Transcript Placental Abruption

IN THE NAME OF GOD
PLACENTAL ABRUPTION
*Refers to bleeding at the decidual-placental interface that causes partial or
total placental detachment prior to delivery of the fetus.
*The diagnosis is typically reserved for pregnancies > 20 weeks of
gestation.
*Is a significant cause of maternal and perinatal morbidity, and perinatal
mortality.
*The perinatal death rate is approximately 12 % (versus 0.6 % in nonabruption births).
*The majority of perinatal deaths (up to 77 %) occur in utero; deaths in the
postnatal period are primarily related to preterm delivery.
PLACENTAL ABRUPTION
The major clinical findings are :
1) vaginal bleeding mild and clinically insignificant to severe
and life-threatening.
2) abdominal pain
3) often accompanied by hypertonic uterine contractions
4 )uterine tenderness
5) and a nonreassuring FHR pattern.
When placental separation exceeds 50 %, acute DIC and fetal death
are common.
WHAT ARE THE RISK FACTORS FOR PLACENTAL
ABRUPTION?
Previous abruption (OR: 7.8)
Hypertension/Preeclampsia
FGR
Non vertex presentations
Polyhydramnios
Multiparity
Advanced maternal age
Low BMI
ART
Intrauterine infection
WHAT ARE THE RISK FACTORS FOR PLACENTAL
ABRUPTION? (CONTINUED)
PROM
Abdominal trauma
Smoking
Drug misuse (cocaine, amphetamines)
First trimester bleeding (OR: 1.48)
First trimester intrauterine hematoma (OR: 1.6)
Maternal thrombophilia (FVL , OR: 1.85, Prothrombin gene,
OR: 2.02)
Abnormal maternal serum aneuploidy analytes ( x10 )
IN WOMEN PRESENTING
WITH APH
A multidisciplinary team including
1) midwifery and obstetrics staff
2) immediate access to laboratory
3) blood bank, blood products
4) operating theater
5) neonatal services
6) anesthetic services
SHOULD provide clinical assessment.
INITIAL INTERVENTIONS
 Initiate continuous fetal heart rate monitoring, since the fetus is
at risk of becoming hypoxemic and developing acidosis.
 Secure intravenous access, administer crystalloid, preferably
Lactated Ringer's, to maintain urine output above 30 mL/h.
 Closely monitor the mother's hemodynamic status (PR, BP, urine
output, blood loss).
 Quantify blood loss.
INITIAL INTERVENTIONS (CONTINUED)
 Draw blood for a CBC, BG, crossmatch, coagulation studies,
creatinine , LFT & TT.
 Replace blood and blood products, as required.
 Notify the anesthesia team.
 Administer standard medications to women likely to deliver( Mg
sulfate <32w & Beta)
 Keep the patient warm and provide supplemental oxygen, as
needed.
If bleeding continues and the estimated blood loss has
exceeded 500 to 1000 ml:
transfuse blood .
Initiate a massive transfusion protocol when:
≥4 units of blood are transfused
(sample protocol: 6 units PC, 6 units of FFP, 1 or 2
cryoprecipitate pools , and 1 dose of platelets)
TRANSFUSION GOALS
Maintain hematocrit at 25 to 30 % or greater
Maintain platelet count ≥75,000/microL
Maintain fibrinogen ≥100 mg/dL.
Maintain a PT & PTT< than 1.5 times control
ULTRASOUND SCAN
Should be performed in women presenting with APH.
Is well established in determining placental location & Dx of placenta previa.
The sensitivity of US in diagnosing retro placental clot( abruption) is poor. ( Glantz C
et al 2002)
Sensitivity: 24%
Specificity: 96%
PPV: 86%
NPV: 53%
However if the US suggests an abruption, the likelihood that there is an abruption is
high.
IMAGING
Identification of a retroplacental hematoma is the classic
ultrasound finding of placental abruption.
Retroplacental hematomas have a variable appearance; they can
appear solid, complex, and hypo-, hyper-, or iso-echoic compared
to the placenta.
Hypoechogenicity and sonolucency are features of resolving rather
than acute hematomas .
Whether a hematoma is identified depends on the extent of
hemorrhage, chronicity of the bleeding, and extent that blood has
escaped through the cervix .
HYPOECHOIC RETRO PLACENTAL
IMAGING
Although the worst outcomes appear to occur when
there is sonographic evidence of a retroplacental
hematoma ,
the absence of retroplacental hematoma does not
exclude the possibility of severe abruption because
blood may not collect behind the uterus.
IMAGING
A thorough search for other findings in symptomatic
patients may improve the sensitivity and specificity of
ultrasound. These findings include:
* Subchorionic collections of fluid (even remote from the
placental attachment site)
* Echogenic debris in the amniotic fluid, or
* A thickened placenta, especially if it shimmers with
maternal movement ("Jello" sign)
MARGINAL SEPARATION
CLOT
HYPOECHOIC & COMPLEX RETRO
HYPERECHOIC
HYPOECHOIC RETROPLACENTAL
THICKENED PLACENTA
ANECHOIC
HYPOECHOIC, COMPLEX
MARGINAL SEPARATION
RETROMEMBRANOUS BLEEDING
PREPLACENTAL HEMORRHAGE
THANK YOU