ABRUPTIO PLACENTAABRUPTIO PLACENTABYBY

Dr. C.E. EnyindahDr. C.E. EnyindahDept of Obstetrics & GynaecologyDept of Obstetrics & Gynaecology

University of Port HarcourtUniversity of Port Harcourt

DEFINITIONDEFINITION

Bleeding following premature Bleeding following premature separation of aseparation of a

normally situated placentanormally situated placenta

AETIOLOGYAETIOLOGY

• This is not known, but there are some associated factors which include:-– Hypertension and severe pre-eclampsia– Direct trauma– High Parity– Low socio-economic status– Folic acid deficiency?– Polyhydramnios– Short umbilical cord

CLASSIFICATION

This is classified into three categories –

• Revealed type – the bleeding is revealed.

• Concealed type – there is no obvious bleeding

• Mixed type – a combination of revealed and mixed.

CLINICAL PRESENTATIONVaginal bleeding –• This is either revealed or concealed. The

concealed form is more dangerous and is associated with increasing pallor, shock, abdominal pain, abdominal girth and fundal height.

• Seepage of blood into the myometrium and then to the peritoneal cavity results in couvelaire uterus and haemoperitoneum respectively.

• Serous fluid from the retro placental clot may be confused with amniotic fluid.

• Ruptured membranes may reveal bloodstained amniotic fluid. Abdominal pain Uterine tenderness. Uterus may be woody hard and tender rendering fetal parts difficult to palpate or impalpable.Fetal distressFetal deathMaternal shock/Death

CLINICAL GRADING OF ABRUPTIO PLACENTA

• The grading of Abruptio placenta according to SHER and STUTLAND (1985) is as belowGrade Clinical features

I Not recognized clinically before delivery.

II Intermediate. The classical signs of abruption are present but the fetus is still alive.

III Severe. The fetus is dead

a. Without Coagulopathy

b. With Coagulopathy

DIAGNOSIS

This is made on clinical grounds but ultrasonography may be helpful in a few doubtful (mild) cases. Symptoms and signs may be diagnostic for moderate to severe cases but mild cases may pose diagnostic difficulty until a retroplacental clot is identified after delivery.

• The other ancillary investigations include –– Full blood count– Coagulation profile -

• Clotting time, platelet count, fibrinolysin test, fibrinogen estimation, and FDP (Fibrinogen degradation products)

• Acid base status (PH, blood gas analysis)

• Blood urea and electrolytes

• Urine microscopy, culture and sensitivity

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISThis must be considered in terms of causes of vaginal bleeding and causes of abdominal pain e.g.• Abdominal pains

– Acute appendicitis– Pyelonephritis– Twisted ovarian cyst– Red-degenerating uterine fibroid– Retroperitoneal haemorrhage– Rectus sheath haematoma– Chorioamnionitis– Lumbar or sacral strain– Ruptured uterus

• Vaginal bleeding– Placenta praevia– Vasa praevia

COMPLICATIONSCOMPLICATIONS

• Maternal– Hypovolaemic shock– Acute renal failure – result of haemorrhagic shock,

acute renal tubular and cortical necrosis and DIC– DIC – from thromboplastin release or excessive blood

loss.– PPH – from DIC or from couvelaire uterus.– Fetomaternal haemorrhage. May result in rhesus

sensitization in Rh (D) negative women.– Maternal mortality

FETALFETAL

• IUGR

• Congenital malformations

• Abnormal neonatal haematology – anaemia and transient coagulopathies.

• Perinatal mortality (FSB and ENND)

MANAGEMENTMANAGEMENT

• This depends on severity, associated complications, state of the patient, state of the fetus and the gestational age.

• General management – resuscitation.

• Specific measures –– Immediate delivery– Expectant management– Management of complications.

AA IMMEDIATE DELIVERYIMMEDIATE DELIVERY

Depends on the severity of the abruption, and the state of the fetus (dead or alive)

i)i) DEAD FETUSDEAD FETUS• Aim at vaginal delivery• Needs adequate resuscitation with IV fluids,

blood and plasma.• ARM plus or minus oxytocin (with oxytocin, close

monitoring to avoid over stimulation and uterine rupture). Where there is the least doubt about the diagnosis, perform ARM in theatre in case there is a concomitant placenta praevia.

• Delivery should be effected within 6 hrs. If bleeding continues and progress of labour is slow, deliver by C/S. Note that C/S is risky in the presence of DIC. If there is not much blood available to resuscitate the patient adequately, then early recourse to C/S may be justifiable.

ii)ii) LIVE FETUSLIVE FETUS

• CS or vaginal delivery. CS offers better chances of survival for the baby. If vaginal delivery is aimed at, then there is the need for continuous fetal electronic monitoring and this may be considered if labour is well advanced. This is not possible in our environment.

• Fetal distress – immediate CS

BB EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT

This may be done for very mild cases in which the fetus is immature. Such cases may develop mild localized tenderness over the uterus. The ultrasound scan identifies a small retroplacental clot.

• Admit patient• Pain relief• Continuous electronic fetal heart rate

monitoring (if available)

• Repeated USS for first few hours to monitor rate of progression of retroplacental clot.

• Monitor fetus subsequently by –– Daily fetal kick counts– Twice weekly CTG– Twice weekly ultrasound scan.

• If abruption progresses, deliver as soon as possible.

• If abruption does not progress, continue expectant management till 37 wks and deliver.

CC MANAGEMENT OF COMPLICATIONSMANAGEMENT OF COMPLICATIONS

Haemorrhagic Shock• The tendency is to underestimate blood loss due

to concealed Abruptio placenta.• The aim of treatment is to restore effective blood

volume and hence tissue perfusion.

This involves the following –– Setting up IV line /collecting blood for investigations.– IV fluids – colloids/crystalloids.– Oxygen by face-mask.– Monitor of fluid replacement to avoid overload.– Watch out for problems of massive transfusion.

22 DISSEMINATED INTRAVASCULAR DISSEMINATED INTRAVASCULAR COAGULATION (DIC)COAGULATION (DIC)

More common in severe abruption or massive haemorrhage. There are three stages based on laboratory measurements and clinical features –– Low grade and compensated.– Uncomplicated, no haemostatic failure– Rampant with haemostatic failure

Treatment Involves• Delivery of the fetus / placenta• Replacement of lost blood and consumed factors;

via fresh whole blood / FFP / Packed cells.

3.3. RENAL FAILURERENAL FAILURE

Caused by hypovolaemic shock and intravascular clotting in the kidneys from DIC. Types of renal damage are acute tubular necrosis and acute cortical necrosis.

Treatment entails –– Consult to renal physician.– Fluid replacement / renal function monitoring.– Diuretics (manitol 20% and IV frusemide)-Use with

caution..

4.4. PPHPPH

• Treatment involves– Adequate blood transfusion– Use of oxytocics – ergometrine, oxytocin,

syntometrine and PGF2a– Internal iliac artary ligation or hysterectomy– Rh-sensitisation

THANK YOU