Abruptio Placentae: Insert or Drag & Drop Your Photo
Abruptio Placentae: Insert or Drag & Drop Your Photo
Abruptio Placentae: Insert or Drag & Drop Your Photo
ABRUPTIO
PLACENTAE
CC JUANICO, CLAREEN MAE
JULY 23, 2020
INTRODUCTION
INCIDENCE
ETIOLOGY
PREDISPOSING FACTORS
PATHOPHYSIOLOGY
OUTLINE
CLASSIFICATION
CLINICAL DIGANOSIS
COMPLICATIONS
MANAGEMENT
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• Premature Placental
Separation (of normally WHAT IS
planted placenta)
ABRUPTIO
• External vs. Concealed PLACENTAE?
Hemorrhage
• Total or Partial
• Acute or Chronic 3
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INCIDENCE
• more common in African
American women than in
white or Latin American
women
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ETIOLOGY
• Chronic process: Retroplacental
hemorrhage or hematoma
Infarctions Underperfusion
Increased placental resistance
destruction of blood vessels feto
maternal bleeding placental
abruption
• Alpha Feto Proteins
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PREDISPOSING
FACTORS
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PREDISPOSING FACTORS
• AGE, PARITY AND FAMILIAL
FACTORS
• increases with maternal age. (40 years
were 2.3 times risk) • SUDDEN DECOMPRESSION OF
• incidence is higher in women of great THE UTERUS
parity
• Premature rupture of membranes: 3-fold
• woman had a severe abruption, then
risk of abruption with preterm rupture was
the risk for her sister is doubled further increased with infection.
• Rupture of membranes in a patient with
• SEVERE PREECLAMPSIA AND CHVD polyhydramnios, or delivery of a first
twin, can lead to a shearing effect on the
placenta as the uterus contracts, thus
• Most common predisposing factor causing abruption placentae.
• 10- fold among women with chronic
hypertension, and slightly more than 2-
foLd for women with pre‐eclampsia
• Damaged vascularization ischemia
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PREDISPOSING FACTORS
• CIGARETTE SMOKING • COCAINE ABUSE
• Predisposes to decidual necrosis and • Hypertension due to decreased
development of hypertension reuptake of epinephrine and
• twofold risk for abruption in smokers. norepinephrine which cause
vasoconstriction leading to increase BP.
• five- to eightfold if smokers had
chronic hypertension, severe
preeclampsia, or both
• RETROPLACENTAL MYOMAS
• Placenta could not attach properly since
• THROMBOPHILIAS myoma can cause poor trophoblastic
invasion. It can also prevent contraction
• Associated with thromboembolic post partum.
disorders during pregnancy.
• Factor V Leiden and prothrombin gene
mutation— are associated with • HISTORY OF ABRUPTION
placental abruption and infarction as
well as preeclampsia. • 2 previous occurrences: 25% risk
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PATHOPHYSIOLOGY
Hemorrhage into
the decidua
basalis (most
commonly from
damaged or
ruptured small
maternal
decidual
arteries, with
the formation of
a hematoma.
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PATHOPHYSIOLOGY
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PATHOPHYSIOLOGY
Further damaging placental vessels.
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PATHOPHYSIOLOGY
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CLASSIFICATION
EXTENT OF COVERAGE
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CLASSIFICATION
REVEALED or CONCEALED 15
CLASSIFICATION
CONCEALED ABRUPTION
• Likely when:
• Bleeding observed is not
appropriate with signs and Effusion of blood behind the
symptoms presented placenta (margins still adhered)
• Patient is pale, hypovolemic but Placenta is completely separated,
with minimal bleeding yet the membranes retain their
attachment to the uterine wall.
• Presents in only a small
percentage of patient with Blood gains access to the
abruptio placenta amnionic cavity after breaking
through the membranes
• Poor prognosis due to under
Fetal head is so closely applied to
management of the physicians.
the lower uterine segment that
blood cannot make its way past.
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CLASSIFICATION
REVEALED ABRUPTION
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Diagnosis of abruptio placenta is a clinical one and it is suspected in women who:
vaginal bleeding or abdominal pain or both, a history of trauma, or those
who present in otherwise unexplained preterm labor.
Classical symptoms are vaginal bleeding and abdominal pain but may occur with neither or
just of one of these signs. Diagnosed clinically when 2 or more of the following criteria are
present:
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CLASSIFICATION
IN RELATION TO CLINICAL SIGNS AND SYMPTOMS
MILD MODERATE
• No to moderate vaginal bleeding
• No to mild vaginal bleeding
• Moderate to severe uterine tenderness
• Slightly tender uterus
with possible tetanic contractions
• Normal maternal BP and • Maternal tachycardia with orthostatic
heart rate changes in BP and heart rate
• No coagulopathy • From 25 to 50% of placental surface is
• No fetal distress separated.
