University of Mosul�College of Medicine

Lecture:5

Subject/year : Antepartum haemorrhage , abruptio placenta 2022-2023

Lecturer: Dr. Saja Al-Jawady

Department: Gynecology & obstetrics

Date:

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The AIM of this lecture is

To understand

• incidence of abruptio-placenta
• Types , risk factors of abruptio-placenta
• Predisposing factors
• management before and during labour

• Intended learning outcomes:

• By the end of this lecture the student will be able to:
• Identify abruptio placenta regarding causes and first aid .
• Remember its incidence and predisposing factors
• Characterize findings in abruptio placenta
• Apply these informations in management of this emergency life – threatening condition .

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Heading 1:

Abruptio placenta

- is defined as hemorrhage

due to separation of

normally situated placenta.

-It is also called accidental

haemorrhage.

Incidence 1%

Heading 2

RISK FACTORS

1.Increase maternal age

2.Increase parity

3.hypertension

4. Defective trophoblastic invasion as

with pre-eclampsia and intrauterine growth retardation.

5.Previous abruption

6. Direct trauma to the abdomen

7. Smoking and cocaine use

8. Folic acid deficiency

9. Sudden decompression of the uterus (after delivery of the first twin & after R.O.M. in polyhydramnios

Heading 3

TYPES

1-Concealed type when

bleeding not visible

but collected retroplacentaly.

2-Revealed type when

bleeding is visible from vagina.

3-Mixed type

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Heading 4

Diagnosis

depends on clinical features and ultrasound

1-Symtoms

*In the early stages of placental abruption, there may be no symptoms.

*When symptoms develop, they tend to develop suddenly.

-Severe and constant abdominal pain (more in concealed than in revealed types).

-Bleeding is present in revealed and mixed types, but may be absent in concealed types

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Heading 5

Signs

-Pallor, which is usually out of proportion

to external bleeding

-Maternal shock without bleeding

in concealed type due to hypovolemic

or neurogenic shock

-If the membrane ruptured spontaneously

or by ARM there is bloody liquor.

-Fetus may be distressed or dead and

engaged

Heading 6

-Abdominal palpation shows tense tender woody hard uterus

-the fetal parts may be difficult to palpate.

-Hypertension may be present.

-The uterus will be larger than expected gestational age

Bleeding my occur within the myometrial tissue… couvelaire uterus

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Heading 7

Heading 8

Mode of delivery

1-If alive baby :

Immediate delivery of the fetus is indicated

-if fetal distress present – LSCS

-No fetal distress and vaginal delivery is imminent then vaginal delivery

Vaginal birth is usually preferred over Caesarean section unless there is fetal distress.

Caesarean section carries an increased risk in cases of disseminated intravascular coagulation

2-if dead fetus :

vaginal delivery unless there is other indication for c/s.

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Heading 9

Maternal complications

-A large loss of blood may require a blood transfusion.

-If the mother's blood loss cannot be controlled, an emergency hysterectomy may become necessary.

-The uterus may not contract properly after delivery so post partum haemorrhage

-The mother may develop a blood clotting disorder, disseminated intravascular coagulation.

-A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland..

-Placental abruption may cause bleeding through the uterine muscle and into the mother's abdominal cavity, a condition called Couvelaire uterus.

-Maternal death

Heading 10

Fetal complications

-The baby may be born at a low birthweight.

-Preterm delivery (prior to 37 weeks gestation).

-The baby may be deprived of oxygen and thus develop asphyxia.

-Placental abruption may also result in death of the baby, or stillbirth.

-The newborn infant may have learning issues at later development stages, often requiring professional aid.

Heading 11

Couvelaire uterus

Couvelaire uterus (also known as uteroplacental apoplexy) is a rare but a life-threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity.

This condition makes the uterus very tense and rigid

Heading 12

Symptoms & SIGNS

-Patients can have pain secondary to uterine contractions, uterine tetany or localized uterine tenderness.

-Signs can also be due to abruptio placentae including uterine hypertonus, fetal distress, fetal death, and rarely, hypovolemic shock (shock secondary to severe blood loss).

-The uterus may adopt a bluish/purplish, mottled appearance due to extravasation of blood into uterine muscle

Heading 13

Treatment

The uterus should be evacuated and contractions should be stimulated using intravenous oxytocin

hysterectomy is performed if the uterus not respond to medical treatment with continuous inertia and bleeding

To summarize:

• Abruptio placenta is one of causes of APH
• Can be diagnosed before labour
• Many predisposing factors for this condition
• Management is needed for saving fetal and maternal lives .

Lets check our knowlege

MCQ

Q- The causes of abruptio placenta are EXCEPT:

a-hypertension

b-folic acid deficiency

c-multi-parity

d-previous uterine surgery

e-direct trauma

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References and recommended further readings:

Obstetrics by Ten Teachers, 19E - Kenny, Louise, Baker, Philip N.

Dewhurst's Textbook of Obstetrics and Gynaecology,Eighth Edition- D.

Keith Edmonds

UNICEF-Sd-Neonatal-Guidelines-report-2018

The end