Placental abruption types diagnosi etc

1. Placental
abruption
Submitted by: Pritish baliyan
Submitted to: Mrs Guli mam
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2. Definition
 Placental abruption is the premature separation of the normally implanted
placenta from the uterine wall after the 20th week of gestation until the
2nd stage of labor.
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4. Etiology
 Primary cause of P A is uncertain
 Several associated conditions identified:
 Increase in age & parity: 1.3-1.5%
 Pre-eclamsia: 2.1-4%
 Chronic hypertension: 1.8-3%
 Preterm ruptured membranes: 2.4-4.9%
 Multifetal gestation: 2.1%
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5. Etiology
 Cigarette smoking: 1.4-1.9%
 Cocaine abuse: NA
 Prior abruption: 10-25%
 Uterine leiomyoma: NA
 Hydromnios: 2%
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6. Classification
 Revealed type: Bleeding is revealed.
 Concealed type: No obvious bleeding.
 Mixed type: Combination of 1&2 above.
 In the concealed type(20%), the hemorrhage
is confined within the uterine cavity,
detachment of the placenta may be
complete, and the complications are often
severe.
 In the revealed type(80%) the blood drains
through the cervix, placental detachment is
more likely to be incomplete, and the
complications are fewer and less severe
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9. Pathophysiology
Placental abruption initiated by hge into decidua basalis
Haematoma formation
In concealed type blood accumulates &
seeps into myometrium
Couvelaire’s uterus
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10. Couvelaire’s uterus
 Also called as Utero-placental apoplexy
 First described by Couvelaire in early 1900
 Extravasation of blood into uterine musculature &
beneath uterine serosa
 Demonstrated only at laparotomy
 These myometrial hge interfere with uterine
contraction to produce PPH
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11. Couvelaire’s uterus
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12. Pathophysiology
Blood gains access to amniotic fluid
through rupture membranes
With disrupted placental site there is reduced
metabolic exchange
Process continues with release
Fetal hypoxia of tissue thromboplastin in
maternal circulation
DIC
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13. Complications
Maternal:
1. Maternal mortality
2. Hypovolaemic shock
3. Renal failure
4. DIC
5. PPH
6. Rhesus sensitization
7. Complication of massive transfusion
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14. Complications
Fetal:
1. Fetal death
2. Hypoxic brain injury
3. IUGR
4. Neonatal anemia
5. Congenital malformations (CNS)
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15. Signs & symptoms
 Vaginal bleeding: 78%
 Uterine tenderness: 66%
 Back pain: 60%
 Fetal distress: 22%
 Hypertonus: 17%
 Fetal demise: 15%
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16. Diagnosis
 Basis of diagnosis consists of :
 History & physical examinations
 Triad of external bleeding through cervical Os, Uterine or
back pain and fetal distress should be of high suspicion
 Defer digital cervical examinations until PP & VP are ruled
out
 Ultrasound – limited value but for large abruptions
hypoechoic areas seen underlying placenta
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17. Ultrasound
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18. Ultrasound
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20. Laboratory tests
1. Complete blood cell count
2. Blood type & screen
3. Urine analysis,
4. Liver function tests
5. Renal function tests
6. Prothrombin time/ aPTT
7. Fibrinogen levels
8. FDP – Fibrin degradation products
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21. Classification of A P depending on history &
investigations
Grade O : Asymptomatic –incidental finding of retro- placental clot
Grade 1 : Vaginal bleeding, no maternal or fetal compromise – uterine tenderness
present
Grade 2 : Fetal distress
No evidence of maternal shock
Vaginal bleeding may not be present
Grade 3 : Maternal shock & fetal demise present
Marked uterine tetany & tenderness
Vaginal bleeding may not be present
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22. Management
 Depends on condition of mother & gestational age of
fetus:
 Large bore IV access obtained
 Fluid resuscitation
 Foley’s catheter
 Maternal vitals close monitoring
 Continuous FHR monitoring
 Rh D immunoglobulin administered to Rh (-) patients
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23. Management
 Term gestation, hemodynamically stable:
 Plan for vaginal delivery with CS for usual indications
 Follow serial hematocrit & coagulation studies
 Continuous fetal monitoring
 Term gestation, hemodynamic instability:
 Aggressive fluid resuscitation
 Transfuse packed RBC, fresh frozen plasma & platelets as
needed
 Maintain Fibrinogen level > 150 mg/deciliter, hematocrit >
25% & platelet over 60000/μ L
 Urgent CS unless vaginal delivery is imminent
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24. Management
 Preterm gestation hemodynamically stable:
 In absence of labor, preterm AP should be followed with
serial USG for fetal growth
 Steroids should be given to promote fetal lung maturity
 If maternal instability or fetal distress arises delivery
should be performed, if not labor can be induced at term
 Preterm gestation hemodynamically unstable:
 Delivery should be performed after appropriate
resuscitation
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25. Conclusion
 Abruptio Placentae is an important cause of
fetal and maternal morbidity and mortality.
The etiology is poorly understood , various
management options are however available.
 The principle of initial assessment of the
patients condition and subsequent planned
management aimed at resuscitation and
prolongation of pregnancy if possible or
immediate delivery either for fetal or
maternal indications.
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