Abruptio placentae

Abruptio placentae

Abruptio placentaeDr.Rupa Rajshekar MBBS, MDSpecialist in ObgAl Bukariya general hospital13 November 20111Abruptio placentae - Dr.Rupa

Definition Abruptio Placentae 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.13 November 20112Abruptio placentae - Dr.Rupa

13 November 20113Abruptio placentae - Dr.Rupa

Epidemiology 1/3 of all ante-partum bleeding is due to A PIncidence ranging from 1 in 75 to 1 in 225 birthsAP recurs in 5 to 17% of pregnancies after 1 prior episode Up to 25% after 2 prior episodes


Etiology Primary cause of A P is uncertainSeveral 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%


EtiologyCigarette smoking:1.4-1.9%Cocaine abuse:NAPrior abruption:10-25%Uterine leiomyoma:NAHydromnios: 2%13 November 2011Abruptio placentae - Dr.Rupa6

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 severe13 November 20117Abruptio placentae - Dr.Rupa

13 November 2011Abruptio placentae - Dr.Rupa8


Pathophysiology Placental abruption initiated by hge into decidua basalis

Haematoma formation

In concealed type blood accumulates & seeps into myometrium Couvelaires uterus 13 November 201110Abruptio placentae - Dr.Rupa

Couvelaires uterusAlso called as Utero-placental apoplexyFirst described by Couvelaire in early 1900Extravasation of blood into uterine musculature & beneath uterine serosaDemonstrated only at laparotomyThese myometrial hge interfere with uterine contraction to produce PPH13 November 2011Abruptio placentae - Dr.Rupa11

Couvelaires uterus13 November 2011Abruptio placentae - Dr.Rupa12

Pathophysiology Blood gains access to amniotic fluid through rupture membranes

With disrupted placental site there is reduced metabolic exchangeProcess continues with release Fetal hypoxia of tissue thromboplastin in maternal circulation DIC


Complications Maternal:Maternal mortalityHypovolaemic shockRenal failureDICPPH Rhesus sensitizationComplication of massive transfusion


Complications Fetal:Fetal deathHypoxic brain injuryIUGRNeonatal anemiaCongenital malformations (CNS)


Signs & symptomsVaginal bleeding:78%Uterine tenderness:66%Back pain:60%Fetal distress:22%Hypertonus:17%Fetal demise:15%13 November 2011Abruptio placentae - Dr.Rupa16

Diagnosis Basis of diagnosis consists of :History & physical examinationsTriad of external bleeding through cervical Os, Uterine or back pain and fetal distress should be of high suspicionDefer digital cervical examinations until PP & VP are ruled out Ultrasound limited value but for large abruptions hypoechoic areas seen underlying placenta


Ultrasound13 November 2011Abruptio placentae - Dr.Rupa18

Ultrasound 13 November 2011Abruptio placentae - Dr.Rupa19


Laboratory tests Complete blood cell countBlood type & screen Urine analysis,Liver function testsRenal function testsProthrombin time/ aPTTFibrinogen levelsFDP Fibrin degradation products


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


Management Depends on condition of mother & gestational age of fetus:Large bore IV access obtainedFluid resuscitationFoleys catheterMaternal vitals close monitoringContinuous FHR monitoringRh D immunoglobulin administered to Rh (-) patients


Management Term gestation, hemodynamically stable:Plan for vaginal delivery with CS for usual indicationsFollow serial hematocrit & coagulation studiesContinuous fetal monitoringTerm gestation, hemodynamic instability:Aggressive fluid resuscitationTransfuse packed RBC, fresh frozen plasma & platelets as neededMaintain Fibrinogen level > 150 mg/deciliter, hematocrit > 25% & platelet over 60000/ LUrgent CS unless vaginal delivery is imminent13 November 201124Abruptio placentae - Dr.Rupa

Management Preterm gestation hemodynamically stable:In absence of labor, preterm AP should be followed with serial USG for fetal growthSteroids should be given to promote fetal lung maturityIf 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


ConclusionAbruptio 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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Abruptio placentae