Dr.

Rupa Rajshekar MBBS, MD

Specialist in Obg
Al Bukariya general hospital

26 August 2016 Abruptio placentae - Dr.Rupa 1

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.

26 August 2016 Abruptio placentae - Dr.Rupa 2

26 August 2016 Abruptio placentae - Dr.Rupa 3
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

26 August 2016 Abruptio placentae - Dr.Rupa 4

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%

26 August 2016 Abruptio placentae - Dr.Rupa 5

Etiology
 Cigarette smoking: 1.4-1.9%
 Cocaine abuse: NA
 Prior abruption: 10-25%
 Uterine leiomyoma: NA
 Hydromnios: 2%

26 August 2016 Abruptio placentae - Dr.Rupa 6

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

26 August 2016 Abruptio placentae - Dr.Rupa 7

26 August 2016 Abruptio placentae - Dr.Rupa 8
26 August 2016 Abruptio placentae - Dr.Rupa 9
Pathophysiology
Placental abruption initiated by hge into decidua basalis

Haematoma formation

In concealed type blood accumulates &

seeps into myometrium

Couvelaire’s uterus

26 August 2016 Abruptio placentae - Dr.Rupa 10

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

26 August 2016 Abruptio placentae - Dr.Rupa 11

 Couvelaire’s uterus

26 August 2016 Abruptio placentae - Dr.Rupa 12

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
26 August 2016 Abruptio placentae - Dr.Rupa 13
Complications
Maternal:
1. Maternal mortality
2. Hypovolaemic shock
3. Renal failure
4. DIC
5. PPH
6. Rhesus sensitization
7. Complication of massive transfusion

26 August 2016 Abruptio placentae - Dr.Rupa 14

Complications
Fetal:
1. Fetal death
2. Hypoxic brain injury
3. IUGR
4. Neonatal anemia
5. Congenital malformations (CNS)

26 August 2016 Abruptio placentae - Dr.Rupa 15

Signs & symptoms
 Vaginal bleeding: 78%
 Uterine tenderness: 66%
 Back pain: 60%
 Fetal distress: 22%
 Hypertonus: 17%
 Fetal demise: 15%

26 August 2016 Abruptio placentae - Dr.Rupa 16

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

26 August 2016 Abruptio placentae - Dr.Rupa 17

Ultrasound

26 August 2016 Abruptio placentae - Dr.Rupa 18

Ultrasound

26 August 2016 Abruptio placentae - Dr.Rupa 19

26 August 2016 Abruptio placentae - Dr.Rupa 20
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

26 August 2016 Abruptio placentae - Dr.Rupa 21

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

26 August 2016 Abruptio placentae - Dr.Rupa 22

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

26 August 2016 Abruptio placentae - Dr.Rupa 23

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
26 August 2016 Abruptio placentae - Dr.Rupa 24
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

26 August 2016 Abruptio placentae - Dr.Rupa 25

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.

26 August 2016 Abruptio placentae - Dr.Rupa 26

26 August 2016 Abruptio placentae - Dr.Rupa 27
26 August 2016 Abruptio placentae - Dr.Rupa 28