Premature separation of the placenta from the uterus

1. ABRUPTIO
PLACENTA
PRESENTED BY:
DEEPSHIKHA
ASSISTANT PROFESSOR
M.M COLLEGE OF NURSING,MULLANA

2. INTRODUCTION
Abruptio placenta also called placental
abruption , is where the placenta separates
from the uterine wall prematurely, usually
after the 20th week of gestation, producing
hemorrhage. It is a common cause
of bleeding during the second half of
pregnancy.

3. DEFINITION
Abruptio Placentae(syn.
Accidental haemorrhage,
Premature placental separation):
It is one form of APH where bleeding
occurs due to premature separation
of normally situated placenta.

5. TYPES OF ABRUPTIO PLACENTA
• Revealed- After separation of the
placenta, the blood insinuates downwards
between the membranes and the deciduas
and comes out of the cervical canal to be
visible externally.

6. • Concealed- The blood collects behind the
separated placenta or between the membranes
and decidua. Collected blood prevented from
coming out of cervix by presenting part which
presses on lower segment Blood percolates into
amniotic sac after rupturing the membrane

7. • Mixed- part of blood collected inside
(concealed) and a part is expelled out
(revealed).

8. COUVELAIRE UTERUS ( Utero-placental
apoplexy)
• It is a pathological entity first described by
Couvelaire and is met with in association with
severe form of concealed abruption placentae.
There is massive intravasation of blood into the
uterine musculature upto the serous coat.
• Naked eye features
• Dark port wine color:patchy and diffused
• Sub peritoneal petechial hemorrhage
• Free blood may be present in peritoneal
cavity

9. • Microscopic appearance:
• Necrosed uterine muscles in the affected part
• Blood infiltration between the muscle bundle
• Blood vessels may show acute degenerative changes
• Muscular dissociation occurs in middle and outer
muscle layer

10. INCIDENCE
• 1 in 200 deliveries
• Significant cause of perinatal mortality (15- 20%) and
maternal mortality (2- 5%)

11. ETIOLOGICAL FACTORS
• Advancing age
• High birth order
• Hypertension in pregnancy
• Trauma
• Sudden uterine decompression
• Short cord
• Supine hypotension syndrome
• Placental anomaly
• Folic acid deficiency
• Uterine factor

12. • Torsion of the uterus
• Cocaine abuse
• Thrombophilias
• Prior Abruption

14. PATHOGENESIS

16. BLOOD COAGULOPATHY:
Blood coagulopathy is due to excess consumption of
plasma fibrinogen due to disseminated intravascular
coagulation and retroplacental bleeding. There is overt
hypofibrinogenemia (<150mg/dl) and elevated levels of
fibrin degradation products

19. LABORATORY INVESTIGATIONS
REVEALED MIXED
Blood: Hb% Low value
proportionate
Markedly lower, out of
proportion to the
visible blood loss
Coagulation profile Unchanged Variable changes:
 Clotting time
increased(> 6 min)
 Fibrinogen level-
low (<150mg/dl)
 Platelet count-low
 Increased
thromboplastin time
Urine protein May be absent Usually present

20. ULTRASONOGRAPHY

21. DIFFERENTIAL DIAGNOSIS
 Revealed type-: There may be occasional diagnostic
difficulty with placenta previa.
 Mixed or concealed type- this variety is often confused
with:
• Rupture uterus
• Rectus sheath haematoma
• Appendicular or intestinal perforation
• Twisted ovarian tumour
• Volvulus
• Acute hydramnios
• Tonic uterine contraction

22.  Essential points to diagnose the concealed variety
are:
• Shock out of proportion to external bleeding
• Unexplained extreme pallor
• Presence of pre-eclamptic features
• Uterus is tense, tender and woody hard
• F.H.S is absent
• Diminished urinary output
• Presence of blood coagulation disorder

23. MANAGEMENT
PREVENTION:
• Early detection and effective therapy of preeclampsia
• Needle puncture during amniocentesis should be under ultrasound
guidance
• Avoidance of trauma- specially forceful external cephalic version
under anaesthesia
• To avoid sudden decompression of the uterus-
• To avoid supine hypotension
• Routine administration of folic acid- from the early pregnancy
• Correction of anaemia during antenatal period so that the patient
can withstand blood loss
• Prompt detection and institution of the therapy to minimise the grave
complications namely shock, blood coagulation disorders
• Renal failure

24. TREATMENT
 AT HOME
• The patient is immediately put to bed
• To assess the blood loss-
 Inspection of the clothings soaked with blood
 To note the pulse, blood pressure and degree of anemia
• Quick but gentle abdominal examination to mark the
height of the uterus, to auscultate the fetal heart sound
and to note any tenderness of the uterus
• Vaginal examination must not be done

25.  TRANSFER TO THE HOSPITAL
• Arrangement is made to shift the patient ta an equipped
hospital having facilities of blood transfusion, emergency
caesarean section and intensive care unit (NICU)
• “Flying squad” service is ideal for transfer of such type
of patients.
• An intravenous dextrose- saline drip should be started
and is kept running during transport.
• Patient should be accompanied by two or three persons
fit for donation of blood, if necessary.

