Mudaliar
and
Menon’s
Clinical
Obstetric
s
13TH EDITION
Chapter 22
ANTEPARTUM
HEMORRHAG
E- ABRUPTIO
PLACENTAE
Antepartum hemorrhage is defined as
DEFINITI bleeding from the genital tract after 24 weeks
ON of gestation and prior to the birth of the
baby.
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Premature separation of placenta or abruptio
placentae
Placenta previa
Circumvallate placenta
Rupture of the marginal sinus of the placenta
CAUSES Vasa previa.
Unclassified or indeterminate
Co-incidental or local factors below
Cervical polyp
Bleeding cervical erosion
Carcinoma cervix (rare)
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PLACENTAL ABRUPTION
Defined as the premature separation of a
normally implanted placenta after 24 weeks of
gestation but before the delivery of the fetus.
Occurs in approximately 1% of all pregnancies.
The Institute of Obstetrics and Gynaecology,
Chennai, has reported an incidence of 0.71%
for the period from 2001 to 2010.
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ETIOLOGY
The primary cause of placental abruption is unknown, but there are several
associated conditions.
Increased age and parity Thrombophilias
African-American and Caucasian Prior abruption
women
Uterine leiomyoma
Preeclampsia
External trauma
Chronic hypertension
Iatrogenic: External cephalic
Preterm ruptured membranes version/cordocentesis
Multifetal gestation Recurrant abruption
Hydramnios Short umbilical cord
Cocaine use
Cigarette smoking
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Placental separation or abruption
begins with uterine vasospasm, followed
by relaxation and subsequent venous
engorgement and arteriolar rupture into
the decidua
The blood escaping under the decidua
basalis can follow one of the four
PATHOLOGY AND courses
MECHANISM 1. Dissect under the membranes;
concealed
2. Breaks through the membranes into
the amniotic cavity
3. Dissect under the placenta,
separating it from the maternal
surface
4. Couvelaire uterus
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Concealed
There is a collection of blood behind the placenta as a
retroplacental clot, but the placental margins remain
adherent.
Revealed
TYPES
Blood collected due to placental separation escapes by
dissecting under the membranes and is seen externally
if the membranes are ruptured.
Mixed type
This is the most common type.
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Abruptio placentae: (a) concealed and (b)
revealed
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CLINICAL FEATURES
Clinical features vary according to the
degree of separation and type of bleeding.
Symptoms
Abdominal pain
Bleeding
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Uterine height is usually greater than that corresponding
to the period of amenorrhea, especially in the concealed
variety
Uterine tenderness and difficulty in palpating fetal parts
in the concealed variety
Uterine contractions may be present
Uterine hypertonus and non-relaxing uterus may be
present
SIGNS
The fetal heart may be normal, abnormal or absent
PIH/pre-eclampsia/eclampsia
In severe abruption, the woman may present with shock
and DIVC
Intense systemic vasospasm may mask the hypovolemia
in the woman, and her BP may be falsely elevated
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INVESTIGATIONS
• CBC (Hb, hematocrit and
platelets)
• Urine analysis,
particularly if there is
associated PIH
• Serum fibrinogen <100
mg is suggestive of
severe abruption
• Coagulation profile:
Prothrombin time (PT),
activated partial
thromboplastin time
(aPTT)
• Blood grouping and Rh
typing
• Renal function tests
• USG
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1. Diagnosed after delivery or Grade 0
In this, the diagnosis is not suspected clinically before delivery
but after seeing a retroplacental clot.
2. The mild types or Grade I
Pain precedes external vaginal bleeding.
On palpation, the uterus - normal tone
Fetal heart is unaffected.
Examination of the placenta after delivery shows dark adherent
clots - on removal - depressed areas over the placenta.
GRADES 3. Moderate or Grade II
Per vaginal bleeding is mild
Uterus is tender
Maternal shock is absent
Fetal distress is invariably present.
4. Severe or Grade III
Per vaginal bleeding is moderate to severe
Uterus is tender
Maternal shock and fetal distress is seen; many a time, fetal
death sets in.
