Post on 11-Apr-2017
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CAUSES Placenta praevia
Abruptio placenta
Local causes like polyp,cancer cervix,varicose
veins and local trauma
Circumvallate placenta
Vasa praevia
Unclassified or indeterminate haemorrhage
ABRUPTIO PLACENTA
DEFINITION
• It is defined as hemorrhage occuring during pregnancy due to separation of normally situated placenta.
• Also called accidental hemorrhage or premature separation of placenta.
GRADING
Sher and statland’s grading
It is of prognostic significance and
differentiates between a live and
dead fetus.
GRADE 1:Unrecognised clinically
before delivery,but evidence of
retroplacental clots on examining
the placenta
GRADE 2:Intermediate with
classical signs of abruption,but no
maternal distress and live fetus
GRADE 3:severe abruption with the
fetus dead
A.with coagulpathy
B.without coagulopathy
INCIDENCE
1% and is leading cause for perinatal
mortality
AETIOLOGY
The following are some of the risk
factors that are implicated
1.Medical factors
Preeclampsia and hypertension are
associated in 50% cases
Another strong correlation is with
chorioamnionitis secondary to
preterm premature rupture of
membranes
2.Thrombophilias
Congenital and acquired thrombophilias
are associated with abruption.
Aquired type is antiphospholipid
syndrome-thrombosis,recurrent
miscarriage,early onset of preeclampsia
and fetal growth restriction in addition to
abruption
Congenital ,includes prothrombin gene
mutation factor v mutation protein C and S
deficiency are also associated with
abruption
3.Hyperhomocystinaemia
Elevated levels of homocysteine-damage vascular endothlium-causes abruption
This is the basis for association noticed in women with folate deficiency
4.trauma
Blunt trauma to the abdomen
Amniocentesis
External cephalic version
Sudden uterine decompression(hydramnios and following delivery of 1st twin)
5.Other associations
Previous abruption
Smoking and cocain abuse
Raised serum α fetoprotein level
Myomas esp. submucus myomas
CLASSIFICATION
Vasospasm→myometrialcontraction→venous engorement and arteriolar rupture into decidua basalis→dev. of decidual hematoma→ seperation of placenta
Abruption is divided into 3 based on the type of hemorrhage:
Revealed(60%):
effused blood dissects the membranes away from the uterine wall and make its way through cervix into vagina.
Concealed(35%):
blood is retained in the uterus
Due to loss of tone of uterine muscle and
absence of uterine contractions
Uterus distends to accommodate the
blood
Sometimes amnion may rupture and
there is bleeding into amniotic sac
Concealed type is more likely to lead to
couvelaire uterus and cause fetal demise
and maternal complications
Mixed(5%):
In this partly revealed and partly concealed
COUVELAIRE UTERUS
There can be extensive extravasation of blood into uterine
musculature beneath serosa esp. in concealed type.
uterus show ecchymoses and tubes and ovaries drain blood.
Peritoneal cavity is also filled with blood.
This is called couvalaire uterus or uteroplacental apoplexy.
Already there is fetal hypoxia due to placental seperation
Tetanic contraction brought about by the seepage of blood
into myometrium in abruption cause ↑sed intrauterine
pressure.
this cuts off placental blood flow adding to fetal
hypoxia.thus sudden fetal death is common.
Concealed abruption is more likely to lead to couvelaire
uterus and cause fetal demise and maternal complications
DIAGNOSIS
SYMPTOMS
Severe and constant abdominal
pain(more in concealed and less in
revealed)
Bleeding is present in revealed and
mixed types but may be absent in
concealed type.
SIGNS
Pallor which is out of proportion to the extent of bleeding
Hypertension(if there is associated preeclampsia)
Uterus larger than the expected for the period of amenorrhoea
Uterus may be tense and tender and even rigid(woody hard)
Difficulty in palpating underlying fetal parts easily
Fetal distress or absent FHS.
