Placental abruption (also known as
abruptio placentae) is an obstetric catastrophe (complication of pregnancy), wherein the
placentaThe placenta is an organ unique to mammals that connects the developing fetus to the uterine wall. The placenta supplies the fetus with oxygen and food, and allows fetal waste to be disposed of via the maternal kidneys...
l lining has separated from the
uterusThe uterus is a major female hormone-responsive reproductive sex organ of most mammals, including humans. It is within the uterus that the fetus develops during gestation. The term uterus is used consistently within the medical and related professions; the Germanic term, womb is more common in...
of the
motherA mother is a biological and/or social female parent of an offspring. Because of the complexity and differences of a mothers' social, cultural, and religious definitions and roles, it is challenging to define a mother to suit a universally accepted definition.-Biological mother:In the case of a...
. It is the most common cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of
pregnanciesPregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the uterus of a female. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets. Human pregnancy is the most studied of all mammalian pregnancies. Obstetrics is the surgical field...
world wide with a fetal mortality rate of 20-40% depending on the degree of separation.
Placental abruption (also known as
abruptio placentae) is an obstetric catastrophe (complication of pregnancy), wherein the
placentaThe placenta is an organ unique to mammals that connects the developing fetus to the uterine wall. The placenta supplies the fetus with oxygen and food, and allows fetal waste to be disposed of via the maternal kidneys...
l lining has separated from the
uterusThe uterus is a major female hormone-responsive reproductive sex organ of most mammals, including humans. It is within the uterus that the fetus develops during gestation. The term uterus is used consistently within the medical and related professions; the Germanic term, womb is more common in...
of the
motherA mother is a biological and/or social female parent of an offspring. Because of the complexity and differences of a mothers' social, cultural, and religious definitions and roles, it is challenging to define a mother to suit a universally accepted definition.-Biological mother:In the case of a...
. It is the most common cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of
pregnanciesPregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the uterus of a female. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets. Human pregnancy is the most studied of all mammalian pregnancies. Obstetrics is the surgical field...
world wide with a fetal mortality rate of 20-40% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality.
The heart rate of the fetus can be associated with the severity.
Lasting effects
On the mother:
- A large loss of blood or hemorrhage may require blood transfusions and intensive care after delivery. 'APH
In obstetrics, antepartum haemorrhage , also prepartum hemorrhage, is bleeding from the vagina during pregnancy from twenty four weeks gestational age to term....
weakens, for PPH to kill'.
- The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract.
- The mother may have problems with blood clotting for a few days.
- If the mother's blood does not clot (particularly during a caesarean section
A Caesarean section , also known as C-section or Caesar, is a surgical procedure in which incisions are made through a mother's abdomen and uterus to deliver one or more babies...
) and too many transfusions could put the mother into disseminated intravascular coagulationDisseminated intravascular coagulation , also known as consumptive coagulopathy, is a pathological activation of coagulation mechanisms that happens in response to a variety of diseases. As its name suggests, it leads to the formation of small blood clots inside the blood vessels throughout the body...
(DIC) due to increased thromboplastin, the doctor may consider a hysterectomyA hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...
.
- 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.
On the baby:
- If a large amount of the placenta separates from the uterus, the baby will probably be in distress until delivery. It may die in utero, resulting in a stillbirth.
- 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.
- If the separation is severe enough, the baby could suffer brain damage or die before or shortly after birth.
Symptoms
- 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)
(dark colour)
- uterus may be disproportionately enlarged
- pallor
Pathophysiology
TraumaPhysical trauma refers to a physical injury, generally of a considerably severe degree. A trauma patient is someone who has suffered serious and life-threatening physical injury with the potential for secondary complications such as shock, respiratory failure and death.-Common causes:Comprehensive...
,
hypertensionHypertension is a chronic medical condition in which the blood pressure is elevated. It is also referred to as high blood pressure or shortened to HT, HTN or HPN. The word "hypertension", by itself, normally refers to systemic, arterial hypertension.Hypertension can be classified as either...
