Obstetrics: Abruptio Placenta

Abruptio Placenta

• Definition: The premature separation of a normally implanted placenta from the uterine wall, occurring after 24 weeks of pregnancy.
• Causes: Unknown, but associated with risk factors such as hypertension, grand multigravida, multiple gestation, polyhydramnios, sudden reduction of uterine size, and short cord.

Clinical Picture

• Depending on the type of premature separation:

  • Covert abruptio placenta: Central separation with blood trapped between the uterine wall and placenta, potentially causing couvelaire uterus (blue discoloration of uterus).
  • Overt or revealed abruptio placenta: Peripheral detachment with blood escaping from the placental site and draining through the vagina.
  • Mixed: Combination of concealed and revealed abruptio.

• Manifestations:

  • Dark vaginal bleeding
  • Abdominal pain, sudden and knife-like
  • Firm and tender uterus
  • Distension of the uterus
  • Signs of shock: low blood pressure, increased pulse rate, decreased respiratory rate
  • Fetal distress or IUFD
  • Difficulty palpating fetal parts

Clinical Grading of Abruptio Placenta

• Grade 1 (mild):
  • Placental bleeding < 500cc
  • Placental separation < 1/4
  • Abdominal pain, discomfort, and uterus incomplete relaxation
  • No fetal distress
• Grade 2 (moderate):
  • Blood loss 500-1000cc
  • Altered coagulation
  • Placental separation > 1/4
  • Continuous tenderness, firm uterus contraction
  • Signs of shock: pale, low blood pressure, and high pulse
  • Fetal distress
  • Possible early consumption coagulopathy
• Grade 3 (severe):
  • Blood loss > 2000cc or concealed
  • Placental separation > 2/3
  • Knife-like pain, tearing, uterus board-like, unrelaxed
  • Patient shocked, low blood pressure, and high pulse
  • Fetal severe distress or demise
  • Consumption coagulopathy

Management

• Grade 1:
  • Bed rest, sedation, F.H.R, U/S, and induction of labor
  • Mature and active baby: Artificial Rupture Membrane (ARM), syntocinon, or C/S
• Grade 2:
  • Blood transfusion, sedation
  • If no fetal distress or death: ARM, syntocinon, or by C/S
• Grade 3:
  • Blood transfusion, clotting factors, and C/S

Complications

• Maternal:
  • Mortality higher than other types of antepartum hemorrhages
  • Renal failure, hypovolemia, and postpartum hemorrhage
  • Disseminated intravascular coagulopathy
• Fetal:
  • IUGR (intrauterine growth retardation)
  • Preterm delivery
  • IUFD (intrauterine fetal death)

Conservative Management

• Hospital admission for rest
• Monitor placental function
• Kick chart, cardiotocograph (C.T.G), and U/S
• Psychological support for mother
• Preparation for preterm baby (resuscitation)

Complications in Severe Bleeding

• Maternal shock
• Anesthetic and surgical complications
• Placenta accrete
• Air embolism
• Postpartum hemorrhage
• Maternal death
• Fetal hypoxia
• Fetal death