Placental Abruption (APH)

Question 1

Define

Answer 1

Separation of the placenta from the uterine wall before delivery (>24 weeks; if <24w, miscarriage)

o Pathology – as placenta separates, retroperitoneal bleeding results in further detachment

o Haemorrhage may be concealed (20%) or revealed (80%)

o Occurs in 1-2% of all pregnancies

· Aetiology – idiopathic or may occur secondary to raised pressure on maternal side or mechanical trauma

· Risk factors – however, 70% of abruption occurs in low-risk pregnancies (i.e. no risk factors)

• o HTN
• Previous APH
• PPROM
• o Abdominal trauma
• Smoking,
• cocaine
• Polyhydramnios

Question 2

Risk factors

Answer 2

Maternal factors

• Abruption in previous pregnancy
• Hypertension (including pre-eclampsia)
• Smoking
• Cocaine, amphetamines
• Trauma to the maternal abdomen
• Multiple pregnancy
• Advanced maternal age (> 35 years)
• Low BMI
• ART for pregnancy
• IU infection

Foetal factors

• Polyhydramnios
• Foetal growth restriction (IUGR)

Question 3

Signs

Answer 3

PAINFUL PV bleeding associated with a tense rigid abdomen

NOTE: absence of tense abdomen does NOT rule out abruption - may not get much bleeding with posterior abruption

• Abdominal pain
• Uterine contractions
• Sweating
• May also get:
• Maternal collapse
• Feeling cold
• Light-headedness
• Restlessness
• Distress and panic

IMPORTANT: vaginal bleeding does NOT necessarily correlate with the degree of abruption as abruptions may be concealed (i.e. significant separation between placenta and uterus but blood is concealed between both so there is little vaginal bleeding seen)

Can have mini abruptions where parts of the placenta (not complete) detach

 

Signs O/E

• Absence or reduced foetal movements
• Uterine tenderness- ‘woody uterus’
• Shock
• Hypotension + tachycardia

Question 4

Investigations

Answer 4

Bloods – FBC, clotting, U&E, crossmatch

o USS – exclude praevia – abruption unlikely to be present unless very large

Praevia = bleed, no pain; abruption = bleed, pain

Question 5

Management

Answer 5

Mild -> if preterm and stable: conservative management with close monitoring à IOL at term

• Admit for at least 48 hours or until bleeding stops
• Anti-D Ig followed by Kleihauer test

Severe -> ABC, emergency CS, 2x wide bore cannulae, fluids, blood transfusions, correct coagulopathies

FBC, G&S, crossmatch, Kleihauer test (and anti-D if needed), steroids (between 24-34+6w)

CTG (if >27w), consider IOL if foetal compromise, TVUSS (query placenta praevia)

Question 6

Complications

Answer 6

Maternal – haemorrhage (APH, PPH), DIC, renal failure, “Couvelaire uterus” (extravasation of blood into myometrium and beneath the peritoneum à very hard uterus)

Foetal – birth asphyxia, death If unsure if praevia, DO NOT BIMANUAL

Prognosis

• Maternal – mortality 0.5% in severe abruption
• Foetal – mortality 3.3% in severe abruption

Maternal complications

• Anaemia
• Infection
• Maternal shock
• Renal tubular necrosis
• Consumptive coagulopathy, DIC
• PPH

Psychological sequelae

• Complications of blood transfusion
• Foetal complications
• Foetal hypoxia
• SGA and FGR
• Prematurity- iatrogenic and spontaneous
• Foetal death
• Neurological impairment of infant
• Perinatal death

Question 7

Prognosis

Answer 7

Prognosis

For the foetus + mother, it depends on the degree of abruption

Extremely preterm gestations and > 50% separation of the placenta are associated with high risk of perinatal death

Preterm birth and associated risk of perinatal asphyxia and long-term neurodevelopment handicap