Categories
Female Reproductive System

Abruptio placentae (Placental Abruption)

Complete/partial detachment of the placenta before delivery,

Complete/partial detachment of the placenta before delivery,

  • Usually after 20 weeks of gestation
  • M/C cause of APH
  • M/C cause of late pregnancy bleeding
  • M/C obstetric cause of DIC
  • 1% pregnancy worldwide
  • MEDICAL EMERGENCY

Classification

Abruptio placentae
Abruptio placentae: A, Mild abruption with concealed hemorrhage. B, Severe abruption with external hemorrhage. C, Complete separation with concealed hemorrhage. | Miller-Keane Encyclopedia: abruptio. (n.d.) Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. (2003). Retrieved October 19 2020 from https://medical-dictionary.thefreedictionary.com/abruptio
  • Partial separation (M/C)
    • With concealed haemorrhage:
    • With apparent haemorrhage
  • Complete separation

Etiology

Risk factors:

  • Previous placental abruption (M/C risk factor)
  • Hypertensive pregnancies (#2 M/C risk factor)
  • Trauma (#3 M/C cause)
  • Toxic metabolites (#4 M/C cause): Alcohol and cocaine use and cigarette smoking
  • Intrauterine growth restriction (IUGR)
  • Advancing maternal age
  • Male fetuses
  • Short umbilical cord (traction during delivery)
  • Prolonged rupture of membranes (>24 hours)
  • Thrombophilia
  • Polyhydramnios (sudden release of ↑ amniotic fluid)
  • Multiparity
  • Multiple pregnancy

Pathophysiology

Etiology
(Smoking, HTN, trauma, etc)
↓
Arterial degeneration
 (at centre of placenta)
↓
Hemorrhage
↓
Separation of placenta
↓
Reduced O2 delivery
(up to 25% reduction can be compensated)
↓
Expansion of bleed (central bleed) or vaginal bleeding (marginal bleed)
↓
↓ surface of O2 exchange & ↓ maternal BP
↓
↓ O2 delivery
↓
(Prolonged O2 deprivation)
↓
Fetal organ damage

Presentation

Placental abruption usually presents as a combination of vaginal bleeding, uterine contractions, and pain.

  • Sudden-onset pain (abdomen + back) (from contractions d/t release of thromboplastin)
    • Pain present between contractions

Concealed abruptio:

  • Firm, tender, enlarged uterus (disproportionate to gestational age of fetus)
  • Decreased fetal movement
  • Decreased fetal heart rate

Page’s classification:

Grading of placental abruption
Grading of placental abruption | Etiology, Clinical Manifestations, and Prediction of Placental Abruption – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Grading-of-placental-abruption_tbl1_44631833 [accessed 19 Oct, 2020]

Complications

  • MATERNAL
    • Sheehan Syndrome
      • Perinatal pituitary necrosis
    • Renal failure
    • Disseminated Intravascular Coagulation (DIC) #1
      • Due to ↑ Thromboplastin release from placenta
  • FETAL
    • Intrauterine hypoxia & asphyxia
    • Premature birth #2
  • Hypovolemic shock (Maternal and/or fetal) #3
  • Death
    • Maternal (0.5-5%)
    • Fetal (35-80%)

Diagnosis

Transabdominal ultrasound:

Investigation of choice
"U/S OB trauma limited"
“U/S OB trauma limited” post motor vehicle collision, showing notable posterior placenta with a heterogeneous echotexture structure extending anteriorly | U/S, ultrasound; OB, obstetric; findings were concerning for placental abruption. | Page N, Roloff K, Modi A P, et al. (September 09, 2020) Management of Placental Abruption Following Blunt Abdominal Trauma. Cureus 12(9): e10337. doi:10.7759/cureus.10337

Management

  • Maternal/fetal risk → C-section
  • Term & stable → Vaginal delivery
  • Preterm & stable → Admit & observation

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