Placental Abruption Could Happen to You

Abruption placenta is the separation of normally located placenta resulting in bleeding occurring after 28 weeks gestation or before the third stage of labour. It is the premature separation of a normally situated placenta occurring after the 28^th week of pregnancy

Simply, abruptio placenta is defined as the cause of bleeding in late pregnancy (after 28 weeks gestation), or prior to onset of third stage of labour due to earlier separation of the placenta abruptio.

Placental abruption is also the cause of antepartum haemorrhage, postpartum haemorrhage, obstetric shock and maternal mortality. The partial separation of the placenta results in bleeding from the maternal venous sinuses in the placental bed.

In this article, I shall consider the causes, types, treatment and prevention of placental abruption. I urge you to exercise patient and read through entire article for better understanding. It is my desire to see that maternal and child morbidity and mortality rate is reduced to its lowest level globally.

What is an abruptio placenta?

Simply, abruptio is a Latin word that means “breaking away from a mass”. Therefore, abruptio placenta is the process of placental detachment from its site or separation of normally situated placenta after 22^nd week of pregnancy.

Signs and symptoms of placental abruption

These are the clinical manifestations:

Vaginal bleeding
Abdominal pain (acute)
Maternal shock fetal death
Fetal sound not heard and fetal part not palpable
Severe vasospasm causes normal or elevated B.P (tend to deceive unsuspecting health worker).

Pathophysiology of abruptio placentae

Initially there is vasospasm followed by relaxation of the vessels, and then vascular engorgement occurs followed by rupture of vessels. This leads to bleeding into decidua basalis. Decidual haematoma is formed, eventually blood escape through the vagina as revealed bleeding or escape into amniotic cavity causing blood stained liquour.

If large volume of blood accumulates under placenta, it will be absorbed into the myometrium causing the uterus to be very tense, rigid and oedematous a condition known as (Couvelaire uterus or uterine apoplexy or uteroplacental apoplexy). It is common with conceal type and causes severe pain and uterine contraction.

With placental separation, utero-placental circulation is impaired resulting in fetal hypoxia and eventually death. Decidual degeneration and necrosis may release thromboplasm into maternal circulation causing Disseminated Intravascular Coagulation (DIC).

How common is abruptio placenta in pregnancy?

Placental abruption occurs in about 10% of all pregnancies and remains the most common cause of prenatal death. It remains an accidental cause of antepartum haemorrhage or the cause of inevitable bleeding in late pregnancy apart from placenta praevia, bleeding from sources such as cervical lesion or cancer of the cervix.

What are key signs of Abruptio placenta?

The diagnosing cues for placenta abruption are the dark vaginal bleeding with abdominal pain, tender/rigid uterus, uterine contraction and back pain.

However, these symptoms can occur without vaginal bleeding especially when the blood is trapped behind the placenta.

What are causes and risk factors of placental abruption?

The actual cause of early separation of placenta prior to labour is not known. However, the predisposing factors of placenta abruptio are:

Short umbilical cord
Multiparity (high parity)
Folic acid deficiency
Pre-eclampsia.
Chronic hypertensive diseases
Artificial rupture of membranes/sudden reduction in uterine size(e.g. when rupturing membrane in polyhydramnios)
Sudden reduction of uterine size after birth of first twin
Pregnancy induced hypertension
Cocaine abuse — which causes vasoconstriction and subsequently abruption.
Direct trauma e.g. road traffic accident, that may partially dislodge the placenta
Previous history of abruption
External cephalic version
Premature rupture of membranes
Uterine abnormalities and abnormal placenta
Hyperemesis gravidarum
Poverty and malnutrition
Previous caesarian section
Cigarette smoking

How is a placental abruption diagnosed?

A thorough history-taking from the patient may reveal incidence of pregnancy induced hypertension or external cephalic version. The patient’s uterus has a hard consistency and there is a guarding on palpation of the abdomen. The fetal parts may be difficult to palpate or not palpated at all and the fetal heart is unlikely to be heard with a fetal stethoscope.

The key diagnosing cues for placenta abruption is the dark vaginal bleeding withabdominal pain, tender/rigid uterus, and back pain. But these symptoms can occur without vaginal bleeding especially when the blood is trapped behind the placenta.

Ultrasound scan performed at this time helps to differentiate placenta praevia from abruptio placenta. However, placenta praevia tends to occur at rest but placenta abruption is often associated with history of trauma or active procedures.

