Abuptio placenta-Bleeding in pregancy cauxses

Courtsney: Geneva Medical Foundation:-Placental abruption (also known as abruptio placentae) is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth.

 Good morning from India : It is morning tea time in India:-Revision class on

All about Placenta abruption:- Courtesy Geneva Foundation for Medical Education and Research:--a Foundation for Medical Education and Reeneva Foundation for Medical Education and Research

Is it worth discussing? I hadn’t seen any abruption in last 10 yrs of practice!!  Yes U are true in your rezoning & arguments. It is equally true that. With near universal practice of modern obstetrics in our country too gone are the days of Couvelaire  uterus and hundreds of maternal  deaths in our state due to placental  abruption .But there is a caveat that  with ever increasing motor vehicle accidents, scooter accidents in particular  the prevalence of abortion (earlier term was a accidental hemorrhage)  have not decreased as was one would have expected.

Earlier Prevalence : It was  in 1%-2%  of    pregnancies worldwide but my belief is that it will be about 4-5% if we carefully observe the uterine surface of placenta.

What risk to mother? Placental abruption is a significant contributor to maternal mortality worldwide; early and skilled medical intervention is needed to ensure a good outcome,

Placental abruption has effects on both mother and fetus. The effects on the mother depend primarily on the severity of the abruption, while the effects on the fetus depend on both its severity and the gestational age at which it occurs.^[2] The heart rate of the fetus can be associated with the severity.^[3]

On the mother:

·         1) Lack of contractions:-The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract.

2) Coagulation & Bleeding tendency:-May have problems with blood clotting.Pl don’t go on transfusing whole blood many times that will add fuel to fire, It happens quite commonly if the mother's blood does not clot  and case is managed by young doctors or in places where blood component Separation  facilities are nonexistent . In societal & nurses pressure quite often in rural areas doctor in charge are forced to Tr whole blood knowing full well  that he/she(Dr) is doing a suicidal attempt / injustice to save te pt who need something other than whole blood. Therefore to sum up  too many transfusions could put the mother into disseminated (DIC) due to increased thromboplastin, the doctor may consider a hysterectomy.

·         A large loss of blood or hemorrhage may require blood transfusions and intensive care after delivery. 'APH weakens for PPH to kill'.

·         Multiorgan failure:-A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland. Diffuse cortical necrosis in the kidney is a serious and often fatal complication.

·         In some cases where the abruption is high up in the uterus, or is slight, there is no bleeding, though extreme pain is felt and reported.

What may be ill effect on  foetus & later neonate?? -

·         If a large amount of the placenta separates from the uterus, the baby will probably be in distress until delivery and may die in utero, thus resulting in a 1) stillbirth.2) Difficulty in resuscitation ,Apagar may be 2-6,

·         3) Premarurity:-The baby may be premature and need to be placed in the newborn intensive care unit. He or she might have problems with breathing and feeding.

·         If the baby is in distress in the uterus, he or she may have a low level of oxygen in the blood after birth.

·         The newborn may have low blood pressure or a low blood count.

·         4) Brain damage If the pl. separation is severe enough, the baby could suffer brain damage or die before or shortly after birth.

·         5) Learning disorders. Behavioral;, Speech disorders:-The newborn may have learning issues at later development stages, often requiring professional pedagogical aid.

What are the symptoms of abruption> How one is going to diagnose who has not seen many cases during her/his residency?

·         Abruption of placenta (contd)  :--uterine contractions that don't stop (and may follow one another so rapidly as to seem continuous)

·         pain in the uterus

·         tenderness in the abdomen

·         vaginal bleeding (sometimes)

·         uterus may be disproportionately enlarged

·         pallor

What may be clinical symptoms? It varies depending on degree of separation, By observing and by analyzing the sympt & signs an astute clinician can understand and prognosticate clinical grading & mode of delivery:-

·         Class 0: asymptomatic. Only diagnosed Post delivery-therefore often missed:- Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.

·         Class 1: mild and represents approximately 48% of all cases. Characteristics include the following:

·         No vaginal bleeding to mild vaginal bleeding

·         Slightly tender uterus

·         But with normal maternal BP and heart rate, no coagulopathy, neither No fetal distress

·         Class 2: moderate grade-again clinical Grading: This type of cases are about 54% of all Abruption but if reviewed in rural hospitals over 10 yrs period then this % will go up as many Class 0  & 1 go  undetected specially if delivered at home. Therefore it all depends who is s maintaining the record for 10 yrs in particular locality,.

·         However, the clinical characteristics include the following:

·         No vaginal bleeding to moderate vaginal bleeding

·         Moderate-to-severe uterine tenderness with possible titanic contractions

·         Maternal tachycardia with orthostatic changes in BP and heart rate

·         Fetal distress

·         Hypofibrinogenemia (i.e., 50–250 mg/dL)

·         Class 3: severe and represents approximately 35% in rural settings as women are brought quite late, Because symtomatology is poorly correlated with  prognosis of foetus & mother. Of all cases this clinical class kills many young women : However the characteristics include the following:

·         No vaginal bleeding to heavy vaginal bleeding

·         Very painful titanic uterus

·         Maternal shock

·         Hypofibrinogenemia (i.e., <150 mg/dL)

·         Coagulopathy

·         Fetal death

Pathophysiology.: The causes of abruption:--

hypertension, or coagulopathy contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into the  decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption.

Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death.

Another way of classification of abruption:-Abruptions are classified according to severity in the following manner:

·         Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta.

·         Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus.

·         Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring.

·         Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.

What predisposes to such kind of APH? When and under what we the obstetrician should forewarn the woman or family members about the future possibility of having abruption albeit small as preg advances. Communicate the relatives about such possibility at each check up. Otherwise she & family members may blame U as she (ANC) was under regular check up but you never apprehended it,

 

 Abruption Pl in preg/in labour:-It is crucial for women to be made aware of the signs of placental abruption, such as vaginal bleeding, and that if they experience such symptoms they must get into contact with their doctor/ N home. Without any delay .If we don’t communicate this possibility well in advance in predisposed cases relatives will think /consider about this:-They may consider dev of such APH as a deficiency of professional service.

 

Now let me quickly enumerate the risk factors/ predisposing factors allowing U sufficient time to forewarn the possibility well ahead,

·         1) Pre-eclampsia, 2) maternal smoking is associated with up to 90% increased risk above the base line risk. 3) Prolonged rupture of membranes (>24 hours). These three compromise more than 70% of cases of abruption.

·         : 

·         Other less relatively uncommon causes are 4) Maternal trauma, such as motor vehicle accidents, (if adequate Preg seat belt is tied up properly) physical assaults, falls particularly at toilets, muddy roads, & staircase.

·          

·         5) Thrombophilic 

·         6) Multiparty 

·         7) Multiple pregnancy

·          

·         Previous Caesarean section some infections are also diagnosed as a cause

·         cocaine intoxication^[