APH II – ABRUPTIO

PLACENTA
PRESENTOR: DR. SAMYA J (PG)
MODERATOR: DR. SURIYA (SR)
ANTEPARTUM HEMORRHAGE

 Antepartum haemorrhage (APH), is defined as bleeding from or into

the genital tract after 24+0 weeks of gestation and prior to the birth
of the baby (GTG no.63 – 2011).
 Occurs in 2 - 5 % of all pregnancies.
 No identifiable cause in 50% at presentation.
 Bleeding from placental bed is most common identifiable cause.
 Causes:
1. Placental: Placenta previa, Placental abruption
2. Extraplacental incidental causes: Cervical erosion, cervical
polyp, cervical cancer, trichomonas vaginitis, vulvovaginal
varicosities
3. Vasa previa
4. Marginal sinus rupture
5. “Show”
6. Trauma
7. Systemic disorders predisposing to bleeding
8. Undetermined
ABRUPTIO PLACENTAE

 Placental abruption is the

“premature separation of a
normally situated placenta
from the uterine wall,
resulting in haemorrhage
before the delivery of the
fetus”.

 50% cases are seen after 36

weeks.
INCIDENCE

 1 in 80 to 1 in 250 births
 0.49 to 1.8 % incidence.
 Recurrence rate:
 5 % with 1 previous episode
 15 % with previous Grade 3 abruption
 20 to 25% with 2 previous episodes.
RISK FACTORS

 INADEQUATE DECIDUALISATION:
• Increased maternal age
• Increased parity (2.5 %)
• Family history (2 x)
• Uterine leiomyoma
• Uterine anomalies
Cont.

 VASOSPASM AND PLACENTAL HYPOPERFUSION

1. Hypertensive disorders in pregnancy:
 Any hypertensive disorder (5 x)
 Patients with chronic HTN (1.5 %)
2. Thrombophilia – acquired or inherited
3. Smoking (2.46 %)
4. Cocaine use (10%)
IN HYPERTENSIVE DISORDERS

Poor trophoblastic Vasospasm of abnormal

invasion arterioles

Inadequate Thrombosis and

uteroplacental flow decidual necrosis

Ischemia and rupture of

vessels

Abruption
Cont.
 RAPID DECOMPRESSION
OF THE UTERUS:
1. Hydramnios:
 Sudden uterine decompression on membrane
rupture (8x)

2. Multiple gestations

3. PPROM (2 to 5 %)
Cont.

 SHEARING OF PLACENTAL
VESSELS:
1. Abdominal Trauma:
 Minor trauma (7 to 9 %), major trauma (13 %)
 Usually d/t RTA or domestic abuse
2. External Cephalic Version
OTHER RISK FACTORS

 Folic acid deficiency

 Previous abruption (Subsequent episodes are earlier and more sudden)
 Threatened Abortion (1 to 1.4%)
 Subclinical Hypothyroidism
 Unexplained increase in maternal serum alpha-fetoprotein in 2nd
trimester
 Sick placenta, short cord
PATHOGENESIS

Placental
Increased
Haemorrhage into decidua Hematoma separation (self-
hydrostatic
basalis of the placenta formation limited/
pressure
continuous)
REVEALED/ EXTERNAL (65 to 80 %) :

 Blood seeps between membranes and uterine wall –

escapes through cervix
 Bright red or clotted blood
 Mild to moderate pain
 Anemia and shock proportionate to apparent blood
loss.
CONCEALED/ INTERNAL (20 to 35 %):

 Blood is trapped behind placenta or membranes

even after total separation
 Little vaginal bleeding
 Severe pain
 Uterus is “woody” hard, tense and tender
 Anemia and shock is greater than apparent blood
loss, FHR ±.
MIXED/ COMBINED :

A varying mixture of the two types

 PAGE GRADING
Grade Severity Incidence Vaginal Uterine Maternal Vitals FHR
Bleeding Tenderness and Labs

0 No symptoms - Small retro- - Normal +

placental clot

1 Mild 40% None to mild ± Normal Normal

2 Moderate 45% Mild to moderate + Tachycardia, Distress +

Normal BP, No
shock
3 Severe 15% Moderate to ++ Shock ++, FHS absent
severe or coagulopathy in
concealed 30% cases
SHER’S CLASSIFICATION

GRADE DESCRIPTION

GRADE I Mild, often retro-placental clot identified at delivery

GRADE II Tense, tender abdomen and live fetus

GRADE With fetal demise

III
IIIA Without coagulopathy (2/3rd cases)

IIIB With coagulopathy (1/3rd cases)

 Hypovolemic
shock

Fetal compromise Acute Renal

Failure

Abruptio
PPH
Placenta Disseminated
Intravascular
coagulopathy

Uterine Couvelaire
Hypertonus uterus
SHOCK

 When blood loss exceeds 25% of

total volume, rapid hemodynamic
deterioration occurs.
 Ongoing uncorrected hemorrhage
leads to left ventricular failure and
thereafter irreversible shock.
RENAL FAILURE

