Download 14-15. Abruption of placenta

PLACENTAL
ABRUPTION
ASSOCIATE PROFESSOR
IOLANDA BLIDARU
MD, PhD.
Definition and nomenclature
The separation of the placenta from its site of
implantation before the delivery of the fetus
premature separation of the normally
implanted placenta;
 placental abruption;
 abruptio placentae;
 utero-placental apoplexy (extravasation of
blood into the myometrium and beneath the
serosa);
 accidental hemorrhage.
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Frequency
average = about 1 in 150 deliveries
 stillbirths = 10 to 15%
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PLACENTAL ABRUPTION
Etiology
cause of placental abruption - unknown
 associated conditions:
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preeclampsia or chronic hypertension (11% to 65%)
 advanced parity / age
 maternal smoking
 thrombophilias
 cocaine abuse
 preterm ruptured membranes - chorioamnionitis
 external maternal trauma
 uterine myoma
 prior abruption
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Very high risk of recurrent abruption in a
subsequent pregnancy (10%).
Pathology
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hemorrhage into the decidua basalis →
decidual hematoma → a decidual spiral
artery rupture → retroplacental hematoma
→ external hemorrhage
→ concealed hemorrhage
Pathology
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Thromboplastin from abnormal subplacental
decidua, the disrupted placenta and serum in
the subplacental clot → intravascular clotting
process = consumption coagulopathy or
disseminated intravascular coagulation
 The blood - incoagulable + abnormal bleeding.
 Factors V, VIII, XIII and platelets are
consumed.
 acute tubular necrosis or bilateral renal
cortical necrosis → oligo-anuria
Classification
Grade 1
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slight vaginal bleeding + uterine irritability
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unaffected maternal blood pressure
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maternal fibrinogen level - normal
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fetal heart rate pattern is normal
Classification
Classification
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Grade 2
external uterine bleeding - mild to moderate
irritable uterus
tetanic contractions
maternal blood pressure is maintained, but the
pulse rate may be elevated and postural blood
volume deficits may be present
fibrinogen level - reduced to 150-250mg%
FHR → signs of fetal distress
Classification
Classification
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Grade 3
bleeding is moderate to severe but may be
concealed
uterus is tetanic and painful
maternal hypotension – hemorrhagic shock
fetal death
fibrinogen levels < 150mg% + coagulation
abnormalities: thrombocytopenia, coagulation
factors depletion.
Classification
Clinical diagnosis
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Signs and symptoms
bleeding + pain
Abdominal examination
the uterus is hard, tender, tetanically contracted;
the uterus will gradually enlarge (concealed
bleeding);
it is impossible to outline fetal parts because of
tenderness and the contracted uterus;
frequent uterine contractions of lower amplitude;
the fetal heart tones → normal / absent
Vaginal examination
Clinical diagnosis
Laboratory examinations
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Sonography
hemoglobin - reduced;
white blood cell count = 20,000 or 30,000;
the clotting defect → in about 10% (in severe
abruption associated with fetal death or brisk
hemorrhage);
coagulation studies (platelet count, prothrombin
time, partial thromboplastin time, fibrinogen,
test for fibrin split products);
Differential diagnosis
placenta praevia
 uterine rupture
 acute hydramnios
 twisted ovarian cyst
 peritonitis.
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Differential diagnosis
placental abruption
placenta praevia
1. bleeding + pain
2. the blood is usually dark
3. signs of shock disproportional
to visible bleeding
4. the first bleeding is often
profuse
5. the uterus may be firm,
tender and tetanically
contracted
6. the fetus may be difficult to
feel and fetal heart tones
may be irregular or absent
7. the placenta cannot be felt
8. the patient may have
hypertensive disease, but
the blood pressure may
be low because of
excessive bleeding
9. the urine may contain protein
or the patient may be oligoanuric
10. a clotting defect may be
present
1. painless bleeding unless
labor has started
2. the blood is bright red
3. observed bleeding and signs
of shock usually are
comparable
4. the bleeding is usually slight
at the onset
5. the uterus is soft, not tender
and may be contracting if
labor has started
6. the fetus can be felt easily
and fetal heart tones are
usually present
7. the placenta may be felt
within the cervical canal
8. there is usually no
hypertensive disease
9. the urine is usually normal
10. the blood usually clots
normally
Management
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ICU therapy → oxygen + i.v. fluid + R.B.C.
blood in large quantities
Furosemide (pulmonary congestion)
Fibrinogen 4g (normal in pregnancy = 300-700mg/dl).
fresh frozen plasma + cryoprecipitate (deficient
plasma factors).
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delivery
cesarean section
vaginal delivery + electronic fetal monitoring
hysterectomy for severely damaged uterus or
absence of hemostasis.
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Prognosis
 Fetal
mortality of 17% +
neonatal mortality of 14%
(anoxia, complications of prematurity
and maternal hypertension).
 Maternal mortality about 1%
(hemorrhage, cardiac failure, acute
renal failure, acute hepatic failure).