Lab Investigations

FBC
Grouping and cross-matching
Platelets count and clotting time
Ultrasound to assess condition of the uterus and degree of haemorrhage and fetal condition.

Midwife’s Assessment during management of abruptio placentae

Assessment maternal condition

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Ascertain maternal history, probably history of pre-eclampsia, recent history of headaches, nausea, vomiting epigastric pain, visual disturbances.

History of physical domestic violence (woman may not want to reveal).
History of road traffic accident or fall causing trauma to the abdomen.
Midwife always bear in mind that placental abruption may occur following birth of one twin or drainage of copious amniotic fluid.
Proper assessment is need because mild degree may not show bleeding from vagina but mother in severe pain, inquire about the onset.

General Examination

Check for anxiety (woman anxious and worried)
Skin may be pale moist indicating shock
Severe abdominal pain
Check Vital Signs Immediately (Blood Pressure TPR). BP may be low or normal due to previously raised B.P in women with pre-eclampsia
Air hunger respiration, tachycardia, if in shock.
Temperature is usually normal.
Check the blood amount and colour, check amount revealed, bright red indicate freshly loss while dark brown showed retained blood.

Abdominal Examination

In concealed type, uterus appears larger than the gestational age.
Uterus is hard on palpation.
Uterus may be rigid and painful, palpation difficult and is better not to palpate.
Fetal parts not palpable and fetal heart and may not be heard.\
In mild or moderate case abdominal palpation should be reduced to avoid further damage.
Establish nature and area of pain during palpation.

Assessing Fetal Condition

Ascertain if there is fetal movement from the woman.
If heart rate is not heard with pinnard stethoscope, it should not be confirmed that the fetus is death.
Ultra sound can be done to determine if the fetus is alive where it is available.
It is also used to show degree of bleeding and nature of the uterus.

Observations

Fetomaternal conditions are assessed and help to determine mode of management. Maternal vital signs should be taken at frequent intervals depending on the severity.

Monitor urinary output through in dwelling catheter. Urinary output should be 30ml/hr., if she is not making enough urine; it is an indication of renal involvement. Also test the urine for protein which also may indicate pre-eclampsia.
Record fluid given and maintain fluid chart.
Monitor fundal height and abdominal birth at regular intervals, if it increases it indicates further bleeding.
If fetus is alive monitor with cardiotocograph.
Report findings to obstetrician especially if fetomaternal condition deteriorates.

What are differences between abruptio placenta and placenta previa?

S/N	Placental previa	Abruptio placenta
1.	Warning bleeding present	Absent
2.	Usually there is an abnormal lie or malpresentation	Usually normal lie and presentation
3.	Abdomen not likely to be tender	Abdomen is likely to be tender
4.	No associated abdominal pain	There is associated abdominal pain
5.	Blood is usually bright red	Blood may be dark or bright red
6.	Mother is usually compromised	Fetus is usually compromised
7.	Uterus is soft on palpation	Uterus is woody-hard on palpation
8.	No particular association with pre-eclampsia	May be associated with pre-eclampsia
9.	No coagulation defect initially	coagulation defect occurs early
10.	Presenting part is high(unengaged)	Presenting part may be high or engaged

What are activities contraindicated during placenta abruption?

Activities contraindicated for women with placental detachment before labour (placenta abruption) are:

Sexual intercourse
Physical activeness and/or antenatal exercises
Artificial rupturing of membranes

What are types of placenta abruption?

Specifically, there are three types of abruptio placenta:

Revealed placental abruption
Concealed placental abruption
Mixed placenta abruptio

Revealed placental abruption

This accounts for about 48% of all cases of abruption placenta and occurs when there is bleeding from the genital tract which may be mild or severe. In Revealed abruption, there isblood flow to the external and no blood is accumulated behind the placenta.Patient often experience mild abdominal pain with some degree of tenderness as well as presence of fetal distress depending on the degree of separation.

Revealed haemorrhage treatment

Management of bleeding in revealed abruptio placenta depends on:

Degree of placental separation
Maternal and fetal conditions
Severity of bleeding
Gestational age of the pregnancy

Specific care for revealed abruptio placenta is:

If bleeding is mild or light, the patient has chances of carrying the baby to term and vaginal birth.
When the bleeding is severe with the fetus being alive, an emergency cesarean section is to be carried out.
When the bleeding is moderate with a dead fetus while the patient is in labour, then vaginal birth can be attempted.
If the bleeding is moderate with a dead fetus while the patient is not in labour, then induction of labour with oxytocin infusion and vaginal birth can be attempted.
In case of severe bleeding, cesarean section is to be performed even if the fetus is dead in order to save the mother and whole blood should be made readily available for transfusion.
A cesarean section can be done to save the fetus but it should not be done in the presence of severe shock.

