ABRUPTIO PLACENTAE

                              ABRUPTIO PLACENTAE

What is placental abruptio?

It is a type of APH where there is premature separation of normally situated placenta in upper part of uterus before delivery of baby, or sometimes even before labour begins.

Definition:

“It is defined as a condition where bleeding occurs due to premature separation of normally situated placenta.”

Etiology & risk factors:

•         Advanced age of mother
•         Grand multipara
•         Poor socioeconomic status
•         Smoking  
•         Malnutrition
•         Premature Rupture of membranes
•         Toxemia of pregnancy
•         Traumatic
•         Idiopathic
•        Short umbilical cord
•        Previous third trimester bleeding

TyTypes of placental abruptio:

REVEALED TYPE : In this type, the bleeding that occurs behind placenta trickles down between the membranes & the uterine wall to be revealed at vaginal opening. There is no collection of blood behind the placenta. Hence separation of placenta from uterus is less likely to occur.

CONCEALED TYPE : The blood fails to trickle down & collects between the placenta & uterine wall. The enlarging blood clot further dissects out the placenta from its bed & placental separation  can occur over a large area.

MIXED TYPE : In this type some part of blood collects inside & a part is expelled out.

Degrees of placental abruptio:

MARGINAL/LOW SEPARATION : This occurs when the separation is low & bleeding is evident.

MODERATE/HIGH SEPARATION : This occurs when separation is high in uterine segment, causing fundus of uterus to rise. The fetus is in grave danger because of lack of oxygen. External bleeding will probably not be present where as amniotic fluid will be a port white color.

SEVERE/COMPLETE SEPARATION : This occurs when fetus head is present in cervical os that prevents external bleeding. An immediate cessarean section will probably be needed in order to save the baby’s & mother’s lives.

Sign & Symptoms:

•         Sharp abdominal pain
•        Backache
•        Uterine tenderness
•        Vaginal bleeding
•        Signs of Maternal shock

Grade for clinical classification:

Grade 0: Absent clinical features.

Grade 1: 

•        slight vaginal bleeding
•        Tender uterus
•        Maternal BP & Fibrinogen unaffected
•        FHS is good

Grade 2:

•        Vaginal bleeding mild to moderate
•         Maternal tachychardia
•         Fibrinogen Elevated
•         Fetal distress or fetal death
•         Shock is absent

Grade 3: 

•        Bleeding is moderate to severe
•        Shock is seen
•        Fetal death is a rule
•        Coagulation defect or anuria

Medical & Nursing Management:

REVEALED TYPE:

If bleeding is slight:

•      If patient is stable & USG shows minimal retro-placental bleeding with a healthy immature fetus- conservative treatment to be given
•      A cessarean section must be done once the fetus reaches maturity
•      If the patient has come in labour intensive monitoring to be done
•      If the fetus is mature term fetus, cessarean section is done as early as possible to minimize blood loss

If bleeding is considerable:

If the bleeding is enough to compromise mother’s life, immediate cessarean section is done regardless of age of fetus.

CONCEALED TYPE :

•        If the patient has come in shock , she is promptly resuscitated with IV fluids , blood transfusion etc.
•        An emergency caesarean section is to be done to cut down blood loss.
•        In most of patients, the fetus is dead at the time of treatment.

CAESAREAN HYSTERECTOMY : in some patients with concealed type, the retroplacental clot may be very large. There may be even bleeding into muscles & blood vessels of uterus causing injury.

• Obtain blood samples for CBC, blood type & cross matching.
• Institute complete bed rest.
• If the patient is having active bleeding, continously monitor her blood pressure, pulse, respiration, CVP, I/O, amount of vaginal bleeding & FHR.
• If patient is rhesus negative & not sensitized, administer anti D immune globulin after bleeding episode.
• Administer prescribed IV fluids & blood products.
• Prepare patient & her family for possible caesarian delivery & birth process.
• If continuation of pregnancy is deemed safe for patient & fetus , administer prescribed magnesium sulphate for preterm labour.
• Assist with application of CTG.
• Encourage patient & her family to verbalize their feelings & help them to develop effective coping strategies or refer them to counselor if necessary.
• Assure patient that frequent monitoring & prompt management greatly reduce death risk of neonate.

Distinctive Facts:

•        Ix: Usg
•        Couvelaire Uterus: also called as uteroplacental apoplexy is a pathological condition characterized by massive intravasation of blood into uterine muscle.
•        Dark white color patchy uterus may be seen.
•        Partial thromboplastin time may be increased in concealed type.
•        Fetus may die & disproportionately large uterus may be seen in concealed type.

Prognosis:

MMR varies from 2-8%. Perinatal mortality is 15-20%.

Contributes 30%  of APH. Some cases who manage to survive

may develop Sheehan's syndrome later.

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