ABRUPTIO PLACENTAE

1. ABRUPTIO PLACENTAE
Dr. Triguna Rupala

2. DEFINATION
• It is one of the antepartum hemorrhage where separation of placenta
either partially or totally from its implantation site before delivery.

4. INCIDENCE AND SIGNIFICANCE
• About 1 in 200 deliveries
• Perinatal mortality(15-20%)
• Maternal mortality(2-5%)

5. CLASSIFICATION
1. CONCEALED:
• Blood collects behind the separated
placenta or collected in between the
membranes and decidua.
• Collected blood is prevented from coming
out the cervix by the presenting part which
presses on the lower segment.
• At times blood may percolate into amniotic
sac after rupturing membranes.
• blood not visible outside.
• This is rare type.

6. 2. REVEALED:
• After separation of placenta
,blood insinuates downwards
between the membranes and
decidua.
• The blood comes out of the
cervical canal to be visible
externally.
• This is most common type.
3. MIXED:
• In this type,some part of the
blood collect
inside(concealed)and a part is
expelled out(revealed).
• this is quite common.

7. ETIOLOGY
HIGH BIRTH ORDERS:Pregnancies with gravida 5 and above -3 times
more common than first birth.
ADVANCING AGE: Of the mother
HYPERTENSION IN PREGNANCY:Association of preeclampsia in
abruptio placentae varies from 10% to 50%.
MECHANISM:Spasm of the vessles in the uteroplacental bed(decidual spiral
artery)=anoxic endothelial damage=rupture of vessles or extravasation of
blood in decidua basalis(retroplacental hematoma)

8. TRAUMA:
traumatic separation of placenta leads to marginal separation with escape of blood
outside.
Trauma due to attempted external cephalic version,road traffic accidents,blow on
abdomen,needle puncture at amniocentesis.
SUDDEN UTERINE DECOMPRESSION:
leads to diminished surface area of the uterus adjacent to the placental attachment
and result in placental separation.
This may occur in:
• Delivery of the first baby of twins
• Sudden escape of liquor amnii in hydramnios
• Premature rupture of membrane.

9. SHORT CORD:causes placental separation by mechanical pull.
SUPINE HYPOTENSION SYNDROME:Due to passive engorgement of
uterine AND placental vessles resulting in rupture and extravasation
of the blood.
PLACENTAL ANOMALY:Circumvallate placenta
SICK PLACENTA
FOLIC ACID DEFICIENCY
UTERINE FACRORS:Septate uterus or submucous fibroid.

10. TORSION OF UTERUS:Leads to increase venous pressure and rupture
of veins with separation of placenta.
COCAINE ABUSE:increase risk of transient hypertension, vasospasm
and placental abruption.
THROMBOPHILIAS: inherited or acquired.
PRIOR ABRUPTIONS.

12. COUVELAIRE UTERUS:
• It is associated with severe form of
conceled abruptio placenta.massive
intravasation of blood into the uterine
musculature upto serous coat.
• This condition is only diagnosed on
laparotomy.
• NAKED EYE FEATURES:
• Dark port wine colour which may be
patch or diffuse.
• Subperitoneal petechial hemorrhages
may extend upto broad ligament.
• MICROSCOPIC APPEARANCE:
• Uterine muscles over affected area are
necrosed and infiltration of blood and
fluid in between muscle bundles.

13. CLINICAL CLASSIFICATION
1. GRADE 0:
• Clinical features absent .
• Diagnosed after inspection of placenta following delivery.
2. GRADE 1(40%):
• Vaginal bleeding is slight, uterus irritable and tenderness may be minimal or
absent,
• Maternal BP and fibrinogen level unaffected, FHS is good.

14. 3. GRADE 2(45%):
• Vaginal bleeding mild to moderate, uterine tenderness always present,
• Maternal pulse high and BP normal, fibrinogen level may be decreased, shock is
absent,
• Fetal distress or even fetal death occurs.
4. GRADE 3(15%):
• Bleeding is moderate to severe or may be concealed, uterine tenderness is marked,
shock is pronounced,
• Fetal death is rule, associated coagulation defect or anuria.

18. CLINICAL FEATURES
CONCEALED ACCIDENTAL HEMORRHAGE:
I. Continuous Abdominal pain
II. Vaginal bleeding absent
III. Features of heamorrhagic shock like sweats,cold
extremities,blanching,tachycardia,hypotension.
IV. Uterus feel tense
V. Fetal parts difficult to palpate and FHS may not be heard easily either
because uterus is tense or they are absent

19. REVEALED ACCIDENTAL HEMORRHAGE:
I. Vaginal bleeding is present
II. Continuous Abdominal pain
III. Features of hemorrhagic shock absent
IV. Uterus feel tender
V. Fetal parts felt and FHS heard but FHS abnormalities may be present
COMBINED ACCIDENTAL HEMORRHAGE:
• Features of both types will be present.
• Bleeding usually starts as concealed become revealed later.
• Fetal well being gets affected.