 Hypotension -- Reduced renal perfusion -- oliguria

 Acute tubular necrosis –– renal failure (reversible)
 Bilateral cortical necrosis (rare)
CONSUMPTIVE COAGULOPATHY

 Incidence 0.03 to 0.35 %

IN NORMAL PREGNANCY

 Fetal trophoblasts in placenta regulate hemostasis by

i. TF expression
ii. Altered anticoagulant function
iii. Suppression of fibrinolysis
IN ABRUPTION

 Large amounts of tissue factor is released at the site of abruption

(extrinsic pathway)
 Activation of coagulation cascade and intrinsic pathway
 Consumption of coagulation factors (consumptive coagulopathy)
COUVELAIRE’S UTERUS

 Also known as uteroplacental apoplexy

 Indicates severe abruption
 This interferes with uterine contraction
causing atony (rarely)
 Diagnosed at laparotomy
 Not an indication for hysterectomy
OTHERS

 UTERINE HYPERTONUS
 Thrombin is an uterotonic
 Causes uterine hypertonus, tetany, preterm labour and PROM

 PPH
 APH is usually followed by PPH
 Due to Atonicity (Couvelaire uterus) or DIC
GROSS EXAMINATION

 Clinically, abruption appears as

i. circumscribed depression on the
maternal surface of a freshly
delivered placenta
ii. Covered by dark clotted blood
iii. Areas of infarction with varying
degrees of organisation
ASSESSMENT OF FETAL WELL
BEING
 Continuous electronic fetal heart rate monitoring and uterine activity
to be done.
 FHR Abnormalities:
i. Fetal tachycardia
ii. Loss of variability
iii. Sinusoidal pattern
iv. Late decelerations. 
 Tocograph:
i. Saw tooth pattern
ii. Low amplitude, high frequency contractions
DIAGNOSIS

 Usually a clinical diagnosis.

 Supported by ultrasound and laboratory findings.
 Avoid vaginal examination till placenta previa and vasa
previa are ruled out.
HISTORY
 Gestational age of fetus
 Presenting symptoms:
 Bleeding - amount and duration (70 – 80%)
 Abdominal pain
 Symptoms of hypovolemia
 H/o Trauma, coitus, ruptured membranes
 Previous vaginal bleeding
 Previous scans
 Past obstetric history
 H/o smoking, drug abuse
CLINICAL SIGNS

 Signs:
1. Uterine tenderness (66%)
2. Uterine contractions (high frequency, low amplitude)
3. Fetal distress (60%)
4. Maternal tachycardia and hypotension
5. Coagulopathy
DIFFERENCES IN PRESENTATION

Parameters REVEALED CONCEALED

Symptoms Mild abdominal pain + bleeding p/v Acute intense continuous abdominal pain ±
bleeding p/v
Bleeding Continuous dark colour Blood stained serous discharge
General condition Proportionate to blood loss Out of proportion to blood loss, shock ++
Pallor Proportionate to blood loss Out of proportion to blood loss
Uterus Height corresponds to GA, normal feel Height greater than GA, globular, enlarged,
with localised tenderness tense, tender, rigid
Fetal parts Identified easily Difficult to make out
FHS Usually present Usually absent
Urine output Normal Reduced
ULTRASOUND

 Sensitivity 2%, specificity 96%

 Early haemorrhage – hyperechoic or isoechoic
 Resolving hematoma – hypoechoic(1 week), sonolucent (2 weeks)
 In acute stage, findings similar to:
 Homogenous thickened placenta
 Fibroid
Retroplacental clots
Subchorionic hematoma
Subamniotic hemorrhage
ROLE OF MRI

 MRI can be used if USG is equivocal

 Detects hematomatous collection and physical separation of
placenta
 Not routinely recommended
 Unclassified

Maternal/fetal
Physical evaluation
History USG Placenta previa
examination IVF/ Blood
tranfusion

Placental
abruption
DIFFERENTIAL DIAGNOSIS

 Placenta previa
 Vasa previa
 Rupture of uterus
 Local cervical lesions
 Marginal sinus rupture
 Indeterminate bleeding
 PLACENTA PREVIA Vs ABRUPTIO
PLACENTA
PARAMETERS PLACENTA PREVIA ABRUPTIO PLACENTA
Bleeding Painless, unprovoked, recurrent Painful, continuous, look for etiology

Character of blood Bright red Dark coloured

General condition Proportionate to blood loss Out of proportion to blood loss in concealed
and mixed types
Preeclamptic features Unrelated Seen in 1/3rd cases
Uterus Height = GA, relaxed Height > GA, tense, tender, rigid

