SOLUSIO PLASENTA

M.THAMRIN TANJUNG

Abruptio Placentae (Accidental

Haemorrhage)
Definition
Premature separation of a normally
situated placenta after the 28th
week of pregnancy and before
delivery of the foetus.
Incidence
0.5-1%.

Aetiology
Unknown , but the following factors may be associated with :
1. Hypertensive disorders of pregnancy (30%) due to spasm
and degenerative changes in the decidual arterioles.
2. Trauma as during external version.
3. Sudden drop of intrauterine pressure as rupture of
membranes in polyhydramnios.
4. Folate deficiency and may be vitamin C,K, or E deficiency.
5. Passive congestion of the uterus due to pressure of the
gravid uterus on the inferior vena cava.
6. Torsion of the uterus.
7. Smoking.

Pathogenesis
Separation of the placenta results in formation of a retroplacental haematoma and
its extension leads to more separation of the adjacent placental tissue (concealed
haemorrhage).
Ultimately the blood reaches the placental margin and tracks between the
membranes and uterine wall to escape from the cervix (revealed haemorrhage).
The presence of concealed and revealed haemorrhage together called mixed
variety. Thus the three varieties are actually different presentations to one process.
lIf separation of the membranes does not occur, there is progressive disruption of
the placental tissue and intravasation of blood through the myometrium even up to
the peritoneal coat resulting in Couvelaires uterus.
Thromboplastin-like substances are released from the damaged placental site and
passed to the maternal circulation initiating the process of disseminated
intravascular coagulopathy (DIC).
Acute renal failure may result from renal ischaemia

Diagnosis
Symptoms:
1. Acute constant severe abdominal pain which may be
localised or diffuse.
2. Dark vaginal bleeding results from escape of blood
from the
retroplacental haematoma.
3. Cessation of foetal movement is common.
Signs:
(A) General examination:
1- Shock is usually present and may be marked and not
proportionate to the amount of visible bleeding due to :

- concealed and/ or revealed haemorrhage,

- overdistension of the uterus and damage of
the myometrium causing neurogenic shock.
2- Blood pressure is;
- subnormal due to haemorrhage,
- normal due to falling from previous hypertension
or
- high due to slight bleeding in hypertensive
patient.

3- Tachycardia.

(B) Abdominal examination:

1. Uterus is large for date and
increasing gradually in size due to
retained blood.
2. Uterus is very tender and hard
(board-like).
3. Foetal parts are difficult to be felt.
4. FHS may be absent due to foetal
death in severe cases or distressed in
mild cases.

(C) Vaginal examination:

Done under the same precautions in
placenta praevia may reveal:
1. Vaginal bleeding which is dark as it
is retained for some time before
escape.
2. If the cervix is dilated the placenta
is not felt.

Differential diagnosis:
1. Other causes of antepartum
haemorrhage.
2. Other causes of acute abdomen.
Investigations:
1. Ultrasound : detects normally sited
placenta with retroplacental haematoma
that may dissect the placental margin.
2. Tests for DIC (see later).

Treatment
At home:
The same as in placenta praevia.
At hospital
As placenta praevia regarding:
1. Assessment of the patients condition,
general and abdominalexamination and
resuscitation.
2. Blood volume preservation.
3. Ultrasonography.

Delivery:
Patient with abruptio placenta has to be
delivered and usually there is no place for
conservative treatment.
(I) Amniotomy + oxytocin if :
- bleeding is not severe,
- vertex presentation,
- the cervix is partially dilated.
- adequate pelvis with no soft tissue
obstruction,

Advantages of amniotomy:
- It reduces the intrauterine tension,
intravasation of blood between
myometrial muscles and its damage.
- Reduces the pain and shock.
- Reduces the incidence of renal failure.
- Stimulates the onset of labour and
improves uterine contractions pattern.

(II) Caesarean section is indicated in :

- Severe haemorrhage whether the foetus is
dead or alive.
- Living foetus and labour is expected to be
longer than 6 hours e.g. closed cervix.
- Foetal distress.
- Failure of progress after amniotomy +
oxytocin.
- Other indications for C.S. as contracted pelvis,
malpresentations and elderly primigravida.

Postpartum:
The patient is more liable for
postpartum haemorrhage so oxytocin
is continued after
delivery of the foetus, methergin is
given with delivery of the shoulders if
there is no
hypertension with continuous
massage of the uterus.