It is associated with complications like renal failure and
consumptive coagulopathy.
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Diagnosis is not difficult with the classical
symptoms and signs of abruptio placentae.
Ultrasound has a sensitivity of 70% in diagnosing
abruptio placentae.
DIFFERENTIAL DIAGNOSIS
1. Placenta previa
2. Acute hydramnios
DIAGNOSIS 3. Rupture uterus
4. Other acute abdominal conditions
a. Torsion of an ovarian cyst,
b. Degeneration of uterine fibroid,
c. Acute appendicitis and so on.
A careful history and examination will confirm or
exclude these conditions.
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Main Goals of Treatment
Restoration of effective circulation to prevent
hemorrhagic shock and renal failure
MANAGEME Early delivery
NT
Continued surveillance of the coagulation
status to prevent DIVC
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Placental abruption needs active management.
Mild cases
Little risk to mother and slightly higher risk to the fetus
Even a mild case may turn into a serious one at any
stage
Require careful observation
MANAGEMENT
Severe cases:
Combating shock and replacing blood loss
Relieving uterine distension
Early detection of complications such as renal failure,
consumptive coagulopathy
Swift and decisive action should be taken
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GENERAL MANAGEMENT
Two large bore intravenous lines
Resuscitation should be with crystalloids: NS or RL
Hemoglobin status and to cross match blood
Coagulation profile
Ultrasound examination: Status of the fetus and
assess the retroplacental clot
Urinary output should be recorded by using an
indwelling catheter
In hemodynamically unstable patients, blood and
component transfusion should be started
Central venous pressure monitoring should ideally be
done
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OBSTETRIC
MANAGEMENT
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Uteroplacental apoplexy, first described by
Couvelaire
Widespread extravasation of blood into the uterine
musculature and below the serous coat of the
uterus
Sometimes, the blood is seen in the broad
ligament and beneath the tubal serosa and in the
peritoneal cavity
COUVELAIRE Indication for cesarean section, not for
UTERUS hysterectomy
Clinically, a Couvelaire uterus is suspected when:
There is no uterine response to induction with artificial
rupture of the membranes and oxytocin infusion.
The patient does not show improvement in her
condition judged by blood pressure and pulse in spite
of blood transfusion.
There are complications such as clotting defects and
renal failure.
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Couvelaire uterus
with
extravasation of
blood
into the
musculature
beneath the
serosa
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Observation in the labour ward for 48 hours
POST-DELIVERY and watched for the development of PPH.
MONITORING Monitoring should include clotting time
every six hours, urine output hourly, Hb%
estimation after 24 hours—if the Hb% level is
low, further blood transfusion is given.
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Hypovolemic shock
Postpartum hemorrhage
Renal failure: ‘Shock proteinuria’
COMPLICATION Consumptive coagulopathy
S AND CAUSES
OF MATERNAL
MORTALITY PERINATAL MORTALITY
20% to 25%
More than half of perinatal deaths are due to
stillbirth.
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Two IV lines using large bore cannula
Blood for grouping and typing
Compatible blood transfusion can be started
Indwelling urinary catheter is introduced and connected to
a urobag
If delivery is not imminent, she should be transferred to a
higher centre in an ambulance
MANAGEMENT IN
THE PHC
If she comes to the PHC in late stages of labour:
Active management of third stage of labour should be
followed.
Retroplacental clots if present should be measured and
removed.
She should be watched carefully for PPH and transferred
to a higher centre in an ambulance after informing well in
advance
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VASA PREVIA
The bleeding is of fetal origin.
In vasa previa, the fetal vessels (umbilical vessels) run
along the membrane below the presenting part before
reaching the placenta.
The vessels may be inserted at the margin of the
placenta—this is called velamentous insertion.
Bleeding occurs when the membrane ruptures,
leading to severe fetal hypoxia.
It is difficult to diagnose antenatally; if it is diagnosed
by Doppler study, elective cesarean section should be
undertaken.
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