ABRUPTIO PLACENTAE

DEFINITION
It is one form of ante partum hemorrhage where bleeding occurs due to premature separation (partial or complete) of normally situated placenta.

Incidence

1 in 150 deliveries Perinatal mortality -15-20% maternal mortality 2-5 %

Varieties

Revealed Concealed Mixed

PREDISPOSING FACTORS High birth order Advancing age of mother Poor socioeconomic condition Malnutrition Smoking Recurrence

ETIOLOGY
Hypertension in pregnancy Trauma Sudden uterine decompression Short cord Supine hypotension syndrome Sick placenta Folic acid deficiency Thrombophilias inherited / acquired

PATHOGENESIS
Premature placental separation initiates by hemorrhage into the decidua basalis

At early phase no morbid pathological changes in uterine wall/ placenta

Depending upon extent of pathology

Degeneration and necrosis of the decidua basalis and the placenta + rupture of basal plate

Retroplacental haematoma

Accumulated blood finds its way in: complete accumulation behind placenta, blood dissects downwards, blood gains access.

CLINICAL CLASSIFICATION Grade 0- C/F absent

Grade 1- external bleeding is slight uterus irritable, tenderness may or may not be present Shock is absent, FHS good

Grade 2 external bleeding mild to moderate Uterine tenderness is always present Shock is absent fetal distress / death Grade 3-bleeding is moderate to severe or may be concealed ,marked uterine tenderness ,shock present fetal death occurs Associated coagulation defects or anuria

CLINICAL FEATURES
Symptoms Character of bleeding Revealed Abdominal discomfort or pain followed by vaginal bleeding Concealed /mixed Acute intense pain abdomen followed by slight vaginal bleeding ,pain becomes continuous Continuous ,dark color blood stained serous discharge Shock is pronounced which is out of proportion to the visible blood loss Pallor is severe and out of proportion to the visible blood loss

Continuous dark color

General condition

Proportionate to the visible blood loss ,shock is absent

Pallor

Related to the visible blood loss

CLINICAL FEATURES
Symptoms Feature of preeclampsia Uterine height Uterine feel Revealed May be absent Proportionate to the period of gestation Normal feel with localized tenderness contractions frequent and local amplitude Can be identified easily Usually present Normal Concealed/ mixed Frequent association either pre existing or appear May be disproportionately enlarged and globular Uterus is tense tender and rigid

Fetal parts FHS Urine out put

Difficult to make out Usually absent Usually dimished

INVESTIGATIONS
Revealed Concealed / mixed

Blood Hb%

Low value; Markedly lower; out proportionate to of proportionate to the blood loss the blood loss

 Coagulation Profile

Unchanged

Variable changes: Clotting time > 6 min Fibrinogen level < 150 mg Platelet count low Partial thromboplastin time

Urine for protein

Absent

Present

DIFFERENTIAL DIAGNOSIS
Revealed type: Placenta previa

Concealed / mixed: Rupture uterus Acute hydramnios Appendicular / intestinal perforation

Placenta Previa v/s Abruptio placenta

Placenta Previa Clinical features Nature of bleeding a)Painless ,causeless and recurrent Painful often attribute to preeclampsia or trauma and continuous Revealed ,concealed or mixed Dark coloured Out of proportion to the visible blood loss in concealed or mixed variety Present in 1 third cases Abruptio placenta

b) Bleeding is always revealed Character of blood Bright red

General condition and Proportionate to anemia visible blood loss

Features of pre eclampsia

Not relevant

Contd;;
Abdominal examination
Height of uterus Proportionate height May be disproportinately enlarged in in concealed type May be tense,tender and rigid Unrelated ,head is engaged

Feel of uterus

Soft and relaxed

Malpresentation

Common ,head is high floating

FHS

Present

Absent in concealed type

Cond..
Placentography Placenta in lower segment
Placenta is feel on the lower segment

Placenta in upper segment

Placenta is not felt on lower segment. blood clot should not be confused with placenta

Vaginal examination

Management

PREVENTIVE AIMS
Elimination of known factors Correction of anemia during antenatal period Prompt detection and institution of therapy to minimize the complications likeShock Blood coagulation disorders Renal failure

Scheme of management of abruption placenta

Abrupto placenta
General and abdominal examination Fetal status Assessment of blood loss Hb%, Hematocript, coagulation profile ABO and RH grouping Resuscitation

Revealed Resuscitation

concealed

pt not in labour Pt in labour ARM +oxytocin >37 weeks <37 weeks

ARM+oxytocin Bleeding stops expectant treatment continue preg upto 37 weeks Bleeding continue ARM+oxxytocin

Concealed
Blood transfusion periodic coagulation urine out put

fetal monitoring
ARM+oxytocin No response falling fibrinogen level oliguria fetal distress C.S

Hysterectomy (rare ) atonic uterus

NURSING MANAGEMENT
1.Assess the patients extent of bleeding and monitor fundal heighteight Continuously evaluate maternal and fetal physiologic status Avoid per vaginal / rectal examination

2. Assess the need for immediate deliveryemergency LSCS indicated

CONTINUED..
On admission place woman on lateral position Fluid replacement by I.V. fluids Administer oxygen by mask if needed Provide client and family teaching Meet the emotional and psychosocial needs

NURSING DIAGNOSES
Pain related to bleeding Impaired fetal gas exchange related to insufficient oxygen Fear related to perceived threat and excessive bleeding Risk for anaemia related to excessive loss of blood

TREATMENT
Revealed type: Assessment of case If patient is in labour- it is accelerated by LROM + oxytocin drip If patient is not in labor <37 wks- LROM + oxytocin drip >37 wks- LROM with/ without oxytocin drip

CONTINUED..
Concealed / mixed type: Sedation with morphine Send blood for blood + urine investigation Correct hypovolemia by NS/ Haemaccel infusion and blood transfusion Initiate uterine contractions Observe blood coagulation profile at 2 hourly interval Closely monitor maternal + fetal condition