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What is Concealed placental abruption?

Concealed placental abruption accounts for about 27% of all cases of abruption placenta. Here, there is bleeding in-utero from the separation of the placenta and blood clots tend to accumulate in the uterus.

That’s, concealed placental abruption is a type of abruption where blood is retained behind the placenta. This makes the uterus to be greater than gestational age and appears more globular. The patient tends to present with all the signs and symptoms of hypovolemic shock, uterine enlargement and extreme pain as well as the uterus appearing bruised and oedematous.

What are the Signs and symptoms of Concealed placental abruption?

Concealed placental abruption has these signs which help the midwife in diagnosis:

Painful uterine distention — due to concealed bleeding
Shock related to concealed bleeding
Hypotension
Rapid pulse may or may not be present due to pain or amount of blood loss
The uterus tends to greater than gestational age and appears more globular
Maternal abdomen is tender to touch and rigid
Abdominal palpation is painful and cannot be done
Fetal heart rate may be hard to hear
Patient look very ill or fatigued
While in labour, abdominal pain and rigidity related to abruption placenta tends to exacerbate the labour pain. This pain exacerbates shock and must be alleviated

How to treat concealed bleeding

All the cases of concealed abruption are severe and patients tend to be in shock due to blood loss and painful distension of the uterus.

Thus, treatment is focused on managing shock. Strong analgesia such as injection morphine 15mg is administered to the patient and blood transfusion is done too. Where blood is not readily available, blood substitutes like Haemacell or Dextran are given to the woman.

Abdominal girth of the uterus and the fundal height as well as fetal heart rate are monitored regularly and recorded per palpation as it increases. And once the woman’s condition improves, the cesarean delivery is done immediately.

Note: Mothers with above 37^th week of pregnancy can receive amniotomy to induce labour but there is further bleeding or evidence of fetal distress, caesarean section is highly necessary.

Mixed abruptio placenta

About 24% of abruptio placenta are mixed abruption placenta — combination of revealed and concealed haemorrhage. It is a situation where some of the blood drains via the vagina and some is retained behind the placenta, a condition known as a mixed haemorrhage

What are the signs and symptoms of mixed abruption placenta?

Signs and symptoms of mixed abruption placenta are the same for concealed bleeding but there is a bit of blood loss which seems not to correspond with the general condition of the patient.

Mixed abruption placenta is managed by adapting both treatment principles for concealed abruption placenta and revealed placental abruption.

What is other classification of placenta abruption?

Alternatively, it can be into three again depending on severity or degree of placental separation or abruption. Thus, the midwife should not depend on blood loss to determine the severity of placenta abruption. These include:

Grade 1/Mild placental separation:

In this condition, the placental separation and bleeding are slight with the condition of both mother and fetus being stable. The uterine is soft and non-tender; diagnosis of placenta abruption is made later. Unless ultrasound scan is done, there may be difficulty in distinguishing this from placenta praevia and other incidental causes of vaginal bleeding. If the woman is not in labour and has gestational age less than 37 weeks, she is to be managed conservatively for a few days with bed rest and antenatal corticosteroids in order to facilitate fetal lungs maturation. But where the gestational age is beyond 37 weeks, induction of labour can be carried out.

Grade 2/Moderate placental separation:

Aboutone-fourth of the placenta gets separated and up to 100ml of blood escaped through vagina while some retained behind the placenta — forming retroplacental clot or extra-vacation into the myometrium (uterine muscle). There is uterine tenderness and abdomen tensed on palpation but the fetus is alive.

Grade 3/ Severe separation:

It is an obstetric emergency which occurs when two-thirds of the placenta has been detached and there is blood loss of about 200ml or more. The woman with this case tends to suffer severe shock and may experience coagulation defects, renal failure or pituitary necrosis.

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Severe abruption is subdivided into:

Grade 3^A: Not associated with bleeding i.e. concealed.
Grade 3^B: Associated with bleeding (mixed).

Management of placenta abruptio due to Severity (Grade)

Grade I: Expectant management is applied if there is mild separation, slight haemorrhage and fetal condition. Uterine consistency is normal (no tenderness or rigidity). This type is differentiated from placenta previa through ultrasound.

