PLACENTAL PLACENTAL ABRUPTIONABRUPTION

ASSOCIATE PROFESSORASSOCIATE PROFESSOR

IOLANDA BLIDARUIOLANDA BLIDARU

MD, PhD.MD, PhD.

Definition and Definition and nomenclaturenomenclature

The separation of the placenta from its site The separation of the placenta from its site of implantation before the delivery of the of implantation before the delivery of the fetusfetus

premature separation of the normally premature separation of the normally implanted placenta;implanted placenta;

placental abruption;placental abruption; abruptio placentae;abruptio placentae; utero-placental apoplexyutero-placental apoplexy ( (extravasation of extravasation of

blood into the mblood into the myometriumyometrium and beneath and beneath the serosathe serosa));;

accidental hemorrhage. accidental hemorrhage.

FrequencyFrequency

averageaverage = = about 1 in 150 deliveries about 1 in 150 deliveries stillbirthsstillbirths = 10 to 15%= 10 to 15%

PLACENTAL ABRUPTIONPLACENTAL ABRUPTION

EtiologyEtiology cause of placental abruption - unknowncause of placental abruption - unknown associated conditions:associated conditions: prepreeclampsiaeclampsia or chronic hypertension (11% to 65%) or chronic hypertension (11% to 65%) advanced parity / ageadvanced parity / age maternal smokingmaternal smoking thrombophiliasthrombophilias cocaine cocaine ababuseuse preterm ruptured membranes - preterm ruptured membranes - chorioamnionitischorioamnionitis external maternal traumaexternal maternal trauma uterine myomauterine myoma prior abruptionprior abruption

Very high risk of recurrent abruption in a Very high risk of recurrent abruption in a subsequent pregnancy (10%).subsequent pregnancy (10%).

PathologyPathology

hemorrhage into the decidua basalishemorrhage into the decidua basalis →→ decidual hematoma decidual hematoma → → a decidual a decidual spiral artery rupture spiral artery rupture → → retroplacental retroplacental hematomahematoma →→ externalexternal hemorrhagehemorrhage

→ → concealedconcealed hemorrhage hemorrhage

PathologyPathology ThromboplastinThromboplastin from abnormal subplacental from abnormal subplacental

decidua, the disrupted placenta and serum in decidua, the disrupted placenta and serum in the subplacental clot → the subplacental clot → intravascular clotting intravascular clotting processprocess = = consumption coagulopathy consumption coagulopathy or or disseminated intravascular coagulationdisseminated intravascular coagulation

The blood - incoagulable + abnormal bleeding.The blood - incoagulable + abnormal bleeding. Factors V, VIII, XIII and platelets are Factors V, VIII, XIII and platelets are

consumed.consumed. acute tubular necrosis or bilateral renal acute tubular necrosis or bilateral renal

cortical necrosis → cortical necrosis → ooligo-anuria ligo-anuria

ClassificationClassification

Grade 1Grade 1

slight vaginal bleeding + uterine slight vaginal bleeding + uterine

irritabilityirritability

unaffected maternal blood pressureunaffected maternal blood pressure

maternal fibrinogen level - normalmaternal fibrinogen level - normal

fetal heart rate pattern is normalfetal heart rate pattern is normal

ClassificationClassification

ClassificationClassification

Grade 2Grade 2 external uterine bleeding - mild to moderateexternal uterine bleeding - mild to moderate irritable uterusirritable uterus tetanic contractionstetanic contractions maternal blood pressure is maintained, but maternal blood pressure is maintained, but

the pulse rate may be elevated and postural the pulse rate may be elevated and postural blood volume deficits may be presentblood volume deficits may be present

fibrinogen level - reduced to 150-fibrinogen level - reduced to 150-250mg%250mg%

FHR FHR →→ signs of fetal distress signs of fetal distress

ClassificationClassification

ClassificationClassificationGrade 3 Grade 3

bleeding is moderate to severe but may be bleeding is moderate to severe but may be concealedconcealed

uterus is tetanic and painfuluterus is tetanic and painful maternal hypotension – maternal hypotension – hemorrhagic shockhemorrhagic shock fetal deathfetal death fibrinogen levels < 150mg% fibrinogen levels < 150mg% + +

coagulation abnormalities: coagulation abnormalities: thrombocytopenia, coagulation factors thrombocytopenia, coagulation factors depletion.depletion.