• Fetal monitoring may show
tachycardia, decreased variability, or
mild late decelerations.
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CLASSIFICATION
IN RELATION TO CLINICAL SIGNS AND SYMPTOMS
SEVERE
• No vaginal bleeding to heavy vaginal bleeding
• Maternal shock
• Symptoms are usually abrupt with a continuous knifelike uterine pain.
• Greater than 50% of placental separation occurs.
• Fetal monitor shows severe late decelerations, bradycardia, or even fetal
death.
• Severe disseminated intravascular coagulation (DIC) may occur. Ultrasound
visualization of a Retroplacental hematoma may be seen.
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NO lab nor diagnostic tests available to detect
lesser degrees of abruptio placenta (more on
clinical presentation)
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HYPOVOLEMIC SHOCK
COUVELAIRE UTERUS
ACUTE RENAL FAILURE
SHEEHAN SYNDROME
CONSUMPTIVE COAGULOPATHY/ DIC
COMPLICATIONS
MATERNAL AND FETAL
FETAL DEATH
INTRAUTERINE GROWTH
RESTRICTION
PRETERM AND LOW BIRTH WEIGHT
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• Placental abruption may be complicated
by massive and sometimes torrential
haemorrhage due to maternal blood loss.
• Bruised appearance
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• Severe intrapartum or early postpartum
hemorrhage rarely followed by pituitary failure.
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• Placental abruption is one of the most
common causes of clinically significant
consumptive coagulopathy
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CONSUMPTIVE
COAGULOPATHY
The most effective and definitive
treatment is correction of the underlying
process
Replacement therapy with blood components
(give only what patient lacks)
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• Fetal anoxia, exsanguination (because rupture of
fetal placental vessels can occur), and
prematurity main causes of fetal death FETAL DEATH,
• Mechanism of effect of placenta abruption on
IUGR still not clear: suggested that IUGR is
INTRAUTERINE
related to response to the chronic effects on the
placenta damage(uteroplacental blood perfusion GROWTH
insufficiency)
RESTRICTION,
• Haemorrhage induces thrombin from decidual
tissue factor, result to PPROM and Preterm PRETERM AND
delivery. Severe, acute abruption can lead to
maternal and fetal mortality.
PROM
• Thrombin also promotes neutrophil trafficking
and uterine contractility increasing risk of
pretern delivery
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MANAGEMENT
Depends on: Gestational Age, Maternal Status and Fetal Status
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GESTATIONAL AGE
Term pregnancy:
without fetal distress + diagnosis uncertain, Mother
stable: close observation
with fetal distress or if diagnosis of AP is certain:
Immediate intervention
Preterm pregnancy
without fetal distress: Delay delivery
with fetal distress: Immediate delivery
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MATERNAL STATUS CPG 2009
• Monitor BP, CR, RR, Fluid Intake Urine 1. Nasal oxygen
Output
2. Intravenous hydration using large bore
• Blood typing and crossmatch catheter
• Correct hypovolemia, anemia, hypoxia 3. Type and crossmatch for 4 units of packed
before surgery red blood cells (RBC)
• Urine output should be 30ml/hr 4. Evaluation of hematologic and clotting
• Blood studies – CBC, platelet count, plasma studies (complete blood count,
prothrombin time, partial thromboplastin
fibrinogen and fibrin degradation products,
time, fibrinogen, platelet count)
PTT (prone to develop DIC)
5. Monitoring of urinary output with
indwelling bladder catheter
FETAL STATUS 6. Continuous electronic fetal heart rate and
uterine activity monitoring
• Fetal Monitor
• Fetal Distress – immediate delivery
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EXPECTANT MANAGEMENT IN PRETERM PREGNANCY
With labor well established, expectant management in abruptio placenta
is an option when both maternal and fetal status are reassuring or when
there is fetal demise as long as the mother is stable.
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TOCOLYSIS
• Side effects such as tachycardia could mask the clinical signs of blood loss
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CESAREAN DELIVERY
At term or near term with a live fetus, prompt delivery is indicated once
there is evidence of fetal compromise, severe uterine hypertonus, life-
threatening vaginal bleeding or DIC when vaginal delivery is not
imminent. Cesarean delivery should be performed promptly because
total placental detachment could occur without warning.
• Rapid delivery of the fetus who is alive but in distress practically always means
cesarean delivery.
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CONSERVATIVE APPROACH WHEN THERE IS ABRUPTIO PLACENTA
IN VERY PRETERM PREGNANCIES (20-34 WEEKS GESTATION)
When there is only partial abruptio placenta and the maternal and fetal status
are reassuring, the patient may be managed conservatively.
• Preterm birth is the leading cause of perinatal death in women with abruptio, and to
optimize perinatal outcomes, it is desirable, if possible, to prolong gestation
• Patient may be managed in out patient department if the fetal status is reassuring once
they have remained stable for several days.
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THANK YOU
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