Malpresentation Common, floating head Unrelated, head may be engaged

FHS Usually present Usually absent

USG Placenta in lower segment (diagnostic) Placenta in upper segment (aids diagnosis)
CHRONIC ABRUPTION

 Placental separation beginning in 1st, 2nd or early 3rd

trimester
 Present with c/o intermittent light vaginal bleeding
 Complications: oligohydramnios, FGR, PTL, PPROM
and PE
 Chronic abruption-oligohydramnios sequence (CAOS)
 Associated with elevated maternal serum aneuploidy
markers
MATERNAL COMPLICATIONS
 Massive haemorrhage leading to hypovolemic shock
 Disseminated Intravascular Coagulation (DIC)
 Postpartum Haemorrhage (d/t coagulation cascade failure/ Couvelaire uterus)
 Acute Renal Failure
 Pituitary Failure (Sheehan’s syndrome)
 Maternal mortality
 Preterm labour
 Instrumental delivery and Caesarean Section
 Fetomaternal haemorrhage in Rh negative
 Recurrence in subsequent pregnancies
FETAL COMPLICATIONS

 Fetal Growth Restriction (80% of infants)

 Periventricular leukomalacia (34%)
 Fetal Anemia
 Preterm birth (10%)
 Perinatal mortality (12%)
 Congenital malformations - CNS (4.4%)
MANAGEMENT

 Depending on
i. Maternal condition
ii. Fetal condition
iii. Grade of placental abruption
iv. Gestational age of the fetus
v. Whether the patient is in labour or not
INITIAL ASSESSMENT

 Maternal Vitals
 Evidence of hypotension
 Assess blood loss
 Abdominal Examination
 Per vaginal Examination (after
ruling out placenta previa)
 Fetal well-being assessment
HEMORRAGE CLASSIFICATION AND
PHYSIOLOGICAL RESPONSE
CLASS ACUTE BLOOD % LOST PHYSIOLOGIC RESPONSE
LOSS (ml)

1 1000 15 Dizziness, palpitations, minimal BP change

2 1500 20 – 25 Tachycardia, tachypnea, sweating, weakness, narrowed

PP

3 2000 30 – 35 Significant tachycardia and tachypnea, restlessness,

pallor, cool extremities

4 ≥ 2500 40 Shock, air hunger, oliguria or anuria

GRADING OF SEVERITY OF
BLEEDING (RCOG)

GRADE DESCRIPTION
SPOTTING Staining, streaking or blood spotting noted on underwear or pad
MINOR Blood loss less than 50ml that has settled
MAJOR Blood loss 50 to 1000ml with no clinical signs of shock
MASSIVE Blood loss > 1000ml and/or clinical signs of shock
ESTIMATING BLOOD LOSS
INVESTIGATIONS

 Complete blood count

 Blood group and type
 Bleeding time, Clotting time (low)
 Prothrombin time/ aPTT (increased)
 Plasma fibrinogen level <150mg/dl
 Fibrin Degradation products and D-dimer (increased)
 Renal Function Test
INITIAL RESUSCITATION
 Insert 2 wide bore IV cannulas
 Catheterise and monitor output
 Blood and urine samples
 Reserve 4 units of blood
 IV Fluids – 3.5 litres (2 L of warmed Hartmann’s solution and 1.5 L of warmed colloid)
 Monitor maternal and fetal vitals and contractions
 Inform OT and pediatric team
 USG to exclude placenta previa and to look for major abruption when maternal and fetal
condition is stable
DEFINITIVE MANAGEMENT

 Indications for immediate cesarean delivery:

1. > Grade I Abruption with live baby
2. Unstable maternal vitals, not responding to resuscitative measures
3. Uncontrolled haemorrhage
4. Evidence of DIC with no imminent delivery
5. Fetal distress
6. Unfavourable cervix
7. Failure of progression of labour
 Indications for vaginal delivery:
1. Grade I or less.
2. FHR normal
3. Facility for continuous FHR monitoring available
4. Favourable cervix
5. Abruption with dead fetus
IN EXTREME PRETERM

 Between 24+0 to 26+0 weeks of gestation, assess:

 Maternal condition
i. Stable mother - Conservative management
ii. Unstable mother – Consider delivery
 Preterm counselling
MANAGEMENT OF COMPLICATIONS

 Complications:
1. Hypovolemic Shock
2. Disseminated Intravascular Coagulation
3. Renal Failure.
HYPOVOLEMIC SHOCK

 Volume resuscitation:
 Crystalloid up to 2 litres Hartmann’s solution
 Colloid up to 1–2 litres until blood arrives
 Blood transfusion:
 Women who were transfused with PRCs developed acute tubular necrosis, while
pulmonary edema was more commonly seen in women given whole blood. More
trials are required before recommendations can be made (GTG no.63 – 2011)
Cont.
Massive Transfusion Protocol (GTG63)
 1 unit PRBC to 1 unit FFP to 1 unit Platelet (1:1:1)
 4 units of FFP (12–15 ml/kg or total 1 litre)
i. for every 6 units of red cells or
ii. if prothrombin time and/or activated partial thromboplastin time (PT and
aPTT) are greater than 1.5 x mean control
 Platelets concentrates if platelet count < 50 x 109/l
 Cryoprecipitate if fibrinogen < 1 g/l.
 In massive hemorrhage, up to 4 units of FFP and 10 units of cryoprecipitate
(two packs) may be given empirically.
Cont.

