ABRUPTIO PLACENTAE

ACHMAD AMINUDDIN

PREMATURE SEPARATION
OF THE PLACENTA
SEPARATION FROM THE SITE OF
UTERINE IMPLANTATION BEFORE
DELIVERY OF THE FETUS.
TWO PRINCIPAL FORM ;
- CONCEALED FORM.
- EXTERNAL FORM.
- RELATIVELY CONCEALED.

ESSENTIAL OF DIAGNOSIS
UNREMITTENT ABDOMINAL ( UTERINE)
OR BACK PAIN.
IRRITABLE, TENDER, AND OFTEN
HYPERTONIC UTERUS.
VISIBLE OR CONCEALED
HEMORRHAGE.
EVIDENCE OF FETAL DISTRESS MAY
OR MAY NOT BE PRESENT DEPEDING
ON THE SEVERITY OF THE PROCESS.

CONCEALED FORM
THE HEMORRHAGE IS CONFINED
WITHIN THE UTERINE CAVITY,
DETACHMENT OF THE PLACENTA
MAY BE COMPLETE, AND THE
COMPLICATIONS ARE OFTEN SEVERE

EXTERNAL FORM
THE BLOOD DRAINS THROUGH THE
CERVIX, PLACENTAL DETACHMENT IS
MORE LIKELY TO BE INCOMPLETE,
AND THE COMPLICATIONS ARE
FEWER AND LESS SEVERE.

RELATIVELY CONCEALED
HEMORRHAGE FROM AN
INCOMPLETELY DETACHED
PLACENTA MAY SOME TIME BE
CONCEALED BY INTACT MEMBRANES.

ETIOLOGY
PREDISPOSING FACTORS ;
- PREVIOUS PLACENTAL SEPARATION.
- HYPERTENSIVE STATES OF
PREGNANCY.
- ADVANCED MATERNAL AGE,
PARITY, UTERINE DISTENTION,
VASCULAR DEFICIENCY OR
DETERIORATION, UTERINE ANOMALI
OR TUMORS, CIGARETTE SMOKING,
ALCOHOL CONSUMPTION AND POSSIBLY
MATERNAL TYPE O BLOOD.

PATHOPHYSIOLOGY
LOCAL VASCULAR INJURY THAT RESULTS IN
VASCULAR RUPTURE IN TO THE DECIDUA BASALIS,
BLEEDING AND HEMATOMA FORMATION.
AN ABRUPT RISE IN UTERINE VENOUS PRESSURE
TRANMITTED TO THE INTERVILLOUS SPACE.
MECHANICAL FACTORS: TRANSABDOMINAL
TRAUMA, SUDDEN DECOMPRESSION OF THE
UTERUS SUCH AS WITH THE DELIVERY OF A FIRST
TWIN OR RUPTURE OF THE MEMBRANES IN
HYDRAMNIOS, OR TRACTION ON A SHORT
UMBILIAL CORD.
INITIATION OF THE COAGULATION CASCADE.

PATHOPHYSIOLOGY
( CONTINUATION )
HEMORRHAGE INTO THE DECIDUAL
BASALIS, LEAVING A THIN LAYER
ADJACENT TO THE MYOMETRIUM.
ALTERNATIVELY, A SPIRAL ARTERY
MAY RUPTURE, CREATING A
RETROPLACENTAL HEMATOMA.
THE CLOT DEPRESSES THE
ADJACENT PLACENTA.
COUVELAIRE UTERUS.

CLINICAL FINDIGS
CORRESPOND TO THE DEGREE OF
SEPARATION.
SMALL SEPARATIONS
- FEW OR NO SYMPTOMS.
- MINIMAL IRRITABILITY.
- NO UTERINE TENDERNESS OR
FETAL DISTRESS.
- LIMITED AMOUNT OF EXTERNAL BLEEDING
LARGER SEPARATIONS

CLINICAL FINDINGS
(CONTINUATION)
LARGER SEPARATIONS
- ABDOMINAL PAIN AND UTERINE
IRRITABILITY.
- HEMORRHAGE MAY BE VISIBLE OR
CONCEALED.
EXTENSIVE PROCESS
- FETAL DISTRESS --- FETAL DEMISE.
- UTERINE TETANY.
- HYPOVOLEMIC SHOCK.
- D.I.C.