26.  IN THE HOSPITAL: Assessment of the case is to be
done as regards:
• Amount of blood loss
• Maturity of the fetus
• Whether patient is in labour or not
• Presence of any complication
• Type and grade of placental abruption

27. DEFINITIVE TREATMENT-
REVEALED TYPE
 Patient in labour :labour accelerated by low rupture of
membranes , oxytocin drips to be started to accelerate
labour
 Patient not in labour:
• A. pregnancy 37 weeks or more then induction of labour
is done by low ruptue of membranes
• b. Indication for caesarean section: fetal distress ,
amniotomy could not be done or failed.
• Pregnancy < 37 weeks : bleeding moderate to severe(
low rupture of membrane , oxytocin drip is started),
bleeding slight or stopped( put on conservative
treatment)

28.  Mixed or concealed type Blood samples are taken
• To correct hypovolemia
• Artificial rupture of membranes
• Vaginal delivery
• Caesarean section – indicated in two extreme cases 1.
early – unfavourable cervix, where speedy delivery is not
possible
• Late – progress of labour delayed in spite of amniotony
and oxytocin

32. COMPLICATIONS

33. NURSING MANAGEMENT
 Assessment:
• Assess for signs of shock, especially when
heavy bleeding occurs.
• Assess if the bleeding is external or internal.
• Monitor contractions if separation occurs during labor.
• Obtain baseline vital signs.
• Assess for the time the bleeding began, the amount and
kind of bleeding, and interventions done when bleeding
occurred if it started before admission.
• Assess for the quality of pain.

34. NURSING DIAGNOSIS
• Ineffective tissue perfusion related to excessive blood
loss as evidenced by altered blood pressure from the
baseline
• Risk for shock related to internal and external bleeding
as evidenced by vaginal bleeding
• Acute pain related to sudden separation of placenta as
evidenced by Sharp, stabbing pain high in the uterine
fundal part
• Fluid volume deficit related to bleeding during premature
placental separation.

35. SUMMARY
• Definition of Abruptio Placenta
• Types
• Incidence and sigificance
• Etiology
• Pathogenesis
• Clinical classification
• Clinical features
• Diagnostic evaluation
• Differential diagnosis
• Management

36. CONCLUSION
Abruption placenta is a obstetrical and medical
emergency which should be treated promptly to prevent
maternal and neonatal mortality. We envisage need for
mass information regarding the importance of antenatal
maternal care and improvement in nutritional status,
which may reduce the frequency of maternal and fetal
morbidity and mortality associated with abruption
placenta

37. RESEARCH ABSTRACT
• Retrospective study of risk factors and maternal and
fetal outcome in patients with abruptio placentae
• Introduction:
Abruptio placentae (AP) which is a major cause of
maternal morbidity and perinatal mortality globally is of
serious concern in the developing world. Study was
retrospectively analyzed for the AP cases and evaluated
its impact on fetal and maternal outcomes.

38. Materials and Methods:
The present study was undertaken from September
2007-August 2009 at a tertiary care center attached to
medical college; patients of AP were selected from all
cases with minimum of 28 weeks of gestation,
presenting with antepartum hemorrhage. Patients
underwent complete obstetrical investigations and were
managed according to maternal and fetal condition.
Results:
4.4% incidence rate of AP was documented accounting
for 318 cases during the study period. Most of cases
were unbooked, with an average age of 34.5 years
(range, 18-44) and nearly two-third of the patients were
from lower socioeconomic class. Anemia was observed
in 96% of patients, with 3.5 and 68% incidence of
maternal and fetal mortality, respectively.

39. Conclusion:
It is observed a higher than expected frequency of AP
and neonatal mortality in study population, which is of
major concern. To envisage need for mass information
regarding the importance of antenatal maternal care and
improvement in nutritional status, which may reduce the
frequency of maternal and fetal morbidity and mortality
associated with AP.