Placental abruption

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 world wide with a fetal mortality rate of 20–40% depending on
the degree of separation. Placental abruption is also a significant contributor to maternal mortality.

The heart rate of the fetus can be associated with the severity.

Lasting effects
On the mother:

• A large loss of blood or hemorrhage may require blood transfusions and intensive care after
delivery. 'APH weakens, for PPH to kill'.
• The uterus may not contract properly after delivery so the mother may need medication to help her
uterus contract.
• The mother may have problems with blood clotting for a few days.
• If the mother's blood does not clot (particularly during a caesarean section) and too many
transfusions could put the mother into disseminated intravascular coagulation (DIC) due to
increased thromboplastin, the doctor may consider a hysterectomy.
• A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland.
Diffuse cortical necrosis in the kidney is a serious and often fatal complication.
• In some cases where the abruption is high up in the uterus, or is slight, there is no bleeding, though
extreme pain is felt and reported.

On the baby:

• If a large amount of the placenta separates from the uterus, the baby will probably be in distress
until delivery and may die in utero, thus resulting in a stillbirth.
• The baby may be premature and need to be placed in the newborn intensive care unit. He or she
might have problems with breathing and feeding.
• If the baby is in distress in the uterus, he or she may have a low level of oxygen in the blood after
birth.
• The newborn may have low blood pressure or a low blood count.
• If the separation is severe enough, the baby could suffer brain damage or die before or shortly after
birth.

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

Clinical 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:
o No vaginal bleeding to mild vaginal bleeding
o Slightly tender uterus
 o Normal maternal BP and heart rate
o No coagulopathy
o No fetal distress
• Class 2: moderate and represents approximately 27% of all cases. Characteristics include the
following:
o No vaginal bleeding to moderate vaginal bleeding
o Moderate-to-severe uterine tenderness with possible tetanic contractions
o Maternal tachycardia with orthostatic changes in BP and heart rate
o Fetal distress
o Hypofibrinogenemia (ie, 50-250 mg/dL)
• Class 3: severe and represents approximately 24% of all cases. Characteristics include the
following:
o No vaginal bleeding to heavy vaginal bleeding
o Very painful tetanic uterus
o Maternal shock
o Hypofibrinogenemia (ie, <150 mg/dL)
o Coagulopathy
o Fetal death

Pathophysiology
Trauma, hypertension, or coagulopathy contributes to the avulsion of the anchoring placental villi from the
expanding lower uterine segment, which in turn, leads to bleeding into the decidua basalis. This can push
the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt
or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta,
known as concealed or internal placental abruption.

Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions,
fetal distress or death.

Abruptions are classified according to severity in the following manner:

• Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta.
• Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there
is no distress of mother or fetus.
• Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can
be found with fetal heart rate monitoring.
• Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There
may be maternal disseminated intravascular coagulation. Blood may force its way through the
uterine wall into the serosa, a condition known as Couvelaire uterus.

Risk factors
• Maternal hypertension is a factor in 44% of all abruptions.
• Maternal trauma, such as motor vehicle accidents, assaults, falls or nosocomial infection.
• Short umbilical cord
• Prolonged rupture of membranes (>24 hours)
• Retroplacental fibromyoma
• 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.
• some infections are also diagnosed as a cause
• cocaine intoxication [2]

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.
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 are 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 are in
distress. Blood volume replacement and 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.
Polyhydramnios

Polyhydramnios (polyhydramnion, hydramnios) is a medical condition describing an excess of amniotic fluid in the amniotic
sac. It is seen in 0.2 to 1.6% of pregnancies. It is typically diagnosed when the amniotic fluid index (AFI) is greater than 20 cm
( ≥ 20 cm) .The opposite to polyhydramnios is oligohydramnios, a deficiency in amniotic fluid.

Causes

A single case of polyhydramnios may have one or more causes. About 14% of cases are due to maternal diabetes
mellitus, which causes fetal hyperglycemia and resulting polyuria (fetal urine is a major source of amniotic fluid)and
also rh-isoimmunisation can cause it. About another 20% of cases are associated with fetal anomalies that impair the ability of
the fetus to swallow (the fetus normally swallows the amniotic fluid). These anomalies include:

• gastrointestinalabnormalities such as esophageal atresia, duodenal atresia, facial cleft, neck masses,
and tracheoesophageal fistula

• fetal renal disorders that results in increased urine production during pregnancy, such as in
antenatal Bartter syndrome[6]. Molecular diagnosis is available for these conditions [7].
• chromosomal abnormalities such as Down's syndrome and Edwards syndrome (which is itself often
associated with GI abnormalities)
• neurological abnormalities such as anencephaly, which impair the swallowing reflex

In a multiple gestation pregnancy, the cause of polyhydramnios usually is twin-twin transfusion syndrome.
It can also be caused by some systemic medical conditions in the mother, including cardiac or kidney
problems. it can also be caused by intrauterine infection(torsh) Additionally, chorioangioma of the placenta
can also cause this condition. However, it should be reported that in 60-65% of cases it is unknown why
polyhydramnios happens.

Diagnosis

There are several pathologic conditions that can predispose a pregnancy to polyhydramnios. These include
a maternal history of diabetes mellitus, Rh incompatibility between the fetus and mother, intrauterine
infection, and multiple pregnancies. During the pregnancy, certain clinical signs may suggest
polyhydramnios. In the mother, the physician may observe increased abdominal size out of proportion for
her weight gain and gestation age, uterine size that outpaces gestational age, shiny skin with stria (seen
mostly in severe polyhydramnios), dyspnea, and chest heaviness. When examining the fetus, faint fetal
heart sounds are also an important clinical sign of this condition.

Associated conditions

Fetuses with polyhydramnios are at risk for a number of other problems including cord prolapse, placental
abruption premature birth and perinatal death. At delivery the baby should be checked for congenital
abnormalities. Another cause of polyhydramnios is skeletal dysplasia, or dwarfism, in the baby. There is a
possibility of the chest cavity not being large enough to house all of the baby's organs causing the trachea
and esophagus to be restricted, not allowing the baby to swallow the appropriate amount of amniotic fluid.

Treatment

• In some cases, amnioreduction, also known as therapeutic Amniocentesis, has been used in response
to polyhydramnios.[8]
• Dietary salt restriction is recommended