Abruptio Plancentae

Dr Dambo D T

Department of Obstetrics & Gynaecology

Introduction
• Abruptio Placentae:- Is the complete or partial
separation of a normally situated placenta from
its uterine site after the 28th week of gestation
until the 2nd stage of labour.
• It normally occurs in the 3rd trimester of
pregnancy, although the process may occur
earlier in pregnancy.
• Abruptio Placenta is classified into 3 types:-
– 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
Incidence

• This has been documented in Britain as

between 0.5%-2% of pregnancies, but
varies depending on the criteria used for
diagnosis. Where the diagnosis is based
on histological examination of the placenta
the incidence has been reported to be as
high as 4%. From the annual report of
2003 the incidence in UPTH is 1.5%.
Aetiology
The aetiology are often difficult to ascertain, although there are risk
factors.

Hypertensive states most consistent risk factor.

Trauma:
- Ritual abdominal massage by birth attendants
- RTA

High parity (AP is independent of age, it occurs in older women
because of high parity.)

Prolonged preterm rupture of membrane.

Sudden decompression of the uterus that accompany
spontaneous or artificial rupture of membranes when there is
polyhydramnios.

Multiple gestation.

Submucous uterine fibroid.

Cigarette smoking.

Cocaine, the heat stable smokable cocaine alkaloid.

Short cord.

Folic acid deficiency.

Chorio-amnionitis
Pathophysiology
• Spontaneous rupture of the placental bed blood
vessels. Leads to haematoma formation. In the
concealed type the haematoma accumulates,
causing increasing pressure and separation of the
placenta. Some blood might dissect into the
myometrium causing COUVELAIRE uterus
• The blood may also rupture through the membranes
and gain access to the amniotic fluid. With the
disrupted placental site, there is reduced metabolic
exchange resulting in fetal hypoxia and probable
death. The process might continue with the release
of tissue Thromboplastin into the maternal
circulation causing Disseminated Intravascular
Coagulopathy.
MANAGEMENT
HISTORY
Vaginal bleeding
usually dark and non-clothing.
However bleeding may be absent.
Abdominal pain
This increase in severity
Back pain
Absence of fetal movement
Symptoms of shock
Restlessness, sweating dizziness
Some may present with no symptoms.
PHYSICAL EXAMINATION:

Signs of shock
Faintness and collapse may occur
Pallor
Cold clammy extremities
Pulse Normal or tachycardia
Blood Pressure:- normal or hypotension
Abdomen
The uterus may be larger than gestation. A tender uterus,
describe as woody hard. it does not relax. Fetal parts are
difficult to palpate. The fetal heart rate may or may not
audible. Vaginal examination is not done if the diagnosis is
in doubt.
If placenta praevia is ruled out, then vaginal examination will
show evidence of bleeding in the reveal type. The cervical
os may be dilated if the patient is in labour, or closed if not
in labour.
INVESTIGATIONS
• Full blood count +differentials
Electrolytes, urea ,creatinine & uric acid
• Urine for urinalysis &m/c/s
• Group & crossmatch at least 4 units of blood

• Coagulation profile
– platelet count
– clotting time
– prothrombin time
– active partial prothrombin time
– fibrin degradation products
– Fibrinogen level
– thrombin level
– Abruptio plancenta is divided into 3 grades according
to clinical and laboratory findings. They are

– Grade 1 or mild slight vaginal bleeding

minimal uterine irritability
• normal BP & HR
• normal FHR
– Grade 2 or Moderate External vaginal bleeding may
be or not present.
• No signs of maternal shock.
• Signs of fetal distress are present
– Grade 3 or Severe External vaginal bleeding may
or may not present. Marked uterine tetany
– Persistent abdominal pain.
– Fetal demise present.
– Coagulopathy may become evident in 30% of
TREATMENT
Principles of mx include
1)Resuscitation
2)Immediate delivery
3)Expectant mx
• Resuscitation
No delay, prompt action, to prevent
maternal and if possible perinatal mortality
• General assessment
• Wide bore cannula to give IV fluids and
transfusion.
• Catheterize
• Oxygen by face mask if needed.
• Bedside clotting time & ward urinalysis
• Other investigations
Grade 3 Severe
• No contraindication to vaginal delivery.
• If in labour,
– amniotomy
– augement labour with oxytocin
– transfuse when necessary
– active management of 2nd stage of labour
– prompt evacuation of the uterus after delivery
of the placenta.
– Continue oxytocin drip.
– If not in labour ripen cervix and induce labour.
Grade 2 moderate
– Resuscitate
– For emergency caesarean section
– If in labour and you anticipate short time
delivery, vaginal delivery can be allowed.
• Grade 1 mild

• Expectant management:-especially when

gestational age favors delaying the
delivery to allow greater fetal maturity.
All facilities for monitoring feto-maternal
well being must be available before this
can be done.
Anytime there is a deviation, for
resuscitation and emergency delivery.
Complications
• Maternal
– Haemorrhage leading to hypovolaemic shock.

– Disseminated Intravascular Coagulopathy

– Acute renal failure

– Increase caesarean section
– Reccurence
– Maternal death
• Fetal
– Hypoxia
– Anaemia
– IUGR
 Conclusion
• Abruptio Placentae is an important cause of fetal
and maternal morbidity and mortality. The
aetiology 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 .