Placenta abruptio

Question 1

Definition of placenta abruptio

Answer 1

Premature separation of normally implanted placenta (decidua from basal plate), results in:
- Blood collecting b/w placenta and uterus
- Deprives baby of oxygen and nutrients

Question 2

Pathophysiology of placenta abruptio

Answer 2

Initiated by rupture of maternal vessel
-> Haemorrhage into the decidua basalis (uterus) with formation of a decidual hematoma
-> Separation of the decidual from the basal plate of placenta
-> Predisposes to further separation and bleeding, as well as to compression and destruction of placental tissue
-> Blood may dissect:
1. Upwards: Towards fundus –> Concealed hemorrhage
2. Downwards: Towards cervix –> Revealed hemorrhage

Question 3

Risk factors of placenta abruptio

Answer 3

Previous history of placenta abruptio
Pregnancy-induced HTN/pre-eclampsia
Polyhydramnios
Abdominal trauma
Smoking
Cocaine

Question 4

Signs & symptoms of placental abruptio

Answer 4

If revealed placenta abruptio:
Vaginal bleed + abdominal pain
- pain increasing in severity
- persistent pain
- a/w uterine contractions

If concealed placenta abruptio:
Abdominal pain of varying degree + absence of vaginal bleed

In either:
Tender, hard, ‘woody’ uterus = Couvelaire uterus
- bleeding into the uterine myometrium that may extend to the peritoneal cavity

Fetal distress
Fetal death

Question 5

Complications of placenta abruptio

Answer 5

Maternal
- Mortality & morbidity
- Haemorrhagic shock
- Disseminated intravascular coagulation
- Ischaemic necrosis of distal organs:
Kidneys -> AKI
Pituitary -> Sheehan syndrome
- Postpartum haemorrhage
- Rhesus sensitization (in Rh -ve mother)

Fetal
- Mortality & morbidity
- Pre-term delivery
- IUGR

Question 6

Physical examination for APH (same as pp)

Answer 6

Assess maternal and fetal well-being and determine the cause of APH

Maternal well-being:
Regular vitals assessment TRO hypovolemic shock
Presence of HTN warrants excluding pre-eclampsia

Fetal well-being:
Continuous CTG monitoring to trace foetal heart beat for signs of fetal distress

Abdomen:
SFH
Palpate for contractions and woody hard uterus for placenta abruptio
Determine fetal lie and presentation

Bedside U/S:
Exclude placenta and vasa previa, retroplacental haemorrhage and confirm fetal presentation

Speculum examination:
Amount of blood in vagina, presence of active bleeding, appearance of cervix to assess dilatation

Vaginal examination:
I will NOT perform a vaginal exam if placenta and vasa previa have NOT been excluded

Question 7

What finding can be seen in U/S in placenta abruptio?

Answer 7

• Retroplacental clot for placenta abruption, but absence does not exclude
• Acute hemorrhage: Hyperechoic compared to placenta
• Resolving hematoma: Hypoechoic within 1 week and sonolucent within 2 weeks

Question 8

Investigations in APH (same as pp)

Answer 8

Placenta abruptio is a clinical diagnosis!
Bloods
1. FBC
- Hb for anemia and platelets for thrombocytopenia
2. GXM (at least 4 units)
- Blood transfusion, anti-D immunoglobulin if RH-neg
3. DIC screen (PT/PTT, INR, Plt, Fibrinogen, D-dimers)
- Prolongation of PT/PTT and fibrinogen
- Fibrinogen < 2 is diagnostic of DIC in pregnancy
4. RP, LFT
- Pre-op bloods

*With every episode of bleed in APH, Rhesus -ve woman needs Kleihauer Betke test + Prophylactic RhoGAM (Anti-D Ig)

Imaging
TVUS
- Confirm location of placenta if unbooked case of placenta previa
- Retroplacental haemorrhage
- Confirm fetal presentation

Foetal
Continuous cardiotocography monitoring to trace foetal heart beat for signs of fetal distress

Question 9

Management of ACUTE placenta abruptio

Answer 9

1. Activate obstetric code –consultant obstetrician, anesthetist, senior midwife and neonatologist
2. ABCs
3. Continuous maternal vital signs monitoring, Continuous cardiotocography monitoring to trace foetal heart beat for signs of fetal distress
4. Keep NBM
5. IDC for hourly I/O charting
6. Pad charting
7. Insert IV line: give IV fluids - crystalloids and colloids as needed
8. Draw blood to send off for investigations
9. Call blood bank for packed red cell and blood product transfusion
10. Monitor bleeding (refer to next card)
    - Fetus stable
    - Fetus alive and in distress
    - Fetus dead
11. Postpartum haemorrhage prophylaxis post delivery

Question 10

Mode of delivery for placenta abruptio

Answer 10

Fetus stable (expectant management)
- Close fetal monitoring
- Discharge once patient is stable and not bleeding
- Plan elective delivery at term: NVD or CS
- IM dexamethasone for fetal lung maturity if fetus is pre-term and delivery is not immediately required

Fetus alive and in distress (pathological CTG)
- IMMEDIATE delivery
- VAGINAL delivery is preferred as patient is already contracting vigorously
- If caesarean section, correct coagulopathy first!!!

Fetus dead
- Delivery ASAP as patient is at risk of worsening DIVC
- Correct coagulopathy and induce vaginal delivery
- C-sect if cannot NVD