Mountainous monitoring of fetal condition is necessary with CTG once or twice daily.
Continue conservative Rx if there is no further bleeding and feto-maternal condition does not worsen till fetal maturity< 37 weeks.
Deliver the baby through induction of labour

Grade II Placenta abruptio: Previously caesarian section is carried out, but with advent of electronic fetal monitoring, CTG fetal monitoring.

Induction with oxytocin drip and amniotomy to stimulate good uterine contraction. There is good perinatal outcome with this. The immediate aim in this condition is to reduce shock and replace blood loss.

Grade III PLACENTA ABRUPTIO (SEVERE): It is a dare obstetric emergency and life threatening (2/3^rd of the placenta detached). In most cases the fetus is dead and the mother in shock with severe pain. C/S is not the first option. Control shock; transfuse the woman, if fetus is death induction of labour is initiated with oxytocin infusion and amniotomy. Caesarian section is not first option because of risk of haemorrhage (DIC). It is only carried out if induction fails or vaginal delivery is contradicted.

Whole blood is transfused immediately and amount to be transfused calculated based on the lost.
Pain relief is given

General management of abruptio placentae

Once diagnosis of placenta abruptio is established or it is suspected, urgent medical attention is needed.
She should be transferred to emergency obstetric unit or a consultant obstetrician be invited.
Admit the woman in labour ward.
The midwife should support the woman and her Partner by give adequate information, attending to their physical and emotional needs.
Alleviate pain with injection Pethidine, 100 – 150mg Pentazocine 30mg or Morphine 15mg.
The midwife should assess nature of pain.
Acute severe pain is associated with conceal type as a result of Couvelaire uterus. Try to differentiate it from labour pain and also try to rule out subcapsular haemorrhage if their woman has pre-eclampsia.
Start IV fluid with plasma expander e.g. IV Ringer’s lactate and arrange for immediate blood transfusion
Position the woman on her side to prevent supine hypotension due to comprehension of gravid uterus on inferior vena cava and aortic compression.
If shock is severe, put her in a semi-recumbent position and on no account should the foot of the bed be elevated.
Insert in dwelling catheter to use it monitor urine output.

Care of the baby delivered by mother with placental abruption

Asphyxiated baby is anticipated, therefore inform paediatrician to be present at birth for resuscitation of the baby.
Neonatal intensive care unit should be informed and get ready to receive the baby.
When baby is born, the couple should be allowed to see the baby, probably take photograph of the baby which the mother can see if she recovers.
The baby’s condition may be complicated with preterm effect of hypoxia from pre-eclampsia and insult of haemorrhage. May have prolonged stay at neonatal intensive care unit.
If baby is stable at birth, he or she should be monitored and allow with the mother.
The mother should be allowed to see and participate in care of the baby when she is more stable and condition of the baby allowed that.
Give the woman and her partner full information about her condition and decision for treatment.
The woman and her partner are support physically and psychologically. The father should always be allowed to visit NBSCU.

Complications of abruptio placenta

Coagulations defects/Disseminated intravascular coagulation (DIC) — this complication is associated with moderate to severe abruptio placenta.
Postpartum haemorrhage due to couvelaire uterus and disseminated intravascular coagulation or both
Renal failure which may be caused by hypovolaemia and poor perfusion of the kidneys
Sheehan syndrome (pituitary necrosis due to prolonged and severe hypovolaemia)
Intrauterine death (IUD) —the death of the foetus in-utero.
Cardiac failure
Increased neurologic defects in babies related to asphyxiation or low Apgar score at birth
Maternal death

Prevention of placenta abruptio

There are no specific ways you can prevent placental abruption. However, embracing healthy lifestyles such as quitting smoking, alcoholics and use of illegal drugs like cocaine; following therapeutic regimen prescribed by your healthcare provider in managing and monitoring high blood pressure; and avoids risk behaviours while on transit by wearing your seatbelt when in a motor vehicle always.

Other helpful in lowering the incidence of placenta abruption may include limitation of activity, bed rest, and/or avoiding sexual intercourse.

The prophylactic use of aspirin reduces the risk of preeclampsia and small-for-gestational-age neonates. A study conducted in 2018 to explore the effect of aspirin use for prevention of preeclampsia on placental abruption and antepartum hemorrhage has found that there is significant reduction in the risk of preeclampsia and small-for-gestational-age neonates following daily intake of Aspirin ≥100 mg from ≤16 weeks of gestation. Invariably, reduction in incidence of preeclampsia would lower the risk of placental abruption and antepartum hemorrhage.

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