abruptio placenta

1. ABRUPTIO PLACENTA-MANISH 1
• 19/04/2077

2. ABRUPTIO PLACENTAE
Manish Kr. Thakur
2nd yr resident
GP/EMR
2

3. DEFINITION
• Separation of the placenta—either partially or
totally—from its implantation site before delivery
is described by the Latin term abruptio placentae
- WILLIAMS OBSTETRICS 24TH EDITION
• Premature separation of a normally situated
placenta
HIGH RISK PREGNANCY Management Options JAMES 4TH EDITION
3

4. 4

5. INCIDENCE
• Frequency
0.5 (0.4-1)percent or 1 in 200 deliveries
• Frequency of abruption causing fetal death
0.048 percent or 1 in 2060
WILLIAMS OBSTETRICS 24TH EDITION
5

6. Predisposing Factors
• Demographic Factors
Maternal age(2.3)
Parity
Race(African- American 1 in 200)
Hereditary(16%)
6

7. Predisposing Factors
• Pregnancy related
Hypertension and Preeclampsia (1.5%)
PPROM (3.1%)
Inflammation and infection
Chorioamnionitis
Preterm delivery
Prior abruption /chronic abruption
Hydramnios/Multifetal gestation
7

8. Predisposing Factors
• Others
Direct abdominal trauma
Genetics
Lupus Anticoagulant and Thrombophilias
Cocaine use
Cigarette smoking
Uterine leiomyoma
Anticoagulant use
protein C deficiency
8

9. Predisposing Factors
• Chronic abruption
Elevated maternal serum
First- and second-trimester bleeding
Chronic abruption-oligohydramnios sequence
9

10. • Recurrent Abruption
a recurrence rate of 12 percent
6.5-fold increased risk for mild abruption and
11.5-fold risk for a severe abruption.
Two severe abruptions-the risk for a third was
increased 50-fold
Half of the recurrence at a gestational age 1 to 3
weeks earlier than the first abruption
10

11. Pathophysiology
• Precise cause – unknown
Begins with rupture of a decidual spiral artery
Retroplacental hematoma self limited
Expand to disrupt more vessels and extend
placental separation
Increased pressure within the intervillous
space
11

12. Pathophysiology
Expanding retroplacental clot dissect into
myometrium
Forces May track beyond the
placental margin of placenta
thromboplastin
into the maternal Burst into amniotic
Circulation sac
12

13. Pathophysiology
• The phenomenon of impaired trophoblastic
invasion of uterine vessels
Decrease in placental blood flow
Abnormal response to vasopressor substance
Related with hypertension and abruption
• Sudden decompression of the uterus
After delivery of 1st twin
After rupture of membranes in polyhydramnios
13

14. Pathophysiology
• Cigarette Smoking
Decidual necrosis at the edge of the placenta
• Lupus Anticoagulant and Thrombophilias
Associated with maternal floor infarction of the
placenta
• Uterine Leiomyoma
If on submucosal surface behind the
placental implantation site
14

15. Pathophysiology
• Most blood in the retroplacental hematoma in
a nontraumatic placental abruption is
maternal.
• Hemorrhage is caused by separation within
the maternal decidua
• Placental villi are usually initially intact
15

16. Pathophysiology
• External trauma
usually from motor vehicle accidents or
aggravated assault
can cause placental separation
• Fetomaternal hemorrhage
more common with trauma
concomitant placental tears or fractures
16

17. Pathophysiology
• Fetal-to-Maternal Hemorrhage
Sensitization can occur in Rh negative
patient
17

18. 18

19. Couvelaire uterus
• Blood may dissect into the myometrium
towards the serosa resulting in Couvelaire
uterus
• Muscle bundles heavily infiltrated with
extravasated blood and oedema fluid
• Constant pain associated with a uterus that is
very hard on palpation
• May lead to atonic uterus and later Post
partum haemorrhage
19

20. 20

21. TYPES
Revealed (65-80%)
Concealed (20-35%)
21

22. 22

23. 23

24. Clinical presentation
Revealed Mixed(Predominant
concealed)
Symptoms Pain followed by
PV bleeding
Intense pain followed by
slight PV bleeding
Bleeding Continuous dark
colour
Continuous dark (slight)or
blood stained serous
discharge
General
condition
Shock
proportionate to
blood loss
Shock out of proportion to
blood loss

25. Clinical presentation
Revealed Mixed(Predomina
nt concealed)
Pallor Proportionate to
visible blood loss
Out of proportion
to blood loss
Features of
pre eclampsia
May be absent Usu. present
25

26. Clinical presentation
Revealed Mixed(Predomin
ant Concealed)
Uterine height Proportionate to
POG
Disproportionatel
y enlarged
Uterine feel Normal feel;
localised
tenderness
Tense, tender and
rigid
Fetal parts Identified easily Difficult to make
out
FHS Usually present Usu. Absent

