ANTEPARTUM HAEMORRHAGE
ABRUPTIO PLACENTAE
(Syn: Accidental haemorrhage, Ablation placentae, Premature Separation of placenta.)
Definition:
It is one form of antepartum haemorrhage where the bleeding occurs due to premature separation of normally situated placenta.
VARIETIES
1) Revealed:
Ø Blood insinuates downwards between the membranes and the decidua.
Ø Blood come out of the cervical canal to be visible externally.
2) Concealed:
Ø Blood collects behind the separated placenta or in between the membranes decidua.
Ø The blood may percolate into amniotic sac after rupturing the membranes.
3) Mixed:
Ø Some part of the blood collects inside the (concealed) and a part is expelled out (revealed).
Ø Usually one variety predominant over the others.
ETIOLOGY
Ø Prevalence is more with
a) High birth order of pregnancy.
b) Advancing age of mother.
c) Poor socio-economic condition
d) Malnutrition and smoking.
Ø Hypertension
Pre eclampsia, gestional hypertension & essential hypertension.
Ø Truma:
a) Attempted external cephalic version specially under anaesthesia using great force
b) Road traffic accidents
c) Needle puncture at amniocentesis.
Ø Sudden uterine decompression:
a) Delivery of the first baby of twins
b) Sudden escape of liquor amnii in hydramnios
c) Premature rupture of membranes
Ø Short cord
Ø Supine hypotension syndrome:
Ø Sick Placenta
Ø Folic acid deficiency
Ø Torsion of uterus
Ø Cocaine abuse
Ø Thrombouphilias
PATHOGENESIS
Ø Premature placental separation is initiated by haemorrhage into the decidua basalis.
Ø Due to decidual haematoma there may be degeneration and necrosis of the decidua basalis and placenta.
The feature of Retroplacental haematoma
a) Depression found on the maternal surface of the placenta with the clot which may be found firmaly attach to the area.
b) Areas of the infarction with varying degree of organisation.
Due to spiral artery rupture a big haematoma is formed and the blood so accumulated find its way in the following direction.
Ø Complete accumulation behind the placenta.
Ø Blood may desects downwards
Ø The blood may gain access to the amniotic cavity after rupturing through the membranes.
COUVELAIRE UTERUS (Utero placental apoplexy):
Associate with severe form of conceled abruption placentae.
Ø Naked eye Features:
- Uterus – dark port wine color, patchy or diffuse.
- Patechial haemorrhage found under the uterine peritoneum and broad ligment.
- Free blood occurs in peritoneal cavity
Ø Macroscopic appearance
- Uterine muscles over the affected are necrosed
- Muscular dissociation occurs in the middle and outer muscle layer.
Ø Changes in the organs
Lever- Fibrin knots in the hepatic sinusoids is found
Kidney- Accute cortical necrosis and tubular necrosis.
Shock proteinuria
Ø Blood Coagulopathy
CLINICAL CLASSIFICATION
· Grade 0
· Grade 1
Ø External bleeding
Ø Uterous erritable, tenderness
Ø Shock is absent
Ø FHS is good.
· Grade 2
Ø External bleeding mild or moderate
Ø Uterine tenderness
Ø Shock is absent
Ø Fetal distress or even fetal death
· Grade 3
Ø Bleeding is moderate to severe
Ø Uterine tenderness
Ø Shock is pronounced
Ø Fetal death is rule.
Ø Coagulation defect or anuria
CLINICAL FEATURE
1) It depends on degree of separation of placenta
2) Speed at which separation occurs
3) Amount of blood concealed inside the uterine cavity.
DIFFERENTIAL DIAGNOSIS
a) Revealed Type:
Difficult to diagnosis with placenta praevia.
b) Mixed or Concealed type:
Confuse with
1) Ruptures uterus
2) Rectus sheath haematoma
3) Appendicular or intenstinal perforation
4) Twisted ovarian tumour
5) Acute hydramnios
6) Tonic uterine contraction
Essential Points to diagnosis of the concealed variety are:
1) Shock out of proportion to external bleeding
2) Presence of preclamptic features
3) Uterus is tense, tender and woody hard.
4) FHS is absent
5) Diminished urinary output
6) Presence of blood coagulation disorders.
MANAGEMENT
Ø Prevention Aims:
1) Elimination of known factor which is produced placental separation.
2) Correction of anemia
3) Prompt detection and institution of the therapy
Ø The following guidelines may be helpful
· Prevention, early detection and effective therapy
· Middle puncture during amniocentesis should be under ultra sound guidance.
· Avoidance of trauma
· To avoid sudden decompression of the uterus
· To avoid supin hypotension
· Routine administration of the folic acid.
TREATMENT
Ø At home
Ø In the hospital:
Reveal Type:
a) Amount of blood loss
b) Maturity of fetus
c) Patient is in labour or not
Preliminaries:
a) Blood Estimation
b) Ringer solution drip is started
Definitive Treatment :
a) The patient is in labour
1) Labour is accelerated by LRM.
2) Oxytosin drip may be started
b) The patient is not in labour
1) Pregnancy 37 weeks or more
o induction of labour is done by LRM
2) Indication of cesarean section
o Fetal distress
o Amniotomy could not be done or fails to control the bleeding
o Associated complicating factors
3) Pregnancy less than 37th weeks
o Bleeding moderate to severe and continuing – LRM is done and oxytocin may be added.
o Bleeding slide or has stopped- patient is put on conservative treatment.
Mixed or Concealed Type:
Principle in the management
1) correct hypovolaemia
2) to bring about effective uterine contraction and termination of the abruption process.
3) To observe blood coagulation
Definitive Treatment
Ø Blood sample is taken
Ø To correct hypovolaemia
Vaginal Delivery
Ø ARM is done
Ø Intravenous methergim 0.2 mg should be given with delivery of the anterior shoulder to minimize postpartum blood loss.
Ø Oxytocin should be used along with the blood transfusion.
Caesarean Section
Ø Place of caesarean section in concealed abruptio is difficult to define unlike that of placenta praevia
1) Early-
Unfavorable cervix where speedy vaginal delivery is not
2) Late-
If in spite of amniotomy and oxytocin, the progress of labour is delayed (6 to 8 hours) and instead. Caesarean delivery is now done much more frequently.
