Abruptio Placentae: (Accidental Hemorrhage, Premature Separation of Placenta)

ABRUPTIO PLACENTAE
(Accidental Hemorrhage,
Premature Separation of Placenta)
JASKARAN SINGH
Definition
It is one form of antepartum hemorrhage where the bleeding occurs due to
premature separation of normally situated placenta.
Varieties of abruptio placenta:
Revealed:
❏ This the most common type.
❏ Following separation of the placenta, The blood insinuates downwards
between the membranes and the decidua. Ultimately, the blood comes out
of the cervical canal to be visible externally.
Concealed:
❏ This is Rare type.

❏ The blood gets collected behind the separated placenta or in between the
membranes and the decidua.
❏ The collected blood is prevented from coming out of the cervix by the
presenting part which presses on the lower segment. At times, the blood
may percolate into the amniotic sac after rupturing the membranes. In any
of the circumstances blood is not visible outside.
Significance:
Cause of perinatal mortality (15 - 20%) and maternal mortality (2 - 5%).
The overall incidence is:

About 1 in 100 deliveries.
Mixed:
❏ Quite common.
❏ Some part of the blood collects inside and a part is expelled out.
❏ Usually, one variety predominates over the other.
Pathogenesis:
Depending upon the etiological factors, premature placental separation is

initiated by hemorrhage into the decidua basalis - the collected blood at the early
phase, hardly produces any morbid pathological changes in the uterine wall or
the placenta. However, depending upon the severity lead to degeneration,
infarction and necrosis of the decidua basalis as well as the placenta adjacent to
it.
Rupture of the basal plate may also occur, thus communicating the hematoma
with the intervillous space. The decidual hematoma may be small and self
limited; the entity is evident only after the expulsion of the placenta
(retroplacental hematoma). It has to be remembered that absence of rhythmic
Pathogenesis cont.
Uterine contractions plays a significant role for the blood to remain
concealed. The features of retroplacental hematoma are: (a.) Depression
found on the maternal surface of the placenta with a clot which may be
found firmly attached to the area. (b.) Areas of infarction with varying
degrees of organization.
When a major spiral artery ruptures, a big hematoma is formed. Thrombin
generated following decidual hemorrhage, triggers the action of matrix
metalloproteinases, inflammatory cytokines and the coagulation cascade.
The absence of rhythmic uterine contractions plays a significant role for
the blood to remain concealed.
Couvelaire uterus (uteroplacental apoplexy)
A pathological entity first described by Couvelaire and is met with in association

with severe form of concealed abruptio placentae. There is massive
intravasation of blood into the uterine musculature upto the serous coat. The
condition can only be diagnosed on laparotomy.
Etiology of Placental Abruption
❏ General factors: (a.) High birth order (b.) Advanced age (c.) Smoking
❏ Hypertension in pregnancy is most important. pre - eclampsia , gestational
hypertension and essential hypertension all are associated (10 - 50%).
❏ Trauma : (a.)The trauma may be external cephalic version, especially under
anesthesia using great force.
(b.)Road traffic accidents, blunt trauma or blow on the abdomen
(c.)Needle puncture at amniocentesis.

❏ Sudden uterine decompression
Clinical situations are:
Following delivery of the first baby of twins.
Sudden escape of liquor amnii in polyhydramnios
Premature rupture of membranes (PROM)
❏ Short cord
❏ Supine hypotension syndrome
❏ Placental anomaly
❏ Sick placenta
❏ Folic acid deficiency
❏ Uterine factor
❏ Torsion of the uterus
❏ Cocaine abuse
❏ Thrombophilias
❏ Hyperhomocysteinemia
❏ Prior abruption
Clinical classification:
Grade 0:
❏ Clinical features may be absent.
❏ The diagnosis is made after inspection of placenta following delivery.
Grade 1 (40%)
❏ Slight vaginal bleeding

❏ Uterus: irritable, tenderness may be minimal or absent.
❏ Maternal BP and fibrinogen levels unaffected
❏ FHS is good.
Grade 2 (45%)
❏ Vaginal bleeding mild to moderate.

❏ Uterine tenderness is always present.
❏ Maternal pulse↑, BP is maintained.
❏ Fibrinogen level may be decreased.
❏ Shock is absent.
❏ Fetal distress or even fetal death occurs.
Grade 3 (15%)
❏ Bleeding is moderate to severe or may be concealed.

❏ Uterine tenderness is marked.
❏ Shock is pronounced.
❏ Fetal death is the rule.
❏ Associated coagulation defect or anuria may complicate.
Clinical features of revealed and mixed
variety of Abruptio placenta
Parametres Revealed Mixed (concealed features
predominate)
SYMPTOMS Abdominal discomfort or Abdominal acute intenses

pain followed by vaginal pain followed by slight
bleeding (slight). vaginal bleeding. The pain
becomes continuous.
CHARACTER OF Continuous dark color Continuous, dark color

BLEEDING (slight to moderate). (usually slight) or blood-
stained serous discharge.
GENERAL CONDITION Proportionate to the visible Shock may be pronounced

blood loss, shock is usually which is out of proportion to
absent. the visible blood loss.
PALLOR Related with the visible Pallor is usually severe and

blood loss. out of proportion to the
visible bleeding.
FEATURES OF PRE- May be absent. Frequent association.
ECLAMPSIA
UTERINE HEIGHT Proportionate to the period May be disproportionately

of gestation. enlarged and globular.
UTERINE FEEL Normal feel with localized Uterus is tense, tender and
tenderness, contractions rigid.
frequent and local
amplitude.
FETAL PARTS Can be identified easily. Difficult to make out.
FHS Usually present FHR - Usually absent (fetus dead).

irregular (hypoxia)
URINE OUTPUT Normal Usually diminished.