LABORATORY
THE DEGREE OF ANEMIA WILL PROBABLY
BE CONSIDERABLY LESS THAN THE
AMOUNT OF BLOOD LOSS.
PERIPHERAL BLOOD SMEAR
- REDUCED PLATELET COUNT.
- THE PRESENCE SCHISTOCYTES,
SUGESTING IV COAGULATION.
- FIBRINOGEN DEPLETION WITH RELEASE
OF FIBRIN SPLIT PRODUCT.
THE CLOT OBSERVATION TEST.

LABORATORY
COAGULATION STATUS ;
- PROTHROMNIN TIME.
- PARTIAL THROMBOPLASTIN TIME.
- PLATELET COUNT.
- FIBRINOGEN.
- FIBRIN SPLIT PRODUCTS.

TREATMENT

EMERGENCY MEASURES.
EXPECTANT THERAPY.
VAGINAL DELIVERY.
CESAREAN SECTION.

EMERGENCY MEASURES
EMERGENCY
hemorrhage uterine spasm fetal distress.
THE MEMBRANES SHOULD BE ARTIFICIALLY
RUPTURED.
LACTATED RINGERS INJECTION AND
ADITIONAL ANTI SHOCK MEASURES AS
NECESSARY.
INTERNAL MONITORING.
BLOOD SHOULD BE DRAWN FOR LAB

EXPECTANT THERAPY
INDICATIONS;
- THE FETUS IS IMMATURE.
- BLEEDING IS NOT EXTENSIVE.
- UTERINE IRRITABILITY IS ABSENT OR
MINIMAL.
- THERE IS NO FETAL DISTRESS.
- PLACENTA PREVIA CAN BE RULED
OUT.
- THE PATIENT SHOULD BE HOSPITALIZED.
- THE TYPE AND CROSS-MATCH IS OBSERVED FOR
A PERIOD OF 24 48 HOURS UNTIL ONE IS
CERTAIN THAT FURTHER PLACENTAL SEPARATION IS NOT
OCCURING.
- PREMATURE LABOR IS NOT LIKELY.

VAGINAL DELIVERY
INDICATIONS;
- THE DEGREE OF SEPARATION
APPEARS TO BE LIMITED.
- THE FETUS CAN BE MONITORED FOR
SIGNS OF FETAL DISTRESS.
- PLACENTAL SEPARATION IS EXTENSIVE AND
FETUS IS DEAD OR OF DUBIOUS VIABILITY
INDUCTION OF LABOR WITH AN OXYTOCIN
INFUSION SHOULD BE INSTITUTED IF ACTIVE
LABOR DAS NOT BEGIN SHORTLY AFTER
AMNIOTOMY.
PUDENDAL BLOCK ANESTHESIA IS
RECOMMENDED.

CESAREA SECTION
THE INDICATIONS;
- DELIVERY IS NOT IMMINENT FOR A
FETUS WITH A REASONABLE
CHANCE OF SURVIVAL WHO EXHIBIT
PERSISTENT EVIDENCE OF DISTRES
- THE CONDITIONS ARE NOT FAVOUR
ABLE FOR RAPID DELIVERY IN THE
FACE OF PROGRESIVE OR SEVERE
PLACENTAL SEPARATION, IF THE FETUS
IS IN GOOD CONDITION
- NULIPAROUS WITH LESS THAN 3-4 CM OF
CERVICAL DILATATION.
- UNCONTROLLABLE HEMORRHAGE FROM A
CONTRACTED UTERUS
- RAPID EXPANDING UTERUS WITH COCEALED HEMORRHAGE
WHEN DELIVERY IS NOT IMMINENT

COMPLICATIONS
DEFIBRINATION SYNDROME.
ACUTE COR PULMONALE.
RENAL CORTICAL AND TUBULAR
NECROSIS.
TRANSFUSION HEPATITIS.
UTERINE APOPLEXY.

PROGNOSIS
UNFAVOURABLE PROGNOSIS
- EXTERNEL OR CONCEALED
BLEEDING.
- EXCESSIVE BLOOD LOSS, SHOCK,NULLIPARITY, A CLOSE CERVIX, ABSENCE OF
LABOR.
- DELAYED DIAGNOSIS AND TREATMENT.
MOST WOMAN DIE OF HEMORRHAGE OR CARDIAC
OR RENAL FAIKURE.
A HIGH DEGREE OF SUSPCION, EARLY DIAGNOSIS
AND DIFINITIVE THERAPY SHOULD REDUCE THE
MATERNAL MORTALITY RATE