Abruptio placenta is the premature separation of a normally positioned placenta from the uterus, occurring in about 1 in 200 pregnancies. Major risk factors include advanced maternal age, high parity, hypertensive disorders, and trauma, with clinical presentations ranging from subtle to severe, often including dark red vaginal bleeding and abdominal pain. Management varies from observation in stable cases to urgent delivery in severe cases, and complications can impact both maternal and fetal health significantly.

1. ABRUPTIO PLACENTA
Moderator : Dr Kushla Pathania
Presented by :Dr Anil Kumar

2. ABRUPTIO PLACENTA
Definition : Premature separation of normally
situated placenta from its uterine
attachment .
Incidence : 1:200 pregnancies.
Etiology : Exact cause unknown in majority.
Risk factors: Increased age ( >40) &parity (>4 )
Poor socio-economic condition.
Malnutrition
Smoking
Folic acid defficiency

3. ABRUPTIO PLACENTA
Racial factor: Africa-American and Caucasian
women than in Asian women.
Hereditary Factor: If women have sever abruption, then
the risk for her sister is doubled
Hypertensive disorder of pregnancy
Pre-eclampsia.
Renal hypertension
Chronic Hypertension.
Responsible for 20-50 % cases of abruptio placenta.
Trauma : Fall ,blunt external trauma &road
traffic accident .
Vascular accident : supine hypotension syndrome .

4. ABRUPTIO PLACENTA
 External cephalic version .
 Short cord .
 Sudden decompression of uterus .
 Preterm rupture of membrane .
- Risk is furthered increased with infection.
 Uterine anomalies .
 Abnormal placentation .
 Hyperhomocystenemia : 3-7 time higher risk of
abruption
 Past h/o abruption increases the recrrence by 10-
25%

5. ABRUPTIO PLACENTA
Thrombophilias
Factor V Leiden Mutation
Factor C Deficiency
Factor S Deficiency

6. ABRUPTIO PLACENTA
Types :-
Concealed .
Revealed .
Mixed.

7. ABRUPTIA PLACENTA
Risk Factors for Placntal Abruption
Risk Factor Relative Risk
Increased age and parity 1.3-1.5
Preeclampsia 2.1-4.0
Chronic hypertension 1.8-3.0
Preterm ruptured membranes 2.4-4.9
Multifetal gestation 2.1
Low birthweight 14.0
Hydramnios 2.0
Cigarette smoking 1.4-1.9
Thrombophilias 3-7
Cocaine use NA
Prior abruption 10-25
Uterine leimyoma NA

10. ABRUPTIO PLACENTA
Concealed : Blood may accumulate behind the
placenta when it is totally separated
from uterine wall except at margin.
Rare &severe type, shock being out of
proportion to visible blood loss (20-35%) .
Revealed type :Blood may dissect downwards in b/n
membrane and uterine wall escape out
through cx. Most common &mild type,
general condition being proportionate to
bleeding (65-80%) .
Mixed type: It is a combination of revealed and
concealed type .It is quite common .
Usually one variety predominates over
other .

11. PATHOPHYSIOLOGY
Hemorrage into decidua basalis
Splitting up of decida basalis
Development of retroplacental clots
Adeverse outcome

12. PATHOPHYSIOLOGY
Maternal Fetal
Continuing bleeding Reduced supply of
clot expansion oxygen to fetus
Revealed bleeding Fetal distress
Maternal shock

13. CLINICAL GRADING OF ABRUPTIO PLACENTAE
Grade 0 : Diagnosed on examination of placenta
after delivery .
Grade 1: External bleeding is slight .
Ut irritable tender .
Shock absent.
Fetal heart is good.
Grade 2 :External bleeding mild to moderate .
Ut tenderness is marked .
Shock absent .
Fetal distress or death
Associated coagulation defect or anuria.

14. CLINICAL GRADING OF ABRUPTIO PLACENTAE
Grade 3 : Maternal shock or coagulopathy with
fetal death.

15. ABRUPTIO PLACENTA
Clinical presentation :
Depends upon the degree of placental separation.
Speed at which separation occurs .
Clinical evidence of abruption may sometimes
appear 24 hrs or more after trauma.
Asymptomatic women giving H/o trauma or road
traffic accident must be observed atleast for 6 hrs
prior to discharge .

16. ABRUPTIO PLACENTA
CLINICAL PRESENTATION -
Pt giving h/o bleeding or uterine contractions
must be observed for at least 24 hrs.
Vaginal bleeding :most common symptom . dark red
vaginal bleeding with pain . Bleeding is maternal
origin .
Abdominal pain : Ac agonizing pain or some
discomfort. Some women may experience faintness,
collapse nausea ,thirst and reduced fetal movement .

17. CLENICAL PRESENTATION-
If placenta present post –severe
backache, abdominal palpation
worsen the pain.
There may be sign & symptom of
haemodynamic compromise .
ABRUPTIO PLACENTA

18. ABRUPTIO PLACENTA
 GPE
Sign of shock (tachycardia, low BP).
Sign and symptom of pre eclampsia( increase
BP, Proteinurea).
Often pt’ s clinical condition is
dispropotionate to amount of blood loss.