LABORATORY TESTS:
BLOOD: hb% Low value proportionate to Markedly lower, out of

the blood test. proportion to the visible
blood loss.
COAGULATION PROFILE Usually unchanged. Variable changes

(consumptive
coagulopathy):
Clotting time increased (>6
min)
Fibrinogen level- low (<150
mg/dL)
Platelet count - low
↑ Partial thromboplastin
time
↑ FDP and D- dimer
URINE FOR PROTEIN May be absent Usually present.
CONFUSION IN With placenta previa. As With acute obstetrical-

DIAGNOSIS such vaginal examination is gynecological- surgical
withheld unless certain in complications.
the diagnosis.
Diagnosis:
Ultrasonography or MRI may be helpful.
ULTRASONOGRAPHY:
Early hemorrhage is hyperechoic or isoechoic. Acute hemorrhage is often

confused with fibroid or a thick placenta.
DIFFERENTIAL DIAGNOSIS:
(a.) Revealed type: There may be occasional diagnostic difficulty with placenta
previa.
(b.) Mixed or Concealed type:
The esential points to arrive at the diagnosos of the concealed type are:
(1.) Shock out or proportion to extend bleeding.
(2.) unexplained extreme pallore.
(3.) presence of pre- eclamptic features.

(c.) Prognosis:
Prognosis of mother and the baby depends upon the clinical type, degree of
placental separation, the interval between the separation of placenta and the
delivery of the baby and the efficacy of treatment.
Bleeding in perinatal abruption is always maternal. Fetal bleeding is observed

only with traumatic variety of placental abruption. Chronic abruption often
presents with chronic inflammation and dysfunction.
Maternal morbidity is high. Maternal mortality varies from 2 - 8%. Some cases
who manage to survive may develop features of ischemic pituitary necrosis.
There is failure of lactation (Sheehan’s syndrome) later on.
Complications:
Maternal type:
Revealed type: Maternal risk is proportionate to the visible blood loss and
maternal death is rare.
Concealed type: (1.) Hemorrhage (2.) Shock (3.) Blood coagulation

disorders
(4.) Oliguria and anuria (5.) Postpartum Hemorrhage (6.) Puerperal sepsis.
Fetal types:
Revealed type: The fetal death is to extent of 25- 30%.
Concealed type: Fetal death is appreciably high ranging from 50 - 100%. The
deaths are due to prematurity and anoxia due to placental separation.
Risk of recurrence in subsequent pregnancy is about 5 -20% with high perinatal

mortality.
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ABRUPTIO PLACENTAE

❏ This is Rare type.

Cause of perinatal mortality (15 - 20%) and maternal mortality (2 - 5%).

The overall incidence is:

Depending upon the etiological factors, premature placental separation is

A pathological entity ﬁrst described by Couvelaire and is met with in association

(b.)Road traﬃc accidents, blunt trauma or blow on the abdomen

(c.)Needle puncture at amniocentesis.

Clinical situations are:

Following delivery of the ﬁrst baby of twins.

Sudden escape of liquor amnii in polyhydramnios

Premature rupture of membranes (PROM)

❏ Slight vaginal bleeding

❏ Vaginal bleeding mild to moderate.

❏ Bleeding is moderate to severe or may be concealed.

SYMPTOMS Abdominal discomfort or Abdominal acute intenses

CHARACTER OF Continuous dark color Continuous, dark color

GENERAL CONDITION Proportionate to the visible Shock may be pronounced

PALLOR Related with the visible Pallor is usually severe and

UTERINE HEIGHT Proportionate to the period May be disproportionately

FETAL PARTS Can be identified easily. Difficult to make out.

FHS Usually present FHR - Usually absent (fetus dead).

URINE OUTPUT Normal Usually diminished.

BLOOD: hb% Low value proportionate to Markedly lower, out of

COAGULATION PROFILE Usually unchanged. Variable changes

URINE FOR PROTEIN May be absent Usually present.

CONFUSION IN With placenta previa. As With acute obstetrical-

Ultrasonography or MRI may be helpful.

Early hemorrhage is hyperechoic or isoechoic. Acute hemorrhage is often

(1.) Shock out or proportion to extend bleeding.

(2.) unexplained extreme pallore.

(3.) presence of pre- eclamptic features.

Bleeding in perinatal abruption is always maternal. Fetal bleeding is observed

Concealed type: (1.) Hemorrhage (2.) Shock (3.) Blood coagulation

Revealed type: The fetal death is to extent of 25- 30%.

Risk of recurrence in subsequent pregnancy is about 5 -20% with high perinatal

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