Abruptio placentae.

Early separation of placena from uterus. Can be partial or complete.

Incidence
If baby is born below 28 weeks: 90/1000 (so often a cause of very premature delivery)
If baby is born at 40 weeks: 2/1000 only

Risk factors (relative risk (RR)

trauma 4.8 – 9.0
Age and parity 1.1 – 3.7
Abruptio before (1x) 4.5 – 16.9
Abruptio before (>1x) 36
Hypertension (CHRONIC) 3
Pre-eclampsia 1.7
Smoking cigarettes 1.7 – 2.1
Use of cocaine 3.9
Premature rupture of membranes 3
Twins 1.5 – 3.0
Caesarean Section in the past 1.3 – 1.7
Abnormal shape of the uterus 8.1

Clinical features
Not always vaginal bleeding after abruption
Much more blood hidden in uterus than seen during vaginal bleeding
Fetal death in 12 – 15% of all cases of abruption.
A bleeding that is so severe that it kills the baby will always need blood transfusions
In books: belly is very painful and very had on palpation. This is not always so.
A soft uterus will not rule out a (partial) abruption.
Clotting disorders usually ONLY if complete abruption.
SO: If baby is in good condition there are no clotting disorders yet and a Caesarean Section is not contra-
indicated

If baby under 32 weeks almost 50% brain damage.

management to get to diagnosis:

If 1 or more of the following: maternal shock o.u.o, vaginal bloodloss or sudden fetal distress:
Suspect abruption and observe
An USS can not rule out an abruption
Lab (not possible here) Hb, Xmatch, thrombocytes, PTT\, APTT, fibrinogen, creatinin, liver function tests

Further management
Consider dexamethasone
If baby is > 32 weeks emergency Caesarean can be considered, Waiting for a few days to let the dexamethasone
work is possible.
Even a vaginal birth is possible if the abruption was small.

If baby is dead coagulopathy is possible: too much clotting in uterus and in the kidney, severe bloodloss by lack
of clotting elsewhere.
No certainty when to get the baby out.
If nothing is done: usually clotting disorder improves after 48-72 hours

Literature used:
Manual of Standard Managements in Obstetrics and Gynaecology for Doctors, H.E.O.s and Nurses in Papua
New Guinea. Sixth edition, 2010
The MOET course Manual. Managing Obstetric Emergencies and Trauma 2nd edition 2009
Dutch Association of Obstetricians and Gynaecologists: Guidelines for abruption placentae 2008

Gert van den Berg, tropical doctor, dept. Of Obstetrics and Gynaecology, Modilon General Hospital, Madang
Gert4/documents/lectures for residents/xxabruptio placentae.doc