management of 2 nd stage of labour
      • prompt evacuation of the uterus after delivery of the placenta.
      • Continue oxytocin drip.
      • If not in labour ripen cervix and induce labour.
  • 15.
      • Grade 2 moderate
      • Resuscitate
      • For emergency caesarean section
      • If in labour and you anticipate short time delivery, vaginal delivery can be allowed.
  • 16.
    • Grade 1 mild
    • Expectant management:-especially when gestational age favors delaying the delivery to allow greater fetal maturity. All facilities for monitoring feto-maternal well being must be available before this can be done. Anytime there is a deviation, for resuscitation and emergency delivery.
  • 17. Complications
    • Maternal
      • Haemorrhage leading to hypovolaemic shock.
      • Disseminated Intravascular Coagulopathy
      • Acute renal failure
      • Increase caesarean section
      • Reccurence
      • Maternal death
    • Fetal
      • Hypoxia
      • Anaemia
      • IUGR
      • Fetal death
  • 18. Conclusion
    • Abruptio Placentae is an important cause of fetal and maternal morbidity and mortality. The aetiology is poorly understood , various management options are however available. The principle of initial assessment of the patients condition and subsequent planned management aimed at resuscitation and prolongation of pregnancy if possible or immediate delivery either for fetal or maternal indications .