ABRUPTIO PLACENTA

OBG B UNIT

Definition A seperation of placenta from site of its

implantation before delivery.(latin-rendering placenta as under).

Incidence• Range of 0.52% - 1.29%.Increases with “increased

gestational age”.

• Perinatal mortality- 119/1000 live births Vs 8.2/1000 due to other causes.

ETIOLOGY

• MATERNAL HYPERTENSION. • PROM. • CIGARETTE SMOKING,COCAINE ABUSE. • THROMBOPHILIAS. • SUDDEN UTERINE DECOMPRESSION

(polyhydramnios). • EXTERNAL TRAUMA. • UTERINE LEIOMYOMA. • PRIOR ABRUPTION.

RISK FACTORS RISK FACTORS

increased age n parity preeclapmsia chronic hypertension PROM

multifetal gestation hydramnios chronic smoking thrombophilias cocaine abuse prior abruption uterine leiomyoma

RELATIVE RISK 1.3-1.5 2.1-4.0 1.8-3.0 2.4-4.9 2.1 2.0 1.4-1.9 3-7 NA 10-25 NA

PATHOLOGY Haemorrhage into decidua basalisdecidua

splits leaving a thin layer adherent to myometriumdecidual haematomaseparation,compression & destruction of placenta.

PATHOLOGY Decidual spiral artery

ruptureretroplacental haematomathe area of separaton becomes more extensive upto marginuterus unable to contractblood dissects membrane from utrine wall & escapes out or remains concealed

Pathological classification

REVEALED CONCEALED CONCEALED

Causes of concealed haemorrhage

• Effusion of blood behind placenta but margin adherent.

• Placenta separeted but membrane still retain their attachment.

• Blood gains access through amniotic cavity.

• Fetal head closely applied to lower segment that prevents blood escape.

CLINICAL FEATURES Vaginal bleeding 78%

utrine tenderness 66% fetal distress 60% preterm labour 22% high frequency of contraction17% hypertonus 17% dead fetus 15%

CLINICAL CLASSIFICATION

GRADE 1- not recognised clinically & diagnosed by retroplacental

clots after delivery.

GRADE 2-intermediate,classical signs present but fetus still alive.

GRADE 3-severe, fetus is dead. 3a-without coagulopathy. 3b-with coagulopathy.

DIFFERENTIAL DIAGNOSIS

WITH VAGINAL BLEEDplacenta praevia, uterine rupture, vasa praevia.

WITHOUT VAGINAL BLEEDrectus sheath haematoma, retro peritoneal haemorrhage, rupture of appendicular abcess, acute degeneration or torsion of uterine fibroid.

COMPLICATION

• Hypovolemic shock.

• Acute renal failure.

• DIC.

• Couvelaire uterus.

Couvelaire uterus

MANAGEMENT OF ABRUPTIO• ROLE OF IMAGING

Poor sensitivity

• When clot visualized,PPV high

IUD with abruption

• Blood for grouping,crossmatching

• Hb%,PCV

• DIC Profile

• LFT,RFT

• Urine routine

• Replace blood loss

• Correct coagulopathy

• Deliver the baby

Evaluation and replacement of blood loss

• Aggressive correction despite normal vitals & Hct

• Insert CVP catheter,Foley’s catheter

• Transfuse packed cells

• Expand volume with RL/NS

• 1 FFP after every 4U packed cells

• Maintain PCV 30%,urine O/P of 30 ml/hr

Management of coagulopathy

Normal values of DIC profileFibrinogen -150 to 600 mg/dl

PT -11 to 16 sec

PTT -22 to 37 sec

Platelet count -1.2 to 3.5 lak/ cmm

D-dimer - <0.5 mg/l

FDP - <10 microgram/dl

• Clot retraction test- For function of platelets

• Clot lysis- Gross measure of fibrinolytic system

• Transfuse 10-20 U of cryoppt if fibrinogen <100 mg/dl

• Transfuse platelets if count <40,000

Termination of pregnancy

• Vaginal delivery unless no CI

• Early amniotomy

• Oxytocin infusion

• Time for obtaining delivery upto 24 hrs

Live fetus but in distress

• Emer LSCS

• Evaluate hemostatic system

• Speed of delivery important

Live fetus ,FHS normal

• Induce and allow for vaginal delivery

• Continuous CTG

• If CTG abnormal,LSCS

Expectant Mx in preterm

• Only in mild cases

• To await lung maturity

• Hospital stay a must