19. ABRUPTIO PLACENTA
Specific systemic examination .
Uterine hypertonicity & frequent uterine
contraction is common.
Difficulty in feeling the fetal part .
Uterus may be tense tender on palpation.
Wood hard due to persistant hypertonus .
Absent or slow FHR.

20. ABRUPTIO PLACENTA
Vaginal examination : Abruptio placenta
is not a contraindication for vaginal
examination .
Vagina examination should ideally not be
performed in pt with h/o APH .
In pt with abruptio placenta ,ARM result in
release of blood stained amniotic fluid .

21. Investigation
CHG, platelet count, leucocyte count and peripheral blood
smear.
Serum fibrinogen level, PT, PTT, Fibrin degradation product
levels ,bleeding time ,clotting time and D-dimer levels .
Serum electrolytes ,blood urea & liver function tests .
Investigation of PIH .
Arterial blood gas analysis .
Blood group &crossmatching .

22. ABRUPTIO PLACENTA
Utrasonography :
To rule out placenta previa .
To reveal the state of the fetus .
Retroplacental clot at previous placental site
(as seen on earlier usg) is helpful .
Jello sign : Placenta jiggle when pressure is
applied by trasducer.
Negative finding with ultrasound examination
do not exclude placental abruption .

23. ABRUPTIO PLACENTA
Ultrasonography
Ultrasonography has sensitivity of 24%
and specificity of 96% for diagnosing
abruptio placenta.

24. ABRUPTIO PLACENTA
Cardiotocographic examination :
Variable &late deceleration,
poor variability,
prolonged bradycardia and
sinusoidal pattern .

25. DIFFERENTIAL DIAGNOSIS
Revealed type :
Placenta previa
Concealed type :
Rupture uterus
Rectus sheath haemetoma
Appendicular or Intestinal perforation
Ac hydromnios
Tonic uterine contraction
Red degeneration of fibroid

26. DIRRENCE B/N PP AND A PLACENTA
 Placenta is partially wholly
situated in lower uterine
segment .
 Incidence 1 in 300
deliveries .
 Etiology not known. More
common in elderly,
multiparous women,
previous cesarean delivery
with placenta and cord
anomalies .
 Premature separation of
normally situated placenta.
 1 in 200 deliveries .
 Not known, common in
hypertensive disorder ,
trauma, thrombophilias,
nutrition deficiencies,
sudden decompression of
uterus and with past h/o
abruption .
Placenta previa Abruptio placenta

27.  History – Vaginal
bleeding sudden painless
profuse recurrent
causeless without onset
of labour. Bright red
always reveal in nature .
 Pain abdomen absent .
 Hypertensive disorder of
pregnancies –usually
absent
 Painful continuous,
dark coloured revealed,
concealed and mixed
in nature .
 Usually present , ac in
severe cases .
 May be present in 35%
cases .
Placenta previa Abruptio placenta

28.  GPE – pallor, sweating ,
hypotension, tachycardia
which is proportionate to
amount of revealed blood
loss .
Heart ,chest -usually
normal and tachycardia.
 Abdominal examination
Fundal height as per
gestation
 Pallor ,tachycardia
,hypotension and shock ,
may be more in
concealed and mixed
abruption .
 Tachycardia is usually
present .
fundal height may be
more than gestation
Placenta previa Abruptio placenta

29. Consistency –usually soft
& relaxed
fetal parts –easily felt .
fetal heart sound –normal
regular .
Malpesentations –breech,
transverse ,oblique lie
are more common
Tense ,tender ,hard
especially in concealed &
mixed .
not easily palpable.
may be absent due to
placental separation .
Absent presenting part
tends to get engaged early .
Placenta previa Abruptio placenta

30.  MRI –better diagnostic
modality , more
expensive . Mainly used
to rule out morbidly
adherent placenta.
 Treatment
Resuscitation with fluids
and blood .
 Mode of deliveries –
Elective LSCS in
treatment of choice in
severe degree of
placenta previa
MRI can quantify the
separation of placenta
and amount of any
concealed abruption.
With fluid & blood .
Vaginal delivery after
amniotomy and oxytocin
is performed . Caesarean
delivery is indicated in
fetal distress.
Placenta previa Abruptio placenta

31.  Vaginal examination –
contraindicated in
placenta previa .
Performed in operation
theatre with arranged
blood .
 Investigation
USG –Demonstrate
localization of placenta in
the lower uterine
segment .
 Placenta is not felt in lower
uterine segment . Soft friable
blood clots are palpable .
 Placenta is demonstrated in
the upper uterine segment .
There is separation of
placenta .There may be
collection of blood under the
placenta in concealed
abruption .
Placenta previa Abruptio placenta

32. MANAGEMENT
Depends on
History –painful reveal bleeding ,pain without bleeding, no of bouts of
bleeding & amount of bleeding .
GPE –severity of anemia &shock .
Abdominal examination –tense uterus, uterine contraction
Fetal heart abnormal or absent
Investigation –CHG, bleeding & coagulation profile ,blood group
crossmatch.
USG –to rule out placenta previa ,to confirm abruption & for fetal
condition .

