ABRUPTIO PLACENTA

ANTEPARTUM HEMORRHAGE DEFINITION Bleeding from or into the genital tract after the 28th weeks of gestation but before the birth of the baby. - D C. Dutta.

CAUSES OF ANTEPARTUM HAEMORRHAGE Obststric Haemorrhage CAUSES OF ANTEPARTUM HAEMORRHAGE PLACENTAL BLEEDING Placenta previa Abruptio placenta UNEXPLAINED EXTRA PLACENTAL CAUSES Local cervico-vaginal lesions Cervical polyp Carcinoma cervix Varicose vein Local trauma

ABRUPTIO PLACENTAE A latin word “Abruptio placentae” means “Rending asunder of placenta”, which means ‘a sudden accident’

DEFINITION Bleeding occurs due to premature separation of normally situated placenta after 28 weeks of gestation and before the birth of the baby. - Williams.

INCIDENCE 1 in 150 deliveries which resulted death of fetus 1 out of 500-750 deliveries lead to maternal mortality about 2-5%

ALTERNATIVE NAMES Premature separation of placenta Accidental haemorrhage Ablatio placentae Abruptio placentae Placental abruption

TYPES REVEALED CONCEALED MIXED

ETIOLOGY PREVALANCE IS MORE WITH High birth order Advancing age of mother Poor socio-economic condition Malnutrition Smocking

ETIOLOGY.....Contd Hypertension in pregnancy Trauma Sudden decompression Short cord Supine hypotensive syndrome Placental anomaly

ETIOLOGY.....Contd Sick placenta Folic acid deficiency Uterine factor Torsion of the uterus Cocaine abuse Thrombophilias Prior abruption

PATHOGENESIS Due to etiology Hemorrhage into decidua basalis Decidua splits Development of decidual hematoma Separation, compression, ultimate destruction of placenta.

Contd… 2. Decidual spiral artery ruptures Retroplacental hematoma forms Expands with increase in bleeding. Area of separation rapidly becomes extensive & reach margins Uterus unable to contract & compress vessels Blood dissect membranes from uterine wall

CLINICAL FEATURES FEATURES REVEALED MIXED/CONCEALED SYMPTOMS Abdominal pain followed by vaginal bleeding Acute intense pain abdomen followed by slight vaginal bleeding 1 Character of bleeding Continous, dark colour, slight to moderate Continous, dark, slight 2 General condition Shock usually absent, proportionate to loss Shock pronounced out of proportion to the blood loss 3 Pallor R/t visible blood loss Severe 4 Features of pre -eclampsia May be present Frequent association

CLINICAL FEATURES……Contd SYMPTOMS REVEALED MIXED/CONCEALED 5 Uterine feel Normal, tenderness, contractions frequent Tense,tender,rigid 6 Uterine height Proportionate Disproportionately enlarged 7 Fetal parts Can be identified easily Difficult to make out 8 FHS Usually present Usually absent 9 Urine output Normal Usually diminished

CLINICAL FEATURES……Contd SYMPTOMS REVEALED MIXED/CONCEALED LABORATORY 1 Blood Hb% Low, proportionate to the blood loss Markedly lower out of proportionate to the visible blood loss 2 Coagulation profile Usually unchanged Variable increase 3 Urine for protein May be absent Usually present 4 Confusion in diagnosis Placenta previa Acute OBG-Surgical complication

CLINICAL CLASSIFICATION: Grade 0 Clinical features absent Grade I Bleeding slight tender and irritable uterus Maternal Bp and fibrinogen level unaffected FHS good. Grade II Bleeding moderate uterus tender shock absent fetal distress present. Grade III Bleeding severe shock present fetal death is ruled coagulation defect or anuria.

MANAGEMENT PREVENTION: Aims - >Eliminate risk factors >Correct anemia >Prompt detection & treatment >Avoid trauma >Avoid sudden decompression of uterus >Avoid supine hypotension >Routine Folic acid administration

Treatment: AT HOME: -Rush to well equipped maternity unit as early as possible………

IN HOSPITAL:

I. REVEALED TYPE: Assessment of case Assess amount of blood loss Assess maturity of fetus Assess whether in labour or not Presence of any complication

*Use Large Bore IV Lines* Preliminaries Sent blood for Hb%, coagulation profile, ABO, Rh grouping. Urine for protein. Ringer’s solution drip & arrange for blood transfusion. Close monitoring of mother & fetus *Use Large Bore IV Lines*

Definitive Treatment: Patient in labour – Accelerate labour - Oxytocin drip. APH = ARM

Contd… Patient not in labour – Pregnancy 37 wks or more Induction of labour by low ARM Caesarean section - fetal distress - complications - control bleeding fails

B. Pregnancy less than 37 wks – Bleeding moderate to severe & continuing -ARM - Oxytocin drip - C. S Bleeding slight & has stopped - conservative treatment -close monitoring

II . MIXED or CONCEALED: Principles; To correct hypovolemia & to restore blood loss To bring effective uterine contraction & termination of abruption process To observe blood coagulation profile Close monitoring

Definitive Treatment: Blood investigation To correct hypovolemia AROM with oxytocin Vaginal delivery Caesarean section

COMPLICATIONS: HAEMORRHAGE SHOCK BLOOD COAGULATION DISORDERS OLIGURIA & ANURIA POSTPARTUM HAEMORRHAGE PUERPERAL SEPSIS ISCHAEMIC NECROSIS

COUVELAIRE UTERUS Massive intravasation of blood into the uterine musculature upto the serous coat Condition diagnosed on laparotomy Uterus is of dark port wine color may be patchy or diffuse Starts at cornu then spread to other area Hemorrhage are found under the uterine peritoneum and may extend into the broad ligament Myometrial hematoma interferes with uterine contractions

COUVELAIRE UTERUS

Fetal Risks PERNATAL MORTALITY GROWTH RESTRICTION CONGENITAL MALFORMATION ANAEMIA

Nursing Management: Monitor vital signs & record Assess amount of blood loss Assess contraction pattern Assess urine output &skin color Send for cross matching & grouping Administer Morphine if pain present Put wide bore IV line or CV line Physical comfort & emotional support Check fundal height & abdominal girth Monitor fetal well being