Abruptio

 DEFINITION:
 Defined as premature separation of normally implanted placentae, after
24 weeks gestation.

 Revealed
 Concealed
 Mixed

 Inadequate decidualization:
 Maternal age
 Increasing parity
 Uterine anomalies/fibroids
 Vasospasm and placental hypoperfusion:
 Hypertension
 Pre-eclampsia
 Thrombophilias
 Smoking/cocaine use
 Rapid decompression of the uterus:
 Polyhydramnios
 Multifetal gestation
 Preterm prelabor rupture of membranes

 Shearing of placental vessels:
 Abdominal trauma
 External cephalic version
 Other causes:
 Previous abruption

 Grade—0: Clinical features may be absent. The diagnosis is made after
inspection of placenta following delivery.
 Grade—1 (40%): (i) vaginal bleeding is slight (ii) uterus: irritable,
tenderness may be minimal or absent (iii) maternal BP and fibrinogen
levels unaffected (iv) FHS is good.
 Grade—2 (45%): (i) vaginal bleeding mild to moderate (ii) uterine
tenderness is always present(iii) maternal pulse ↑, BP is maintained (iv)
fibrinogen level may be decreased (v) shock is absent(vi) fetal distress or
even fetal death occurs.
 Grade—3 (15%): (i) bleeding is moderate to severe or may be concealed
(ii) uterine tenderness is marked (iii) shock is pronounced (iv) fetal death
is the rule (v) associated coagulation defect or anuria may complicate.
.

 Vaginal bleeding
 Mild/profuse
 Abdominal pain
 Mild/severe/persistent
 Backache
 Uterine tenderness
 Uterine tetany
 Uterine contractions
 Overdistended uterus
 Maternal
 Hypotension
 Tachycardia
 Decreased urine output
 Signs of disseminated intravascular coagulation

 Fetal heart rate abnormalities:
 Variable/late decelerations
 Poor variability
 Prolonged bradycardia
 Sinusoidal pattern

 HISTORY:
 Gestational age
 Presenting symptoms:
 Vaginal bleeding(mild/profuse)
 Pain
o Abdominal pain
o Backache
o Pain of uterine contractions
 Vaginal discharge
 Symptoms of blood loss and hypovolemia:
o Fainting
o Restlessness
o Palpitation

o Tachypnea
o Thirst
o Sweating
 Decreased fetal movements
 Past history:
 Hypertension
o Obstetric history
 Pre-eclampsia
 Previous abruption
 Recurrent episodes of bleeding

 PHYSICAL EXAMINATION IN PLACENTAL ABRUPTION:
 General examination
o Pulse
o Blood pressure
o Amount of bleeding
 Abdominal examination
o Uterine size
o Consistency
o Tenderness
o Contractions
o Palpation of fetal parts
o Presentation
o Fetal heart sounds

 Local examination:
o Vaginal bleeding
o Leaking of amniotic fluid
 Vaginal examination(if performed)
o Clots in the vagina
o Cervical effacement
o Cervical dilatation
o Presence or absence of membranes
o Presentation/station
o Blood stained amniotic fluid

 Ultrasonography:
 This is more useful in excluding placenta previa rather than confirming
abruption.
 The two may coexist in 10% of cases.
 Findings on ultrasonography are variable.
o A retroplacental hematoma is not always seen. Early retroplacental clot is
isoechoic or hyperechoic and may be interpreted as thickened placental
tissue. The clot becomes hypoechoic and sonolucent after 1-2 weeks
o If a retroplacental hematoma can be identified, it indicates massive
bleeding and the woman will be in shock
o Subchorionic and preplacental hematomas may be seen located between
membranes and the uterine wall or on the fetal surface of the placenta.
o Intrauterine clots may be seen floating in amniotic fluid which ‘jiggle’ on
maternal movement or on bouncing with the transducer(‘jello’) sign.
o The sensitivity of ultrasonography in identifying placental abruption is
25%-50%.

 Magnetic resonance imaging:
 Can be used to diagnose abruption when in doubt but is not
recommended routinely.

 Management depends on the following:
 Severity of abruption
 Gestational age
 Maternal condition
 Condition of the fetus

 Irrespective of gestational age:
o Moderate-to-severe bleeding
o Maternal complications
o Fetal distress
o Fetal death
 Gestational age>34 weeks
o Mild bleeding

 Nonsevere abruption at <34 weeks
 No maternal complications
 Fetal surveilance tests are normal

 Expectant management consists of the following:
 Discharge after 48 hours
 Counseling regarding immediate return to hospital if:
o Fetal movements decrease
o Bleeding recurs
o Uterine contractions begin
 Weekly biophysical profile and estimation of fetal growth and weight
 Betamethasone 2 doses 24 hours apart to accelerate pulmonary maturity
 Role of tocolysis in the event of preterm labor controversial; not
recommended as routine
 Kleihauer-Betke test and administration of anti-D immunoglobin, if Rh
negative.
 Deliver if fetal growth restriction,oligohydramnios or recurrent bleeding
 Induction of labor 37-38 weeks by cervical ripening with prostaglandin
E2,amniotomy and oxytocin

 Cesarean section, if:
o The abruption is severe and bleeding persistent
o Nonreassuring fetal status
o Maternal renal failure or DIC
 Vaginal delivery, if:
o The fetus is alive, fetal heart rate pattern is normal
o Bleeding is mild to moderate
o Fetus is dead but maternal condition is stable

 Maternal pulse, blood pressure and urine output should be monitored
 20 units of oxytocin should be administered in 500ml of normal saline.
 If the uterus is atonic, ergometrine and prostaglandin F2 alpha should be
administered.

Abruptio

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Abruptio