1. ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD.
PLACENTAL ABRUPTION
ASSOCIATE PROFESSOR
IOLANDA BLIDARU
MD, PhD.

2. 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.

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

4. PLACENTAL ABRUPTION

5. 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%).

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

7. 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

8. Classification Grade 1 slight vaginal bleeding + uterine irritability
unaffected maternal blood pressure
maternal fibrinogen level - normal
fetal heart rate pattern is normal

9. Classification

10. 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 mg%
FHR → signs of fetal distress

11. Classification

12. 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.

13. Classification

14. 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

15. Clinical diagnosis

16. 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);

17. Differential diagnosis
placenta praevia
uterine rupture
acute hydramnios
twisted ovarian cyst
peritonitis.

18. 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

19. Management ICU therapy → oxygen + i.v. fluid + R.B.C.
blood in large quantities
Furosemide (pulmonary congestion)
Fibrinogen 4g (normal in pregnancy = mg/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.

20. 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).