Abruptio Placenta

Abruptio Placenta

Bleeding is due to premature separation of a normally situated placenta occurring after 22wks of pregnancy. (Sometime refered as Abruption – tear asunder) Accidental ble eding, it is about 2% of all pregnancies. It may occur at any stage of pregnancy or during labour.

Causes

The aetiology of haemorrhage is not always clear (40%) but it is often associated with hypertensive disease in pregnancy, sudden reduction in uterine size polyhydramnious, preterm labour, rupture of membrane, acute emotional state previous history of placenta abruption. Strenuous physical exercises over distension of the uterus, road traffic accident, direct trauma to abdomen or version.

Multiparty, cigarette smoking, Poor nutritional status, Infection, after the delivery of 1^st twin – Recurs in 10-25% of cases.

Types

1. Revealed hemorrhage

In this case blood escapes from the vagina it is the commonest type. Bleeding may become severe from slight. It may be accompanied by abdominal pain and tenderness, delivery of the baby should be accomplished within a few hours (6 hrs) to avoid coagulation failure developing. Bleeding is proportional to the amount of visible vaginal blood loss.

2. Mixed or combined hemorrhage.

This hemorrhage is primarily concealed then later becomes revealed with little vaginal bleeding. A degree of shock is exhibited which is usually severe compared with the vaginal bleeding. It is usually associated with blood coagulation disorders.

3. Concealed hemorrhage

This is a serious condition with high maternal and fetal mortality. It account for 55% of maternal death. It is associated with severe bleeding but no vaginal bleeding occurs but large retro-placental clot forms behind the placenta – maternal surface.

Mother shows signs and symptoms of hypovolaemic shock, uterine enlargement and severe pain.

Signs and Symptoms:

History of pregnancy induced hypertension, headache, nausea and vomiting, epigastric pain, following road traffic accident or trauma.

Mild - general condition is fair, pain on one side of the uterus, there may or may be no vaginal bleeding, vital signs may be normal and B/P may be raised.

Severe

Shock – B/P may be below 90/60 or more, Severe abdo minal pain, anxiety, Uterus is tender to touch, No fetal heart beat is heard or not heard, Pulse is rapid and thready, signs of pre-eclampsia pitied oedema, Urine is scanty – protein is positive or ne gative, Fetal lie is normal. Amount of visible bleeding is not a guide to severity of the hemorrhage.

Management

Mild

Admit, treat as undiagnosed APH, Set up I.V. infusion Destrose 5%, Set up sintocynon to induce labour, ARM is done if she is over 37 weeks, Observations of vital signs, blood loss, pallor oedema and record, Vaginal delivery is contemplated.

Severe

1.           Routine blood investigation; Plasma fibrinogen and clotting time test. The Fi-test Baxter hyland for hypofinogenaemia when facilities for laboratory test are not available.

2.           Pethidine 100mg, morphine 15mg to relief pain

3.           Blood transfusion of at least 2 litres of fresh blood within 1hr

rapidly .Fibrinogen 4-6g intravenously followed b y 1gm at ½ hourly until clotting mechanism is normal – fresh blood is the best source.

4.           Monitor Renal secretion – at least 30mls per hour. Record fluid intake – urinalysis for protein.

5.           When Clotting defect is controlled Caesarean Section is done.

6.           Record weight of retro placental clot.

7.           EUA is done in the theatre. Rupture the membranes to reduce intra uterine pressure and induce labour. Oxytocin is set up to start uterine contraction.

8.           Vigilant observation of the vital signs, contractions and Fetal heart beats.

9.           Usually labour is rapid.

10.      To prevent PPH deliver the placenta by controlled cord traction.

11.      Examine the placenta for retro placental clots .

12.      Prepare for resuscitation of an asphyxiated baby – pediatrician should be around.

Post Natal Care

1.           Observe carefully for renal function – Acute renal  failure.

2.           Restrict fluid intake to 1000mls daily.

3.           Low Protein diet, low sodium and potassium, Estimate blood area, Potassium for 3 days.

4.           Accurate fluid balanced chart.

5.           Report signs of Oliguria (less than 500mls daily.

6.           Treat anaemia – Transfusion or give haematinics.

Complication

1.           Disseminated intravascular coagulation (DIC) – mode rate & severe

2.           PPH. Due to convelaire uterus or DIC.

3.           Renal failure – hypovolaemia, poor kidney perfusion .

4.           Pituitary necrosis resulting from prolonged and severe hypotension – shock.

5.           Increased mortality for the infants – 50-80%