ClassificationClassification

Clinical diagnosisClinical diagnosis Signs and symptomsSigns and symptoms

bleedingbleeding + pain+ painAbdominal examinationAbdominal examinationthe uterus is the uterus is hard,hard, tender tender,, tetanically tetanically contractedcontracted;;the uterus will gradually enlarge the uterus will gradually enlarge ((concealed concealed bleedingbleeding););it is impossible it is impossible to outline fetal parts because to outline fetal parts because of tenderness and the contracted uterus;of tenderness and the contracted uterus;frequenfrequentt uterine contractions of lower uterine contractions of lower amplitudeamplitude;;tthe fetal heart tones he fetal heart tones →→ normal / absentnormal / absent Vaginal examinationVaginal examination

Clinical diagnosisClinical diagnosis

Laboratory examinationsLaboratory examinations

SonographySonography hemoglobin - reduced;hemoglobin - reduced; white blood cell count white blood cell count == 20,000 or 30,000; 20,000 or 30,000; the the clotting defect clotting defect →→ in about 10% in about 10% ((in in

severe abruption associated with severe abruption associated with fetal fetal deathdeath or or brisk hemorrhagebrisk hemorrhage));;

coagulation studies (platelet count, coagulation studies (platelet count, prothrombin time, partial thromboplastin prothrombin time, partial thromboplastin time, fibrinogen, test for fibrin split time, fibrinogen, test for fibrin split productsproducts));;

Differential diagnosisDifferential diagnosis

placenta praeviaplacenta praevia uterine rupture uterine rupture acute hydramnios acute hydramnios twisted ovarian cyst twisted ovarian cyst peritonitis.peritonitis.

Differential diagnosis Differential diagnosis

placental abruption placental abruption placenta placenta praeviapraevia

1. 1. bleeding + painbleeding + pain2. 2. the blood is usually darkthe blood is usually dark3. 3. signs of shock signs of shock

disproportional to visible disproportional to visible bleedingbleeding

4. 4. the first bleeding is often the first bleeding is often profuseprofuse

5. 5. the uterus may be firm, the uterus may be firm, tender and tetanically tender and tetanically contractedcontracted

6. 6. the fetus may be difficult to the fetus may be difficult to feel and fetal heart tones feel and fetal heart tones may be irregular or absentmay be irregular or absent

7. 7. the placenta cannot be feltthe placenta cannot be felt8. 8. the patient may have the patient may have

hypertensive disease, but hypertensive disease, but the blood pressure may the blood pressure may be low because of be low because of excessive bleedingexcessive bleeding

9. 9. the urine may contain the urine may contain protein or the patient may protein or the patient may be oligo-anuricbe oligo-anuric

10. 10. a clotting defect may be a clotting defect may be presentpresent

1. 1. painless bleeding unless painless bleeding unless labor has startedlabor has started

2. 2. the blood is bright redthe blood is bright red3. 3. observed bleeding and observed bleeding and

signs of shock usually are signs of shock usually are comparablecomparable

4. 4. the bleeding is usually the bleeding is usually slight at the onsetslight at the onset

5. 5. the uterus is soft, not the uterus is soft, not tender and may be tender and may be contracting if labor has contracting if labor has startedstarted

6. 6. the fetus can be felt easily the fetus can be felt easily and fetal heart tones are and fetal heart tones are usually presentusually present

7. 7. the placenta may be felt the placenta may be felt within the cervical canalwithin the cervical canal

8. 8. there is usually no there is usually no hypertensive diseasehypertensive disease

9. 9. the urine is usually normalthe urine is usually normal10. 10. the blood usually clots the blood usually clots

normallynormally

ManagementManagement ICUICU therapy therapy →→ oxygen + i.v. fluid + R.B.C. oxygen + i.v. fluid + R.B.C. blood in large quantities blood in large quantities Furosemide Furosemide ((pulmonary congestionpulmonary congestion)) Fibrinogen 4g Fibrinogen 4g (normal (normal in in pregnancy pregnancy == 300 300--

700mg/dl).700mg/dl). fresh frozen plasma fresh frozen plasma ++ cryoprecipitate cryoprecipitate

((deficient plasma factorsdeficient plasma factors))..

delivery delivery ccesarean sectionesarean section vvaginal deliveryaginal delivery + e + electronic fetal lectronic fetal

monitoring monitoring hysterectomy hysterectomy for severely damagedfor severely damaged uterus uterus

or or absence ofabsence of hemostasis. hemostasis.

PrognosisPrognosis

FFetal mortalityetal mortality of of 17%17% + + neonatal mortalityneonatal mortality of of 14% 14% ((anoxia, complications of anoxia, complications of prematurity and maternal prematurity and maternal hypertensionhypertension))..

Maternal mortalityMaternal mortality about about 1% 1% ((hemorrhage, cardiac failure, acute hemorrhage, cardiac failure, acute renal failure, acute hepatic failurerenal failure, acute hepatic failure))..