27. Retroplacental clot
27

28. Couvelaires uterus
28

29. Laboratory findings:
Revealed Mixed(Predominant
concealed)
Blood Hb% Low value
proportionate to blood
loss
Markedly lower, out of
proportion to visible
blood loss
Coagulation
profile
Usu. unchanged Variable changes:
CT increased
Fibrinogen level low
Platelets level low
↑ PTT
↑ FDP and D dimer
Urine for
protein
May be absent Usu. Present

30. Clinical Findings
• Sudden-onset abdominal pain
may mimic normal labor
• Vaginal bleeding(dark and non clotting)
• Reduced fetal movements , non reassuring
fetal status
• Abdominal palpation typically reveals a
tender, tense uterus described as being
‘woody hard’
30

31. Clinical Findings
• Fundal height may be increased
disproportionately
• Difficult to palpate fetal parts or
presentation in severe cases
• frequent contractions(>5 in 10min) and
persistent hypertonus due to the irritable
effect of blood within the uterus
• Gross examination of placenta after
delivery reveals a clot and/or depression in
the maternal surface
31

32. DIAGNOSIS
• Clinical
• Sonography: limited use because the placenta
and fresh clots may have similar imaging
characteristics
Initially hemorrhage is hyperechoic or isoechoic
to placenta
Later with resolution it becomes hypoechoic and
sonoluscent later
Negative findings with sonographic examination
do not exclude placental abruption
32

33. Thickened Placenta
33

34. Retroplacental Haematoma
34

35. • Sonography
Thickened globular placenta with diameter
of at least 6 cm
Retroplacental clots can also be visualised
It may assess fetal presentation, estimated
wt. and fetal well being.
Low sensitivity(24%) but a high
specificity(96%) for placental abruption.
35

36. DIAGNOSIS
• Magnetic resonance (MR) imaging is highly
sensitive for placental abruption
length of scan time
size limitation of the imaging chamber
high susceptibility for motion artifact
high cost and lack of availability
36

37. DIAGNOSIS
• Intravascular coagulation elevated serum levels
of d-dimers may be suggestive
• serum levels of alpha-fetoprotein > 280 μg/L have
a positive-predictive value of 97 percent.
• Maternal serum alpha-fetoprotein may increase
as a consequence of the transfer of fetal red cells
in the maternal circulation, causing a false
increase in the risk for open neural tube defects
as determined by the triple or quad screening.
• Plasma fibrinogen level will be < 150 mg/dL
37

38. Differential diagnosis:
• Ruptured uterus
Severe continuous pain and shock, no
proteinuria, BP is not high
• Placenta previa -brighter bleeding as the
blood is fresh, associated signs of
preeclampsia and pain are absent.
USG will diagnose low lying placenta
• Acute hydramnios -no vaginal bleeding and
shock.

39. Differential diagnosis
• Acute pyelonephritis -associated with fever, pain
is situated more to one side
• Hematoma of rectus abdominis muscle
pain ,shock and abdominal mass
no vaginal bleeding & signs of fetal distress
evidence of preeclampsia absent
uterus will be of normal consistency

40. Maternal risks
• Hypovolemic Shock
• Consumptive Coagulopathy
consequence of intravascular coagulation
activation of plasminogen to plasmin
which lyses fibrin microemboli to maintain
microcirculatory patency.
40

41. • Acute Kidney Injury
Due to intravascular volume depletion
DIC
Irreversible acute cortical necrosis
Acute tubular necrosis
The long-term prognosis for acute renal failure
after placental abruption in women who are
adequately resuscitated is excellent.
• Fetomaternal haemorrhage
41

42. • Postpartum hemorrhage:
Due to coagulation disorder
couvelaire uterus
• Sheehan Syndrome
failure of lactation, amenorrhea, breast atrophy,
loss of pubic and axillary hair, hypothyroidism, and
adrenal cortical insufficiency.
• Maternal mortality
42

43. Fetal Risks
• Perinatal mortality:early gestational age
• Fetal growth restriction
• Neonatal anemia
• Marked elevation in still birth rate if placental
separation is >50%
43

44. GRADING OF PLACENTAL ABRUPTION
GRADE DESCRIPTION
0 Asymptomatic patient with a small retroplacental clot
1 Vaginal bleeding,uterine tetany and tenderness may be
present;no signs of maternal shock or fetal distress
2 External vaginal bleeding possible ;no signs of maternal
shock;signs of fetal distress
3 External bleeding possible ;marked uterine tetany
;yielding a boardlike consistency on palpation ;persistent
abdominal pain ;with maternal shock and fetal
demise;coagulopathy evident in 30% of cases
HIGH RISK PREGNANCY MANAGEMENT
OPTIONS JAMES 4TH EDITION