 Therapeutic goal of management of massive blood loss is

to maintain:
 Haemoglobin > 8 g/dl
 Platelet count > 75 x 109/l
 Prothrombin time < 1.5 x mean control
 Activated partial prothromboplastin time < 1.5 x mean control
 Fibrinogen > 1.0 g/l.
CONSUMPTVE
COAGULOPATHY(DIC)
 Bed side clotting test
 Clotting time
 Clot retraction time
 PT, INR
 aPTT
 Fibrinogen
 D-Dimer
 Platelets
INTERNATIONAL SOCIETY ON
THROMBOSIS AND HEMOSTASIS (ISTH)
SCORING SYSTEM
THROMBOELASTOGRAPH
 This device can examine clot formation and dissolution in whole blood and it can
identify clot strength reduction and can be used to predict need for rapid
transfusion.
MANAGEMENT OF DIC

 15-30 ml/kg of FFP

 Two pools of cryoprecipitate when fibrinogen less than 1.5g/L
(raise the fibrinogen level by 1.0 g/l)
 One to two adult doses of platelets when less than 50000/mm3 (PT
and APTT prolonged 1.5x normal range)
 Repeat lab values every 4 hours
Cont.
 Vitamin K
 Recombinant Factor VIIa therapy (rFVIIa)
 Fibrinogen concentrate
 Prothrombin complex concentrate
 Tranexemic acid
 Hemostatic agents
 Antithrombin
 Recombinant human APC
Rh NEGATIVE PREGNANCY

 Fetomaternal hemorrhage can be significant.

 Kleihauer-Betke test
 HbF is more acid resistant than HbA
 FMH (ml) = fetal cells(HPF)/maternal cells (HPF) x 2400
 100 mcg anti-D for 4ml fetal blood
 Anti-D Ig to all non-sensitised RhD-negative women after any presentation with
APH
 In recurrent vaginal bleeding after 20 weeks, anti-D Ig 100 mcg at a minimum of
6-weekly intervals
POSTPARTUM CARE

 PPH should be anticipated – Active Management of Third Stage of Labour

 Anti-D should be given when indicated (300mcg)
 Thromboprophylaxis may be necessary (GTG no.63-2011)
 In case of fetal demise
 Suppression of lactation
 Counselling
PREDICTION

 First Trimester:
 Family history, h/o abruption
 Pregnancy-associated plasma protein A (PAPP-A)
 Second Trimester:
 Uterine artery Doppler (high PI, diastolic notch)
 Maternal Serum Alpha-Fetoprotein level (MSAF)
 Maternal Serum free Beta Human Chorionic Gonadotrophin (b-hCG)
 Maternal serum activin A
 Fibronectin
 Thrombomodulin
PREVENTION

 Good Antenatal care

 Anemia prevention and correction
 Folic acid administration
 Low dose Aspirin (when indicated)
 Optimal management of hypertensive disorders of pregnancy
 Avoid sudden decompression of uterus (controlled ARM)
 Avoid smoking and drug abuse
TAKE HOME MESSAGE

 Risk factor assessment to identify high risk patients

 Severe pain ± bleeding p/v - ?ABRUPTION
 Maternal and fetal condition should be assessed and monitored to plan
management
 Timely diagnosis and treatment of DIC with fluid resuscitation and blood
components transfusion
 Serial testing is recommended to increase diagnostic precision
 Antenatal correction of anemia and optimum blood pressure control is
recommended
REFERENCES

 Gabbe Obstetrics – Normal and Problem Pregnancies (First South Asian Edition)
 William’s Obstetrics (25th edition)
 James High Risk Pregnancy Management Options (5 th edition)
 Ian Donald’s Practical Obstetric Problems (7 th edition)
 DC Dutta’s Textbook of Obstetrics (8 th edition)
 Greentop Guideline no.63 – Antepartum hemorrhage
 Greentop Guideline no.52 – Postpartum hemorrhage
 Greentop Guideline no.47 – Blood Transfusion in pregnancy
 Jecko Thachil a, Cheng-Hock Toh, Disseminated intravascular coagulation in obstetric disorders and its
acute haematological management, Blood Reviews 23 (2009) 167–176
THANK YOU