In revealed uterus fundal height may
correspond to period of gestation
FHS are present
Initial presentation may be as preterm
labour with an irritable uterus and there
should be a high index of suspicion
Due to association of preeclampsia BP
may be normal even with severe
abruption.Hence findng of a normal BP
is not always reassuring
VAGINAL EXAMINATION
Performed after ruling out placenta praevia
Usually patient will be in labour with fixed
presenting part and on artificial rupture of
membranes,liquor will appear to be uniformly blood
stained
ULTRASOUND
Less significant role
Mainly useful to rule out placenta praevia
Sometimes retroplacental hematoma may be seen
Negative findings do not exclude abruption
Abruption is essentially a clinical diagnosis and not
an ultrasound diagnosis
DIFFERENTIAL DIAGNOSIS
Placenta praevia
Other causes of APH
Preterm labour
Acute polyhydramnios(absence of pallor and
ultrasound is diagnostic)
Rupture uterus(esp. incomplete rupture)
Red degeneation,pyelonephritis,and other causes
of acute abdomen
COMPLICATIONS
MATERNAL
1.shock
2.renal failure
3.disseminated intravascular coagulation
(liberation of thromboplastin from placenta →intravascular
coagulation→ consumption of all coagulation factors →
fall in fibrinogen level →bleeding).
4.Postpartum hemorrhage(due to atonicity and
coagulation failure)
FETAL
1.Prematurity
2.Hypoxia and fetal death
MANAGEMENT
Immediade management
Similar in all cases of APH
Resuscitation with blood and crystalloids and prompt delivery
Blood transfusion
Indwelling catheter introduced and monitered
Central venous pressure line inserted
Blood taken for Hb,PCV,grouping,cross matching and coagulation profile
Coagulation profile includes fibrinogen ,fibrin degradation products , partial thromboplastin time, prothrombin time and platelet count
(best marker –fibrinogen)
Clotting time,clot retracton test,stability of the clot is also looked for
Ultrasound to confirm normal placenta and live fetus
Obstetric management
Immediate delivery is vital in abruption
Mode of delivery depends on gestational
age and condition of mother and fetus
fetus is alive
Ceasarian is the best method
In mild cases of revealed
abruption,imminent vaginal dlivery is
carried out
Fetus is dead
Vaginal delivery preferred unless bleeding is so severe or there are other obstetric complications
Hence artificial rupture of membranes and immediate infusion of oxytocin to hasten delivery
If delivery is not imminent after reasonable time,caesarean section may have to be resorted to
Caesarean section
Done by experienced person with the help of an expert anaesthetist
PPH must be anticipated
Indications for caesarean section:
Fetus is alive and capable of survival
Severe bleeding and vaginal delivery is not imminent
Failure to progress after artificial rupture of membranes and oxytocin
o Coagulation failure
o It is treated by blood tranfusion
o Human recombinant activated factor vii is best agent but very expensive
o Cryoprecipitate used if fibrinogen is very low
o Vaginal delivery is preferred ,if caesarean becomes neccesary,coagulation defect is corrected before proceeding.
o Plenty of cross matched bood should be available
OTHER TYPES OF APH CIRCUMVALLATE PLACENTA
In this condition chorionic plate which is on the fetal
side is smaller than than basal plate on maternal side
Fetal surface of placenta presents a central
depression surrounded by thickened greyish white ring
These pregnancies may be complicated by IUGR,↑sed
chance of fetal malformations
Bleeding is usually painless
Antenatal diagnosis is unlikely and diagnosis usually
made after examination of placenta post delivery
VASA PRAEVIA
When the fetal vessels in the membrane cross the region of the internal os and are ahead of presenting part the condition is called vasapraevia.
Occurs in 2 situations
Type 1-velamentous to cord insertion where cord insertion is into the membranes
Type 2-presence of fetal vessels running between lobes of a placenta with one or more accessory lobes
these can remain undiagnosed and and it can rupture during artificial rupture of membranes leading to death of the fetus
Apts test or singer’s alkali denaturation test can
be used to confirm vasa praevia
Principle-fetal Hb more resistant to alkali
denaturation
When water and blood are mixed with NaOH it
remains pink for longer if fetal in origin or turns
yellow brown in 2 min if maternal in origin
Risk factors-
Succenturiate lobe
Multiple pregnancy
IVF
Sometimes vessels can b palpated on vaginal
examination
Prenatal diagnosis is rarely possible by
ultrasound and doppler
Vaginal bleeding associated with variable
deccelerations on cardiotocography alerts one to
diagnose vasa praevia
Unclassified or intermediate APHExact cause of APH is unknown
There is mild bleeding but no features of abruption or placenta praevia
Speculum examination may not reveal local cause
Apt test-exclude VP
IUGR and poor perinatal outcome are associated
If there is recurrent bleeding and GA is 37 weeks or more,risk factors like fetal growth restriction delivery is preferred
In majority of cases marginal sinus rupture is later found to be the cause