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Abruptio Placenta

Dr. K. Bharathi

Prof. and Head

Dept. of Prasutitantra

National Institute of Ayurveda

Jaipur

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Definition

  • Premature separation of normally located placenta after 22 weeks of gestation ( > 500g) and prior to delivery of fetus.
  • Abruption = breaking away
  • Incidence: 1 in 150 to 250 deliveries
  • Significant cause of Perinatal mortality 15-20%
  • Maternal mortality – 2-5%

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PLACENTAL SEPARATION

  • Prasutimaruta

Causes for separation of placenta

  • Vitiation of Apanavayu

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Types of A.P.

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Etiology

1. Prevalent in – High birth order pregnancies

Advancing of maternal age,

2.Hypertenstion in pregnancy – Gestational Hypertension, Pre-eclampsia

3. Trauma –direct blow or MVA

4. Sudden uterine decompression – Twins, Hydramnios

5. Short cord

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Etiology

6. Preterm premature rupture of membranes or prolonged PROM

7.Thrombophilias

8. Uterine anomaly

9. Abnormal placentation

10. Torsion of the uterus

11. Malnutrition, Smoking, Recurrence

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Pathogenesis

  • Placental abruption is initiated by haemorrhage in decidua basalis
  • Vasospasm in uterine vessels venous engorgement and arteriolar rupture in decidua.
  • Development of decidual hematoma separation, compression degeneration and necrosis of the decidua basalis
  • Rupture of the basal plate may also occur
  • Communicates the haematoma with the intervillous space
  • Decidual haematoma may be small and self limited

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Pathogenesis

  • If major spiral artery ruptures – big retroplacental hematoma, which expands and disrupts more vessels separation of more placental tissue
  • Ut do not contract and compress the bleeding points
  • Result into

Complete accumulation of blood behind the placenta and even between the muscles

Blood may dissect down wards

Blood may gain access to the amniotic cavity

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Based on the degree of abruption it is classified into four grades

  • Grade-0: Clinical features absent
  • Grade-1: External bleeding is slight

Uterus – irritable, tenderness +/-

FHS good, shock is absent

  • Grade-II: Uterine tetany with uterine tenderness, fetal distress/death, no maternal shock
  • Grade-III: Uterine tetany, IUFD, maternal shock or coagulation defect

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Principles of management

  • Swift action – to prevent Maternal and fetal mortality
  • Early delivery
  • Adequate blood transfusion
  • Adequate analgesia
  • Detailed monitoring of mother and fetus

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Decide Mode of delivery

  • Vaginal delivery – when fetal death
  • Caesarean section –if maternal/ fetal health compromised
  • Indicated when early DIC sets in
  • Consent should be taken for hysterectomy in case bleeding could not be controlled.

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Management

  • For Rh negative mothers,

Anti-D Ig should be given to all after any presentation with APH, independent of whether routine antenatal prophylactic anti-D has been administered.

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In the non-sensitised RhD-negative woman for all events after 20 weeks of gestation, at least 500 iu

anti-D Ig should be given followed by a test to identify FMH, if greater than 4 ml red blood cells; additional

anti-D Ig should be given as required.

RCOG Guidelines