, or
coagulopathyCoagulopathy is a defect in the body's mechanism for blood clotting, causing bleeding diathesis.-Causes:...
, 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 distressIn medicine , fetal distress is the presence of signs in a pregnant woman—before or during childbirth—that the fetus is not well or is becoming excessively fatigued.-Signs and symptoms:Signs and symptoms of fetal distress include:...
or death.
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
Disseminated intravascular coagulation , also known as consumptive coagulopathy, is a pathological activation of coagulation mechanisms that happens in response to a variety of diseases. As its name suggests, it leads to the formation of small blood clots inside the blood vessels throughout the body...
. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterusCouvelaire uterus is a life threatening condition in which loosening of the placenta causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity....
.
Risk factors
- Maternal hypertension
Hypertension is a chronic medical condition in which the blood pressure is elevated. It is also referred to as high blood pressure or shortened to HT, HTN or HPN. The word "hypertension", by itself, normally refers to systemic, arterial hypertension.Hypertension can be classified as either...
is a factor in 44% of all abruptions.
- Maternal trauma, such as motor vehicle accidents, assault
Assault is a crime of violence against another person. In some jurisdictions, including Australia and New Zealand, assault refers to an act that causes another to apprehend immediate and personal violence, while in other jurisdictions, such as the United States, assault may refer only to the threat...
s, falls, or nosocomial
- Short umbilical cord
In placental mammals, the umbilical cord is the connecting cord from the developing embryo or fetus to the placenta...
- Prolonged rupture of membranes (>24 hours)
- Retroplacental fibromyoma
A uterine fibroid is a non-cancerous tumor that originates from the smooth muscle layer and the accompanying connective tissue of the uterus...
- Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk.
- Previous abruption: Women who have had an abruption in previous pregnancies are at greater risk.
- some infections are also diagnosed as a cause
The risk of placental abruption can be reduced by maintaining a good
dietIn nutrition, the diet is the sum of food consumed by a person or other organism. Dietary habits are the habitual decisions an individual or culture makes when choosing what foods to eat. Although humans are omnivores, each culture holds some food preferences and some food taboos. Individual...
including taking
folic acidFolic acid and folate , as well as pteroyl-L-glutamic acid and pteroyl-L-glutamate, are forms of the water-soluble vitamin B
9...
, regular
sleepSleep is a naturally recurring state of relatively suspended sensory and motor activity, characterized by total or partial unconsciousness and the inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, and it is more easily...
patterns and correction of
pregnancy-induced hypertensionGestational hypertension or pregnancy-induced hypertension is defined as the development of new arterial hypertension in a pregnant woman after 20 weeks gestation.Pre-eclampsia and eclampsia are sometimes treated as components of a common syndrome....
.
Intervention
Placental abruption is suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The
fundusThe fundus of the uterus is the top portion, opposite from the cervix.Fundal height, measured from the top of the pubic bone, is routinely measured in pregnancy to determine growth rates....
may be monitored because a rising fundus can indicate bleeding. An ultrasound may be used to rule out
placenta praeviaPlacenta praevia is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix . It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum haemorrhage...
but is not diagnostic for abruption. The mother may be given Rhogam if she is Rh negative.
Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36 weeks and neither mother or fetus are in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first.
Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement and to maintain blood pressure and
blood plasmaBlood plasma is the yellow liquid component of blood, in which the blood cells in whole blood would normally be suspended. It makes up about 55% of the total blood volume. It is mostly water and contains dissolved proteins, glucose, clotting factors, mineral ions, hormones and carbon dioxide...
replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over
caesarean sectionA Caesarean section , also known as C-section or Caesar, is a surgical procedure in which incisions are made through a mother's abdomen and uterus to deliver one or more babies...
unless there is fetal distress. Caesarean section is contraindicated in cases of disseminated intravascular coagulation.
Patient should be monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy if family size is completed.
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