This document provides an overview of abruption placenta, including: 1. Couvelaire uterus, which is a severe form associated with massive bleeding into the uterine muscles. 2. Pathological changes in other organs like the liver, kidneys, and blood. 3. A clinical classification system grading abruption from mild to severe. 4. Clinical features that depend on the degree and speed of placental separation. 5. Ultrasonography and differential diagnosis with conditions like placenta previa. Complications are more severe for concealed abruption, and can include maternal hemorrhage, shock, and death as well as high rates of fetal death from anoxia.

1. ABRUPTIO PLACENTA
Anantha Chaitanya J
Final Year MBBS
BGS GIMS
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2. Overview
1. Couvelaire Uterus.
2. Pathological Changes In Other Organs.
3. Clinical Classification.
4. Clinical Features.
5. Ultrasonographic Localization.
6. Differential Diagnosis.
7. Complications.
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3. Couvelaire Uterus
 Aka Uteroplacental Apoplexy.
 First described by Alexandre Couvelaire.
 Associated with Severe form of Concealed Abruptio Placenta.
 Massive intravasation of blood into uterine musculature
upto serous coat.
 Can only be diagnosed on laparotomy.
 NOTE: Myometrial Hematoma rarely interferes with uterine
contractions following delivery. Therefore, presence of
Couvelaire uterus observed during C-section is NOT AN
INDICATION FOR HYSTERECTOMY.
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4. Couvelaire Uterus4
Gross
Uterus is dark port wine colour
which maybe patchy/diffuse.
Initially over cornu, spreads over
placental site.
Sub peritoneal petechial
haemorrhage under uterine
peritoneum and may extend into
broad ligament.
Free blood in peritoneal cavity or
broad ligament hematoma.
Microscopy
Uterine muscles over affected
areas are necrosed with
infiltration of blood and fluid
between muscle bundles.
Mostly in middle and outer
muscle layers.
On occasions, serosa splits and
blood enters peritoneal cavity.
Blood vessels show acute
degenerative changes with
thrombosis.

5. Couvelaire Uterus5

6. Pathological Changes In Other Organs
 Liver:
1. Changes of Pre-eclampsia.
2. Fibrin knots in Hepatic Sinusoids.
 Kidney:
1. Acute cortical/tubular necrosis[Massive haemorrhage  intrarenal vasospasm].
2. Shock proteinuria due to renal anoxia[Disappears 2 days post delivery, unlike in pre-
eclampsia].
 Blood:
1. Coagulopathy[Excess consumption of plasma fibrinogen due to DIC and retroplacental
bleeding].
2. Overt hyperfibrinogenaemia(<150mg/dL), elevated FDP and D-dimer.
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7. Clinical Classification
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Grade 0 Grade 1 Grade 2 Grade 3
Incidence - 40% 45% 15%
Vaginal Bleeding None. None to mild. None to moderate. None to severe.
Uterine
tenderness
None. Slight. Moderate. Severe.
Maternal
Hemodynamics
Stable. Normal HR and
BP.
Tachycardia &
Orthostatic
hypotension.
Hypovolemic
Shock
HR>120/min &
SBP<80mmHg.
Hyperfibrinogen
aemia
None. None. Mild(>150mg/dL). Severe(<150mg/d
L).
Coagulation
Profile
Normal. Normal. Mild abnormality. Frank
Coagulopathy.
Fetal Status Reassuring. Reassuring. Fetal distress/death. Fetal death.

8. Clinical Features
 Depends on:
1. Degree of separation.
2. Speed at which separation occurs.
3. Amount of blood concealed in uterine cavity.
 Diagnosis:
Mainly Clinical.
USG/MRI maybe helpful.
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9. Clinical Features
9 Clinical Features Revealed Mixed
(Concealed
predominant)
Symptoms Abdominal discomfort
followed by vaginal
bleeding.
Acute abdominal intense
pain followed by slight
vaginal bleeding.
Character Of Bleeding Continuous dark colour. Continuous blood
stained serous
discharge.
General Condition Proportionate to visible
blood loss.
Disproportionate shock
usually present.
Uterine Height Proportionate to
Gestational Age.
Disproportionately
enlarged.
Uterus Feel Normal with local
tenderness.
Tense, tender and rigid.
Fetal Parts Easily identified. Difficult.
FHS Usually present. Absent.
Urine Output Usually normal . Diminished.

10. Clinical Features-Laboratory Tests10
Laboratory Tests Revealed Mixed
(Concealed predominant)
Hb% Low value, proportionate to
blood loss.
Markedly lower, out of
proportion to the visible
blood loss.
Coagulation Profile Unchanged. Variable changes.
Urine For Protein May be absent. Usually present.

11. Clinical Features-Ultrasonography
 Early haemorrhage is hypo or isoechoic.
 Acute haemorrhage is often confused with fibroid or thick placenta.
 Negative findings do not exclude abruption.
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12. Ultrasonographic Localization12

13. Differential Diagnosis13
•Placenta Previa.
•Indeterminate bleeding.
Revealed
type
•Rupture uterus.
•Rectus sheath hematoma.
•Appendicular/Intestinal perforation.
•Twisted ovarian tumour.
•Volvulus.
•Acute hydramnios.
•Tonic uterine contractions.
Concealed
type

14. Differential Diagnosis
Essential Features to diagnose concealed type:
1. Shock out of proportion of external bleeding.
2. Unexplained extreme pallor.
3. Presence of pre-eclamptic features.
4. Uterus is tense, tender and woody hard.
5. FHS absent.
6. Diminished urinary output.
7. Presence of blood coagulation disorder.
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15. Differential Diagnosis-Placenta Previa and
Abruptio Placenta
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Clinical Features Placenta Previa Abruptio Placenta
Nature of bleeding a)Painless, apparently
causeless and recurrent.
b)Bleeding always revealed.
a)Painful, continuous, often
attributed to pre-eclampsia
or trauma.
b)Revealed/concealed/mixe
d.
Character of blood Bright Red. Dark coloured.
General condition and
anaemia
Proportionate to blood loss. Out of proportion to visible
blood loss in
concealed/mixed.
Features of Pre-eclampsia Not relevant Present in one third cases.

16. Differential Diagnosis-Placenta Previa and
Abruptio Placenta
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Abdominal Examination Placenta Previa Abruptio Placenta
Height of uterus Proportional to gestational
age.
Maybe disproportionately
enlarged in concealed type.
Feel of uterus Soft and relaxed. Tense, tender and rigid.
Malpresentation Common. Head is high
floating.
Uncommon. Head may be
engaged.
FHS Usually present. Usually absent.
Vaginal Examination Placenta felt on lower
segment.
Placenta not felt in lower
segment. Blood cots not
to be confused with
placenta.
USG Placenta in lower
segment.
Placenta in upper
segment.

17. Complications
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Revealed
Maternal
• Risk proportional to
blood loss. Death is
rare.
Fetal
• Death- 25 to 30%
Concealed
Maternal
• Haemorrhage
• Shock
• DIC
• Amniotic Fluid
• Blood Coagulopathy
• Oliguria/Anuria
• PPH
• Puerperal Sepsis
• Sheehan Syndrome
Fetal
• Death- 50 to 100%(Due to
prematurity and anoxia)

18. Bibliography
DC Dutta’s Textbook Of Obstetrics, 8th Edition.
Williams Obstetrics, 24th Edition.
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19. Thank You
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