Abruptio placentae is the separation of the placenta from the implantation site before delivery. It occurs in about 1 in 200 deliveries and can lead to high rates of perinatal mortality (15-20%) and maternal mortality (2-5%). It is classified as concealed, revealed, or mixed based on whether bleeding is internally or externally visible. Management involves resuscitation, monitoring, and immediate delivery to prevent further bleeding, typically through induction of labor or cesarean section. Expectant management may be considered for mild cases near term.
Under the topic of (APH) I talked about the most common causes of (APH) which are placental causes, including Placental Abruption, Placenta Previa and Vasa previa and I depended on the most famous obstetric and gynecological books, Like:
1-An evidence-based text for MRCOG, THIRD EDITION. 2016
2-Bedside Obstetrics and Gynecology (2010)
3-Differential_Diagnosis_in_Obstetrics and gynecology
And other books
Haemorrhage is a major cause of maternal morbidity and mortality throughout the world. Antepartum haemorrhage is defined as the bleeding from or within the genital tract after 28th week of pregnancy but before the birth of the baby. Causes may be placental, extra placental or unexplained Major causes of APH are two: placenta previa and abruptio placenta. h Placenta previa is 4 types. Placentography (USG) confirms the diagnosis .Abruptio placenta should be differentiated placenta previa Placenta previa can be diagnosed by—(i) Ultrasonography (preferred), (ii) Clinically. Transvaginal ultrasound classify placenta previa: (a) within 2 cm or (b) > 2 cm from the undilated internal cervical os. Vaginal examination for the diagnosis of placenta previa should not be done as it provokes severe hemorrhageImaging modalities (Doppler USG, MRI) have reduced the need of double set up examination and the risk of bleeding thereof as they can make the improved diagnosis of placenta previa, accreta and abruption. h Placental abruption is diagnosed mainly clinically and supported by laboratory, USG or MRI. h Complications of placenta previa and abruptio placenta affect both the mother and the fetus. Management of placenta previa and abruptio placenta depends upon the severity of the problem and also on the duration of pregnancy.
THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI
PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE
Under the topic of (APH) I talked about the most common causes of (APH) which are placental causes, including Placental Abruption, Placenta Previa and Vasa previa and I depended on the most famous obstetric and gynecological books, Like:
1-An evidence-based text for MRCOG, THIRD EDITION. 2016
2-Bedside Obstetrics and Gynecology (2010)
3-Differential_Diagnosis_in_Obstetrics and gynecology
And other books
Haemorrhage is a major cause of maternal morbidity and mortality throughout the world. Antepartum haemorrhage is defined as the bleeding from or within the genital tract after 28th week of pregnancy but before the birth of the baby. Causes may be placental, extra placental or unexplained Major causes of APH are two: placenta previa and abruptio placenta. h Placenta previa is 4 types. Placentography (USG) confirms the diagnosis .Abruptio placenta should be differentiated placenta previa Placenta previa can be diagnosed by—(i) Ultrasonography (preferred), (ii) Clinically. Transvaginal ultrasound classify placenta previa: (a) within 2 cm or (b) > 2 cm from the undilated internal cervical os. Vaginal examination for the diagnosis of placenta previa should not be done as it provokes severe hemorrhageImaging modalities (Doppler USG, MRI) have reduced the need of double set up examination and the risk of bleeding thereof as they can make the improved diagnosis of placenta previa, accreta and abruption. h Placental abruption is diagnosed mainly clinically and supported by laboratory, USG or MRI. h Complications of placenta previa and abruptio placenta affect both the mother and the fetus. Management of placenta previa and abruptio placenta depends upon the severity of the problem and also on the duration of pregnancy.
THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI
PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE
Retained placenta by dr alka mukherjee & dr apurva mukherjeealka mukherjee
Retained placenta after vaginal delivery is diagnosed when a placenta does not spontaneously deliver within a designated amount of time, variably defined as a period of 18–60 mins. It may also be diagnosed if a patient experiences significant hemorrhage prior to delivery of the placenta. Normal placenta delivery requires adequate uterine contractions, with shearing of the placenta and decidua from the uterine wall and expulsion of the tissue. Thus, retained placenta can occur in the setting of significant uterine atony, abnormally adherent placenta, as with placenta accreta spectrum (PAS), or closure of the cervix prior to placental expulsion. Risk factors for retained placenta parallel those for uterine atony and PAS and include prolonged oxytocin use, high parity, preterm delivery, history of uterine surgery, and IVF conceptions. History of a prior retained placenta and congenital uterine anomalies also appear to be risk factors. Management entails manual removal of the placenta with adequate analgesia, as medical intervention alone has not been proven effective. Complications can include major hemorrhage, endometritis, or retained portions of placental tissue, the latter of which can lead to delayed hemorrhage or infection. Prophylactic antibiotics can be considered with manual placenta removal, though evidence regarding effectiveness is inconsistent. If hemorrhage is encountered, deployment of a massive transfusion protocol, uterine evacuation with suction, and use of intrauterine tamponade, as with an intrauterine balloon, should be initiated immediately. When a separation plane between the placenta and uterus is particularly difficult to create, PAS should be considered, and preparations should be made for hemorrhage and hysterectomy. Patients with risk factors for retained placenta should have a laboratory sample sent for blood type and antibody screening on admission to labor and delivery, and plans should be made for appropriate analgesia and preparations for hemorrhage if a retained placenta is encountered.
A serious pregnancy complication in which the placenta detaches from the womb (uterus).
Placental abruption occurs when the placenta detaches from the inner wall of the womb before delivery. The condition can deprive the baby of oxygen and nutrients.
Symptoms include vaginal bleeding, stomach pain and back pain in the last 12 weeks of pregnancy.
Depending on the degree of placental separation and how close the baby is to full-term, treatment may include bed rest or a Caesarean (C-section).
Retained placenta by dr alka mukherjee & dr apurva mukherjeealka mukherjee
Retained placenta after vaginal delivery is diagnosed when a placenta does not spontaneously deliver within a designated amount of time, variably defined as a period of 18–60 mins. It may also be diagnosed if a patient experiences significant hemorrhage prior to delivery of the placenta. Normal placenta delivery requires adequate uterine contractions, with shearing of the placenta and decidua from the uterine wall and expulsion of the tissue. Thus, retained placenta can occur in the setting of significant uterine atony, abnormally adherent placenta, as with placenta accreta spectrum (PAS), or closure of the cervix prior to placental expulsion. Risk factors for retained placenta parallel those for uterine atony and PAS and include prolonged oxytocin use, high parity, preterm delivery, history of uterine surgery, and IVF conceptions. History of a prior retained placenta and congenital uterine anomalies also appear to be risk factors. Management entails manual removal of the placenta with adequate analgesia, as medical intervention alone has not been proven effective. Complications can include major hemorrhage, endometritis, or retained portions of placental tissue, the latter of which can lead to delayed hemorrhage or infection. Prophylactic antibiotics can be considered with manual placenta removal, though evidence regarding effectiveness is inconsistent. If hemorrhage is encountered, deployment of a massive transfusion protocol, uterine evacuation with suction, and use of intrauterine tamponade, as with an intrauterine balloon, should be initiated immediately. When a separation plane between the placenta and uterus is particularly difficult to create, PAS should be considered, and preparations should be made for hemorrhage and hysterectomy. Patients with risk factors for retained placenta should have a laboratory sample sent for blood type and antibody screening on admission to labor and delivery, and plans should be made for appropriate analgesia and preparations for hemorrhage if a retained placenta is encountered.
A serious pregnancy complication in which the placenta detaches from the womb (uterus).
Placental abruption occurs when the placenta detaches from the inner wall of the womb before delivery. The condition can deprive the baby of oxygen and nutrients.
Symptoms include vaginal bleeding, stomach pain and back pain in the last 12 weeks of pregnancy.
Depending on the degree of placental separation and how close the baby is to full-term, treatment may include bed rest or a Caesarean (C-section).
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This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
2. DEFINATION
• It is one of the antepartum hemorrhage where separation of placenta
either partially or totally from its implantation site before delivery.
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.
11.
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.
15.
16.
17.
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.
24.
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