45. Management
• Depending primarily on maternal clinical
condition, the gestational age, and the amount of
associated hemorrhage.
• General measures
• Specific measures
Immediate delivery
Expectant management
Management of complications
45

46. Management :General measures
• Maternal assessment.
monitoring of vital signs, blood loss, urine output.
• Insert two large bore cannula – 14 or 16G
• Fluid replacement with Ringer lactate
• Transfuse two units of Packed Red Cell
• Keep the hematocrit at 30% or more
• Maintain the urinary output of at least 30 ml/hr
• In case of severe Abruption large amount of IV fluids
and CVP catheter should be inserted
• Coagulopathy should be managed.
46

47. Severity of bleeding
I II III IV
Blood loss <750ml
<15%
750–1500
ml 15-30%
1500–2000 ml
30-40%
>2000 ml
>40%
Pulse rate
(bpm)
<100 100-120 120-140 >140
BP Normal Decreased Decreased Decreased
Respirator
y rate/min
14-20 20-30 30-40 >40
Urine
output
(ml/hour)
>30ml/hr 20-30 5-15 Negligible
CNS S/S Normal Anxious confused Lethargic
47

48. Specific measures
• Immediate delivery
For moderate to severe abruption
• If the fetus is dead, vaginal delivery is the goal.
Maternal resuscitation is emphasized.
• Fetal membranes should be ruptured to hasten the
onset of labor
• If the fetus is alive: cesarean delivery has advantages.
• Coagulopathy adds considerable maternal risk, and the
likelihood of injury or death may be increased by
surgery .When abruption is severe, cesarean section
must be performed once resuscitation has started.
Delivery should be performed promptly
48

49. • 20-minute decision-to-delivery interval:
neurologically good outcome
• In mild cases of abruption, the mode of
delivery is determined by the condition of the
fetus, its presentation, and the state of the
cervix
49

50. Expectant Management
• To prolong pregnancy, with the hope of
improving fetal maturity and survival
• In cases of mild placental abruption occurring
before 37 weeks’ gestation.
• If bleeding episodes are recurrent, induction
at 37 to 38 weeks is usually undertaken if fetal
indices of health (e.g., biophysical param-
eters and growth) are satisfactory
50

51. Management:
Fetal Demise
Yes No
Renal failure
DIC
If IV volume deficit > 30%
Renal failure
DIC
If IV volume deficit > 30%
Correction of hypovolemia
Treatment of DIC
Initial management of renal failure
Correction of hypovolemia
Treatment of DIC
Initial management of renal failure
Contraindication for vaginal
delivery?
Uterus hard and rigid?
Yes No
Yes No
Cesarean
section
Induction of
labour
Vaginal
Delivery
Induction of labour
Abnormal FHR
Cesarean section
Cesarean
section
normal FHR

52. Complications
• DIC
The triggers known to precipitate DIC include
tissue thromboplastin release
endothelial damage to small vessels
pro-coagulant phospholipid production
secondary to intravascular coagulation
52

53. • DIC can present with
petechiae,purpura,echymosis,haemorrhagic
bulla and subcutaneous hematomas
• Signs of surgical or traumatic wound bleeding
or bleeding from the venepuncture sites.
• May present with shock and acidosis

54. Laboratory test
• Peripheral smear and platelet count-shows
thrombocytopenia,leucocytosis,schistocytes
• Platelet count may fall below 20000/ul
• Prothrombin time
• Partial thromboplastin time
• Fibrinogen level
• D dimer assay

55. Normal values for DIC profile
Test Normal result
Fibrinogen 150-600mg/dl
Prothrombin time 11-16sec
Partial thromboplastin
time
22-37 sec
Platelet count 120000-350000
D-dimer <0.5mg/l
Fibrin degradation
products
<10ug/dl

56. Management
• Treatment consist of correction of the
underlying problem
• Simultaneous supportive treatment is vital to
restore the circulatory system,maintain blood
pressure and electrolyte balance
• Transfusion of blood and blood products
• Heparin therapy-is avoided
• Human recombinant factor VIIa

57. References
1.Williams Obstetrics 24th edition. cunningham,leveno,
bloom, sponge, Dashe,Hoffman, Casey, Sheeffield.
Obstetrical Haemorrhage
2.HIGH RISK PREGNANCY Management options 4TH EDITION
James.Steer.Weiner.Gonik CROWTHER.ROBSON Bleeding
in Late Pregnancy
3.Arias’ Practical guide to HIGH RISK PREGNANCY AND
DELIVERY 4TH EDITION Amarnath
Bhide,Sabaratnam,Kaizad,Shirish Antepartum
Haemorrhage
4.IAN DONALD’s PRACTICAL OBSTETRIC PROBLEMS 7TH
EDITION RENU MISHRA Antepartum Haemorrhage.
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58. THANK YOU
ABRUPTIO PLACENTA-MANISH 5819/04/2077