1. A placental abruption: - pre-mature separation of normally situated placenta after 22 weeks of pregnancy. - etiology unclear

2. - associated factors. sever pre-eclampsia, not chronic HTN. 2. after delivery of 1 st twins,and occurrence ROM. 3. direct trauma to the abdomen RTA. 4. seat belt injury 5. violence. 6. previous c.s 7. High parity. 8. cigarette smoking. 9. ECV. - incidence 0.4-1.8 %

3. * partial separation: - bleeding from maternal venous sinus. apparent bleeding from vaginal due to. retained bleeding behind placenta and forced into the myometrium, and infiltrate between muscle fibers [bruised, edematous uterus] -couvelaire uterus -uterine apoplexy

4. -clp -no vaginal bleeding. -Signs of hypovolemic shock (concealed Hge ) uterine enlargement. Extreme pain.

5. 3) Mixed Hge: - bleeding per vagina. - concealed Hge. In the uterine muscle. - revealed, concealed, mixed.

6. * according to mother and baby condition mild moderate. sever Hge. assessing mother condition.

7. Hx: pre eclampsia.\recent hx of N,V headache, blurred vision. Physical domestic violence appear. ECV - RTA. Delivery of first twins Loss of copious amount of amniotic fluid. Slight localize pain – revealed. - concealed (sever abd. pain.)

8. General examination: Anxious, abd pain, pallor edema of the face, fingers, pretibial area. Alteration of v/s, except Bp in case of PIH Respiration & pulse within normal. Temp. :normal – air hunger if sever infection developed fever. Brown dark blood. Fresh bright.

9. Abd examination. More than expected gestational age concealed. Hard uterus. Rigid uterus, painful. Gaurading on palpation of abdomen Us CTG Fetal death is common out come

10. assessing fetal condition : -fetal movement -CTG -U\s

11. management: I Vcanula, CBC, blood group, cross match,clotting factors. psychological care. analgesic for pain morphine 15 mg, pethidine 100- 150mg. differentiate between pain from concealed hemorrhage, or pain from uterine contraction.

12. source of pain: bleeding between muscle and membrane of placenta labor pain sub capsular hemorrhage ( pre -eclampsia) management of shock (hypovolemic shock,hemorrhagic plasma or blood transfusion haemacele :-doesn't alter platelet functions,improve renal function position left side,sever shock elevate legs,semi recumbent position

13. -midwifery role : Resuscitate mother before surgery Check v\s regularly Cvp Canula in place I&o recorded by indwelling catheter Urinanalysis for proteinuria Fluid requirement should record Fundal height checked regularly Continuous CTG if baby living Anti D for mother RH –ve

14. *management of different degree of placental abruption 1-mild (incidental ): Mild separation of placenta ( partial ) Slight vaginal bleeding Mother &fetus in stable condition

15. -no signs of shock -abdomen lax -soft uterus -??pp Dx: u/s Rx:u/s -v/s -fetal condition monitoring by CTG -if mother not in labor,< 37 weeks follow up ->37 weeks IOL

16. *IOL:done in case of : 1-mild episode of bleeding 2-no evidence of fetal compromise Nb: anemic mother with mild abruption placenta need more concern

17. Moderate: Separation of placenta 1\4 -vaginal bleeding -formation of retro placental blood clot C/p: -uterine tenderness -increase pulse rate -decrease blood pressure -hypoxic baby -IUFD

18. Management : -manage shock -analgesic -fluid & blood transfusion -cvp monitoring -continuous CTG -vaginal birth : contracted & stop bleeding after birth -psychological support * augmentation of labor :1-amniotomy ROM 2-oxytocin infusion

19. - sever type : -acute emergency condition -detachment of placenta 2\3 -life threatening condition -most of blood concealed -sever shock decrease blood pressure,if normal suspect pre-eclampsia cases -fetus almost died -sever abdominal pain -board like abdomen

20. * Complications DIC -RF Pituitary dysfunction -The same as moderate treated by blood transfusion, cs delivery in case of sever bleeding cvp pain relief

21. *Care of the baby: Asphyxia (pediatrician, equipment well prepared) may need neonatal ICU physical care : full information and explanation to the family.

22. Partner support. If baby go neonatal ICU "visit her" Let mother to handle her baby before going to nursery. N.B abruption placenta has a risk factor for recurrence in the next pregnancy.

23. Complications DIC is a complication of moderate to severe placental abruption. Postpartum hemorrhage may occur as a result of the Couvelaire uterus and disseminated intravascular coagulation, or both. Intravenous ergometrine 0.5 mg is given at birth as a prophylactic measure. Renal failure may occur as a result of hypovolaemia and consequent poor perfusion of the kidneys.

24. Pituitary necrosis is another possible consequence of prolonged and severe hypotension (also known as Sheehan's syndrome; see medical texts for details of this rare condition). The maternal mortality rate due to placental abruption is 1%

25. شكرا لحسن الإستماع