1. IN THE NAME OF GOD

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

3. 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.

4. 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.

5. 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

6. 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 )

7. 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.

8. 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.

9. 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.

10. 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)

11. 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

12. 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.

13. 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 .

14. Hypoechoic retro Placental

15. 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.

16. 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)

17. Marginal separation

18. clot

19. Hypoechoic & complex retro

20. Hyperechoic

21. Hypoechoic retroplacental

22. Thickened placenta

23. anechoic

24. Hypoechoic, complex

25. Marginal separation

26. Retromembranous bleeding

27. Preplacental hemorrhage

30. THANK YOU