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ABRUPTIO PLACENTA
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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.
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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
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ABRUPTIO PLACENTAE A latin word “Abruptio placentae”
means “Rending asunder of placenta”, which means ‘a sudden accident’
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DEFINITION Bleeding occurs due to premature separation of normally situated placenta after 28 weeks of gestation and before the birth of the baby. - Williams.
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INCIDENCE 1 in 150 deliveries which resulted death of fetus
1 out of deliveries lead to maternal mortality about 2-5%
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ALTERNATIVE NAMES Premature separation of placenta
Accidental haemorrhage Ablatio placentae Abruptio placentae Placental abruption
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TYPES REVEALED CONCEALED MIXED
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ETIOLOGY PREVALANCE IS MORE WITH High birth order
Advancing age of mother Poor socio-economic condition Malnutrition Smocking
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ETIOLOGY.....Contd Hypertension in pregnancy Trauma
Sudden decompression Short cord Supine hypotensive syndrome Placental anomaly
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ETIOLOGY.....Contd Sick placenta Folic acid deficiency Uterine factor
Torsion of the uterus Cocaine abuse Thrombophilias Prior abruption
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PATHOGENESIS Due to etiology Hemorrhage into decidua basalis
Decidua splits Development of decidual hematoma Separation, compression, ultimate destruction of placenta.
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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
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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
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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
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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
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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.
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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
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Treatment: AT HOME: -Rush to well equipped maternity unit as early as possible………
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IN HOSPITAL:
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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
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*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*
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Definitive Treatment:
Patient in labour – Accelerate labour - Oxytocin drip. APH = ARM
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Contd… Patient not in labour – Pregnancy 37 wks or more
Induction of labour by low ARM Caesarean section - fetal distress - complications - control bleeding fails
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B. Pregnancy less than 37 wks –
Bleeding moderate to severe & continuing -ARM - Oxytocin drip - C. S Bleeding slight & has stopped conservative treatment -close monitoring
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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
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Definitive Treatment:
Blood investigation To correct hypovolemia AROM with oxytocin Vaginal delivery Caesarean section
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COMPLICATIONS: HAEMORRHAGE SHOCK BLOOD COAGULATION DISORDERS
OLIGURIA & ANURIA POSTPARTUM HAEMORRHAGE PUERPERAL SEPSIS ISCHAEMIC NECROSIS
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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
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COUVELAIRE UTERUS
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Fetal Risks PERNATAL MORTALITY GROWTH RESTRICTION
CONGENITAL MALFORMATION ANAEMIA
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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
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