ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD. 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.

Frequency average = about 1 in 150 deliveries stillbirths = 10 to 15%

PLACENTAL ABRUPTION

Etiology cause of placental abruption - unknown associated conditions: 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 Very high risk of recurrent abruption in a subsequent pregnancy (10%).

Pathology hemorrhage into the decidua basalis → decidual hematoma → a decidual spiral artery rupture → retroplacental hematoma → external hemorrhage → concealed hemorrhage

Pathology 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 slight vaginal bleeding + uterine irritability unaffected maternal blood pressure maternal fibrinogen level - normal fetal heart rate pattern is normal

Classification

Classification 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 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 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 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.

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 oligo-anuric 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 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). delivery cesarean section vaginal delivery + electronic fetal monitoring hysterectomy for severely damaged uterus or absence of hemostasis.

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).