Abruptio placentae, a form of Antepartum hemorrhage

1. ABRUPTIO PLACENTA
Dr. Nandan Nagaonkar

2. Definition
• Abruptio placenta is the premature separation of normally situated
placenta from uterine wall after 20 weeks of gestation Till 2nd stage of
Labour.

3. TYPES
• 1. Concealed type – The blood collects behind the separated placenta
or collected in between the membranes and decidua. Blood is not
seen outside. Detatchment of placenta may be complete and the
complications might be severe.
• 2. Revealed type - the blood comes out of the cervical canal to be
visible externally. The Complications are fewer and less Severe.
• (3) Mixed : In this type, some part of the blood collects inside
(concealed) and a part is expelled out (revealed).

5. • The overall incidence is about 1 in 200 deliveries. Depending on the
extent (partial or complete) and intensity of placental separation, it is
a significant cause of perinatal mortality (15–20%) and maternal
mortality (2–5%)

6. Risk factors
• high birth order pregnancies with gravida 5 and above — three times
more common than in first birth
• advancing age of the mother
• poor socio-economic condition
• More in blacks and whites less in asian women
• malnutrition
• smoking (vasospasm).
• Single umbilical artery

7. • Hypertension in pregnancy-
Spasm of the vessels → anoxic endothelial damage → rupture of
vessels or extravasation of blood in the decidua basalis (retroplacental
hematoma).
• Trauma: usually leads to its marginal separation with escape of blood
outside. The trauma may be due to:
(i) Attempted external cephalic version specially under anesthesia using
great force
(ii) Road traffic accidents or blow on the abdomen
(iii) Needle puncture at amniocentesis.
(iv)Sudden uterine decompression: 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.

8. • Short cord
• Supine hypotension syndrome: passive engorgement of the uterine
and placental vessels resulting in rupture and extravasation of the
blood.
• Placental anomaly: Circumvallate placenta.
• Poor placentation, evidenced by abnormal uterine artery Doppler
waveforms is associated with placental abruption.
• Folic acid deficiency
• Uterine factor: Placenta implanted over a septum (Septate Uterus) or
a submucous fibroid.

9. • Torsion of the uterus leads to increased venous pressure and rupture
of the veins with separation of the placenta.
• Cocaine abuse
• Thrombophilias inherited or acquired (SLE, factor V leiden, preteins C
and S deficiency)
• Prior abruption: Risk of recurrence for a woman with previous
abruption varies between 5% and 17%.
• Hyperhomocystinemia (causes vascular endothelium damage)
• Snake bite

10. CLINICAL CLASSIFICATION
• 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.

11. • Grade—2 (45%):
i)vaginal bleedingmild 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.

12. • Grade—3 (15%):
• (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.

13. Sher’s classification
Grade Retroplacental clots Fetal heart
1 150mL or less Present
2 150-500mL Abnormal in 92% Cases
3 As above
3A without coagulopathy
3B with coagulopathy
Absent fetal heart

14. Sharma, J. B. (2023). Textbook Of Obstetrics.

15. Investigations
• General –
1) CBC
2) Sr fibrinogen level, PT, PTT, fibrin degradation product level, BT/CT,
D-dimer level
3) sr. Electrolyte levels, blood urea and LFT
4) Blood group and cross matching
5) Kleihauer-Betke test, if available

16. Ultrasound abdomen
1) To rule out placenta previa
2) To reveal the state of the fetus
3) Retroplacental clots at placental site
4) Jello sign. Placenta may jigglewhen sudden pressure is applied by
transducer
5) In case of concealed haemorrhage, the placenta can seem thick and
globuler measuring almost 6cm in diameter.
However A negative usg finding does not exclude abruption.

17. Clinical grading of abruptio placentae
Sharma, J. B. (2023). Textbook Of Obstetrics.

18. Complications
Maternal –
• Hemorrhagic shock
• Postpartum hemorrhage
• Disseminated intravascular coagulation
• Oliguria and anuria
• Puerperal sepsis
• Sheehan’s syndrome
• Reccurance
• Death

19. Fetal –
• High perinatal mortality is seen in abruptio placentae
• Perinatal death occurs in 25-30% cases in revealed but 50-100% cases
in concealed variety.
• Causes of death are –
• Prematurity
• Asphyxia due to placental abruption
• Small for gestational age
• Congenital abnormalities

21. Couvelaire uterus (uteroplacental apoplexy)
• Extensive intravasation of blood into the uterine musclesin
association with severe form of concealed abruptio placentae.
• It can only be diagnosed on laparotomy.
• Gross appearance –
Dark port wine colour of the uterus.
petechial hemorrhages underneath the uterine peritoneum.
There may be effusion of blood in the peritoneal cavity, broad ligament
beneath the tubal serosa and in the substance of ovaries.

23. Microscopic examination –
There is intravasation of blood and fluid in between the uterine muscle
bundles causing muscular dissociation in the middle and outer muscle
layers.
There may be tears in serosa with hemorrhage in the peritoneal cavity.
Blood vessels show acute degeneration and thrombosis. It seldom
interfers with uterine contractions. Thus presence of it during C-section
is not an indication for hysterectomy.