Placental abruption

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Placental abruption (also known as abruptio placentae) is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother. It is the most common pathological 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 pregnancies worldwide. Placental abruption is a significant contributor to maternal mortality worldwide; early and skilled medical intervention is needed to ensure a good outcome, and this is not available in many parts of the world. Treatment depends on how serious the abruption is and how far along the woman is in her pregnancy.[1]

Placental abruption has effects on both mother and fetus. The effects on the mother depend primarily on the severity of the abruption, while the effects on the fetus depend on both its severity and the gestational age at which it occurs.[2] The heart rate of the fetus can be associated with the severity.[3

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)
uterus may be disproportionately enlarged
pallor

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HideClinical Manifestation

Class 0: asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.
Class 1: mild and represents approximately 48% of all cases. Characteristics include the following:
No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress
Class 2: moderate and represents approximately 27% of all cases. Characteristics include the following:
No vaginal bleeding to moderate vaginal bleeding
Moderate-to-severe uterine tenderness with possible tetanic contractions
Maternal tachycardia with orthostatic changes in BP and heart rate
Fetal distress
Hypofibrinogenemia (i.e., 50–250 mg/dL)
Class 3: severe and represents approximately 24% of all cases. Characteristics include the following:
No vaginal bleeding to heavy vaginal bleeding
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (i.e., <150 mg/dL)
Coagulopathy
Fetal death

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factors

Pre-eclampsia [2]
Maternal smoking is associated with up to 90% increased risk.[4]
See also: Smoking and pregnancy
Maternal trauma, such as motor vehicle accidents, assaults, falls or nosocomial infection.
Short umbilical cord
Prolonged rupture of membranes (>24 hours)
Thrombophilia [2]
Retroplacental fibromyoma
Multiparity [2]
Multiple pregnancy[2]
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.
Previous Caesarean section[2]
some infections are also diagnosed as a cause
★Prevention

Although the risk of placental abruption cannot be eliminated, it can be reduced. Avoiding tobacco, alcohol and cocaine during pregnancy decreases the risk. Staying away from activities which have a high risk of physical trauma is also important. Women who have high blood pressure or who have had a previous placental abruption and want to conceive must be closely supervised by a doctor.[6]

The risk of placental abruption can be reduced by maintaining a good diet including taking folic acid, regular sleep patterns and correction of pregnancy-induced hypertension.

It is crucial for women to be made aware of the signs of placental abruption, such as vaginal bleeding, and that if they experience such symptoms they must get into contact with their health care provider/the hospital without any delay
*Intervention

Placental abruption is suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The fundus may be monitored because a rising fundus can indicate bleeding. An ultrasound may be used to rule out placenta praevia 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 is 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 is in distress. Blood volume replacement to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over caesarean section 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.
**Prognosis•=•

The prognosis of this complication depends on whether treatment is received by the patient, on the quality of treatment, and on the severity of the abruption.

In the Western world, maternal deaths due to placental abruption are rare; for instance a study done in Finland found that, between 1972 and 2005 placental abruption had a maternal mortality rate of 0.4 per 1,000 cases (which means that 1 in 2,500 women who had placental abruption died); this was similar to other Western countries during that period.[7] The prognosis on the fetus is worse, currently, in the UK, about 15% of fetuses die following this event.[2]

Without any form of medical intervention, as often happens in many parts of the world, placental abruption has a high maternal mortality rate.