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