1. Dr.Rupa Rajshekar MBBS, MD
Specialist in Obg
Al Bukariya general hospital
26 August 2016 1Abruptio placentae - Dr.Rupa
2. 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.
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4. Epidemiology
1/3 of all ante-partum bleeding is due to A P
Incidence ranging from 1 in 75 to 1 in 225 births
AP recurs in 5 to 17% of pregnancies after 1 prior
episode
Up to 25% after 2 prior episodes
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5. Etiology
Primary cause of A P 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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6. Etiology
Cigarette smoking: 1.4-1.9%
Cocaine abuse: NA
Prior abruption: 10-25%
Uterine leiomyoma: NA
Hydromnios: 2%
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7. 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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10. 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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11. 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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13. 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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17. 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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21. 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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22. 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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23. 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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24. 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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25. 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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26. 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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