33. ABRIPTIO PLACENTA
MANAGEMENT
ABRUPTIO
PLACENTA
FETUS
ALIVE
FETUS
DEAD
Revealed
hemorrhage
Concealed or
mixed hemorrhage

34. Patient in
spontaneous labor
Patient not in
labor
Amniotomy +
Oxytocin, <37 weeks
> 37 weeks
Amniotomy
+ Oxytocin,
Expectant
treatment
No bleeding
Fetal heart normal
Active vaginal
bleeding
Amniotomy +
Oxytocin
Delivery Cesarean
delivery
Fetal distres or
excesive
bleeding or non
progress of labor

35. Concealed or mixed
hemorrhage
1. Arrange blood for transfusion
2. Periodic coagulation profile
3. Urine output
4. Fetal mnitoring
Amniotomy + Oxytocin
-Satisfactory
progress
- No fetal distress
1. No response
2. Falling fibrinogen levels
3. Oliguria
4. Fetal distress + other obstetric
indications for cesarean delivry
5. Cervix unfavourable.
Vaginal delivery
Cesarean delivery

36. Fetus Dead
No coagulopathy Coagulopathy
Vaginal delivery Give blood and
blood products
If no progress or
general condition
worsens
Cesarean delivery

37. MANAGEMENT
Delivery in all patients >37 weeks
Patient in labor – ARM synto .
Pt not in labour
pregnancy >37 weeks
ARM Synto cont CTG monitoring
Pregnancy < 37 weeks
Bleeding moderate to severe and continue
ARM Synto . Labour usually start soon .
Cesarean delivery is often indicated .
ABRUPTIO PLACENTA

38. ABRUPTIO PLACENTA
Bleeding slight or has stoped :
conservative treatment
close observation of mother & careful fetal
monitoring by CTG .
betamethasone
blood sample for blood group cross match
blood transfusion

39. ABRUPTIO PLACENTA
Pre requisite for expectant
management :
Fetal maturity not achieved (<36 weeks ).
Bleeding has stopped and there is not active
bleeding .
The fetus is not in distress .
The mother s ital signs are stable .
Patient is not in labour .

40. ABRUPTIO PLACENTA
Steps of expectant management:
Admission to hospital.
Bed rest .
Avoid sexual intercourse .
Blood group , cross matching , hematocrit and
coagulation profile .
USG for placental lacalisation .
Fetal monitoring with daily fetal movement count
,USG measurement of fetal growth and NST .
Once the active bleeding has stopped ,cervix
need to be inspected with a speculum .

41. MANAGEMENT
 Caesarean delivery
Indication –significant abruption where fetus is alive
sufficiently mature to alive .
Uncontrolled bleeding .
Fetal distress .
Failure to progress in labour .
Maternal condition unstable not responding to
resuscitative measures.
Evidence of DIC
ABRUPTIO PLACENTA

42. MANAGEMENT
Haemodynamic stability with normal blood pressure
,pulse rate &good urine output are sign of well
resuscitated patient .
Coagulation profile should be done as there
increase risk of coagulopathy
ABRUPTIO PLACENTA

43. MANAGEMENT
Bed site test ;
Bleeding time –normal 2-6 minutes .
prolonged in thrombocytopenia .
hypofibrinogenemia.
Whole blood clotting time- normal 5-10
minutes
affected mainly by defect in intrinsic pathway ,by
defect in fibrin & fibrinogen.
prolonged in impaired coagulation
ABRUPTIO PLACENTA

44. ABRUPTIO PLACENTA
Clot retraction – normal 30-60 minutes
prolonged in thrombocytopenia .
weak friable clot indicates hypofibrinogenamia .
early dissolution indicate enhanced fibrinolysis

45. COMPLICATION
Maternal : Hemorrhagic shock
Post partum hemorrhage
Disseminated intravascular coagulation
Oliguria & anuria
Puerperal sepsis
Sheehan syndrome
Recurrence
Death

46. ABRUPTIO PLACENTA
Fetal :
Perinatal death occurs in 25-30 % cases of
revealed ,50-100 % of concealed variety.
The causes of death are prematurity, asphyxia due
to placental abruption ,small for gestational age and
congenital anomalies( 2-5 times higher )

47. PREVENTION
Elimination of known risk factor for placental
abruotion .
Correction of anaemia
Routine administration of folic acid from early
pregnancy
Early diagnosis & treatment minimize serious
complication
Appropriate treatment of hypertensive disorder of
pregnancy

48. PREVENTION
Avoidance of physical trauma
To avoid sudden decompression of uterus
To avoid supine hypotension
ABRUPTIO PLACENTA