IN THE NAME OF GOD

Ultrasound in Placental Abruption Laleh Eslamian MD, Prof of Obstetrics & Gynecology, Perinatologist, TUMS

Placental abruption *Refers to bleeding at the decidual-placental interface that causes partial or total placental detachment prior to delivery of the fetus. *The diagnosis is typically reserved for pregnancies > 20 weeks of gestation. *Is a significant cause of maternal and perinatal morbidity, and perinatal mortality. *The perinatal death rate is approximately 12 % (versus 0.6 % in non- abruption births). *The majority of perinatal deaths (up to 77 %) occur in utero; deaths in the postnatal period are primarily related to preterm delivery.

Placental abruption The major clinical findings are : 1) vaginal bleeding mild and clinically insignificant to severe and life-threatening. 2) abdominal pain 3) often accompanied by hypertonic uterine contractions 4 )uterine tenderness 5) and a nonreassuring FHR pattern. When placental separation exceeds 50 %, acute DIC and fetal death are common.

What are the risk factors for placental abruption? Previous abruption (OR: 7.8) Hypertension/Preeclampsia FGR Non vertex presentations Polyhydramnios Multiparity Advanced maternal age Low BMI ART Intrauterine infection

What are the risk factors for placental abruption? (continued) PROM Abdominal trauma Smoking Drug misuse (cocaine, amphetamines) First trimester bleeding (OR: 1.48) First trimester intrauterine hematoma (OR: 1.6) Maternal thrombophilia (FVL , OR: 1.85, Prothrombin gene, OR: 2.02) Abnormal maternal serum aneuploidy analytes ( x10 )

In women Presenting with APH A multidisciplinary team including midwifery and obstetrics staff immediate access to laboratory blood bank, blood products operating theater neonatal services anesthetic services SHOULD provide clinical assessment.

Initial interventions Initiate continuous fetal heart rate monitoring, since the fetus is at risk of becoming hypoxemic and developing acidosis. Secure intravenous access, administer crystalloid, preferably Lactated Ringer's, to maintain urine output above 30 mL/h. Closely monitor the mother's hemodynamic status (PR, BP, urine output, blood loss). Quantify blood loss.

Initial interventions (continued) Draw blood for a CBC, BG, crossmatch, coagulation studies, creatinine , LFT & TT. Replace blood and blood products, as required. Notify the anesthesia team. Administer standard medications to women likely to deliver( Mg sulfate <32w & Beta) Keep the patient warm and provide supplemental oxygen, as needed.

If bleeding continues and the estimated blood loss has exceeded 500 to 1000 ml: transfuse blood . Initiate a massive transfusion protocol when: ≥4 units of blood are transfused (sample protocol: 6 units PC, 6 units of FFP, 1 or 2 cryoprecipitate pools , and 1 dose of platelets)

Transfusion goals Maintain hematocrit at 25 to 30 % or greater Maintain platelet count ≥75,000/microL Maintain fibrinogen ≥100 mg/dL. Maintain a PT & PTT< than 1.5 times control

Ultrasound scan Should be performed in women presenting with APH. Is well established in determining placental location & Dx of placenta previa. The sensitivity of US in diagnosing retro placental clot( abruption) is poor. ( Glantz C et al 2002) Sensitivity: 24% Specificity: 96% PPV: 86% NPV: 53% However if the US suggests an abruption, the likelihood that there is an abruption is high.

Imaging Identification of a retroplacental hematoma is the classic ultrasound finding of placental abruption. Retroplacental hematomas have a variable appearance; they can appear solid, complex, and hypo-, hyper-, or iso-echoic compared to the placenta. Hypoechogenicity and sonolucency are features of resolving rather than acute hematomas . Whether a hematoma is identified depends on the extent of hemorrhage, chronicity of the bleeding, and extent that blood has escaped through the cervix .

Hypoechoic retro Placental

imaging Although the worst outcomes appear to occur when there is sonographic evidence of a retroplacental hematoma , the absence of retroplacental hematoma does not exclude the possibility of severe abruption because blood may not collect behind the uterus.

imaging A thorough search for other findings in symptomatic patients may improve the sensitivity and specificity of ultrasound. These findings include: * Subchorionic collections of fluid (even remote from the placental attachment site) * Echogenic debris in the amniotic fluid, or * A thickened placenta, especially if it shimmers with maternal movement ("Jello" sign)

Marginal separation

clot

Hypoechoic & complex retro

Hyperechoic

Hypoechoic retroplacental

Thickened placenta

anechoic

Hypoechoic, complex

Marginal separation

Retromembranous bleeding

Preplacental hemorrhage

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