20. Complications
MATERNAL:
Revealed type
• Maternal risk is proportionate to the visible blood loss and maternal death is rare.
Concealed variety
• Hemorrhage which is either totally concealed inside the uterus or more commonly,
part is revealed outside. There may be intraperitoneal or broad ligament hematoma.
• Shock may be out of proportion to the blood loss. Release of thromboplastin into the
maternal circulation results in DIC or there may be amniotic fluid embolism.
• Blood coagulation disorders.

21. • Oliguria and anuria due to—
i. Hypovolemia
ii. Serotonin liberated from the damaged uterine muscle producing renal
ischemia
iii. Acute tubular necrosis.
iv. Cortical necrosis
v. Renal failure.
• Postpartum hemorrhage due to — (a) atony of the uterus and (b) increase in
serum FDP
• Puerperal sepsis.

22. FETAL:
Revealed type: the fetal death is to the extent of 25–30%.
Concealed type:
• The fetal death is appreciably high, ranging from 50% to 100%.
• The deaths are due to prematurity and anoxia due to placental separation.
• Risk of recurrence in subsequent pregnancy is about 5–20% with high
perinatal mortality.

23. DIFFERENTIAL DIAGNOSIS
• Differential diagnosis for accidental hemorrhage depends on its clinical
type and the symptoms of the characteristics of pain in abdomen and
vaginal bleeding.
Concealed accidental haemorrhage
1. Grade < 1 : Early labour
2. Grade >2 : Acute hydramnios, obstructed labour, torsion ovary with pregnancy,
causes of intraperitoneal haemorrhage, causes of acute abdomen.
Revealed accidental haemorrhage : Placenta previa.

25. Management
For Diagnosis
Ultrasonography
• Diagnosis made by ruling out the placenta previa and finding a retroplacental clot.
To know the effect
Haemoglobin estimation
Kidney function tests: Urea,creatinine.
Coagulation studies : Bleeding time , Clotting time,Platelet count,Prothrombin
time and fibrin degradation products.
To help to resuscitate
ABO-Rh typing, Arterial blood gas analysis.

26. Management
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:
• amount of blood loss
• maturity of the fetus
• whether the patient is in labor or not (usually labor starts)
• presence of any complication
• type and grade of placental abruption

27. Emergency measures:
• Blood is sent for hemoglobin and hematocrit estimation, coagulation profile
(fibrinogen level, FDP, prothrombin time, activated partial thromboplastin
time and platelets), ABO and Rh grouping and urine for detection of protein
• Ringer’s solution drip is started with a wide bore cannula
• Arrangement for blood transfusion is made for resuscitation.
• Close monitoring of maternal and fetal condition is done.

28. • Management options are:
1. Immediate delivery
2. Expectant management (rare).
Defnitive treatment (immediate delivery):
 Patient is in labour:
• 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.

29. Vaginal delivery
• Favored in cases with:
A. limited placental abruption
B. FHR tracing is reassuring
C. facilities for continuous (electronic) fetal monitoring is available
D. prospect of vaginal delivery is soon.
E. placental abruption with a dead fetus.

30. The advantages of amniotomy are:
A. initiates myometrial contraction and labor process
B. expedites delivery
C. better compression of spiral artery to arrest hemorrhage
D. reduces entry of thromboplastin into maternal circulation and thereby
E. reduces the risk of renal cortical necrosis and DIC

31. The patient is not in labor:
(i) Bleeding continues
(ii) > Grade I abruption:
Delivery either by
induction of labor
cesarean section.

32. 1. Induction of labor
• Done by low rupture of membranes.
• Oxytocin may be added to expedite delivery. Labor usually starts soon in majority
of cases and delivery is completed quickly (4–6 hours).
• Placenta with varying amount of retroplacental clot is expelled most often
simultaneously with the delivery of the baby.
• Inj. oxytocin 10.IU IV (slow) or IM or Inj. methergine 0.2 mg IV is given with the
delivery of the baby to minimize postpartum blood loss.
• Oxytocics should be used to improve the uterine tone along with blood
transfusion.

33. 2. Cesarean section:
• Indications are :
i. Severe abruption with live fetus
ii. Amniotomy could not be done (unfavorable cervix)
iii. Prospect of immediate vaginal delivery despite amniotomy is remote
iv. Amniotomy failed to control bleeding
v. Amniotomy failed to arrest the process of abruption (rising fundal height)
vi. Appearance of adverse features (fetal distress, falling fibrinogen level,
oliguria).

34.  Expectant management
• Cases where bleeding is slight and has stopped (Grade I abruption),
• Fetus reactive (CTG) and remote from term, may be considered.
• The goal of expectant management is to prolong the pregnancy with the hope of improving fetal
maturity and survival.
• Patient should be observed in the labor ward for 24–48 hours to ensure that no further placental
separation is occurring.
• Betamethasone is given to accelerate fetal lung maturity in the event preterm delivery has to be
contemplated.
• Further separation of placenta at any moment may cause fetal death or maternal complications

36. THANK YOU