Description
Placental abruption is a serious medical emergency where the placenta detaches from the uterine wall before delivery, potentially depriving the fetus of oxygen and nutrients. Prompt recognition of placental abruption is crucial for effective emergency management. The main presenting symptom of placental abruption is vaginal bleeding, which may be accompanied by abdominal pain and uterine tenderness. If placental abruption is suspected, immediate medical assistance should be sought. Emergency medical personnel should be informed about the suspected placental abruption and the need for urgent care. The pregnant woman should be transported to a healthcare facility capable of providing appropriate obstetric care and neonatal support. During transportation, the woman should be positioned on her left side to improve blood flow to the fetus. Emergency cesarean section may be required in cases of severe abruption, fetal distress, or maternal instability.
Résumé
- Abruptio placentae is defined as the premature separation of a normally implanted placenta from the uterine wall after 20 weeks of gestation until delivery. It complicates 0.5 to 1.5% of pregnancies and can lead to fetal death in approximately 1 in 500 births. Around one-third of antepartum hemorrhages are due to abruptio placentae, also known as accidental hemorrhage.
- Common predisposing factors include maternal hypertension, previous placental abruption, trauma, polyhydramnios, short umbilical cord, maternal tobacco use, folate deficiency, advanced maternal age, and uterine abnormalities. Hypertension is the most common risk factor, with a 10% recurrence rate after one previous abruption and a 25% rate after two.
- There are three types of abruptio placentae: revealed (bleeding per vaginum), concealed (no bleeding per vaginum), and mixed. Diagnosis often relies on clinical findings like uterine tenderness, signs of hypovolemic shock, and retroplacental clots seen on ultrasound. There are four grades of placental abruption ranging from asymptomatic to fetal death and maternal compromise.
- The pathophysiology involves hemorrhage into the decidua basalis, leading to separation and compression of placental tissue. Blood may dissect upwards, causing concealed hemorrhage, or trickle down, resulting in revealed hemorrhage. This disruption reduces metabolic exchange, leading to fetal hypoxia.
- Concealed hemorrhage can lead to a Couvelaire uterus, where blood effuses into the myometrium, hindering contraction and increasing the risk of postpartum hemorrhage. Diagnosis is clinical, based on painful vaginal bleeding, uterine tenderness, and fetal distress. Ultrasonography detects only 20% of cases.
- Management depends on gestational age and maternal stability. Stable patients at term may attempt vaginal delivery, while unstable patients require aggressive resuscitation and potential cesarean section. Preterm gestations require serial monitoring and steroid administration for fetal lung maturity. Tocolysis is generally contraindicated.
- Disseminated intravascular coagulation (DIC) is a severe complication involving thromboplastic material entering maternal circulation, leading to consumption coagulopathy. Management includes massive transfusion protocol with specific targets for fibrinogen, hematocrit, and platelets. Potential complications include maternal mortality, fetal death, hypoxic injury, and IUGR.
- Prevention strategies include counseling patients to avoid tobacco, cocaine, and smoking, as well as emphasizing early reporting of suspicious symptoms. Better surveillance and control of hypertension are crucial for those with hypertensive disorders.
Exemple de certificat
À propos des intervenants
Dr Isha Rani
Consultant Obstetrics and Gynecology, Laparoscopic surgeon· Asarfi Hospital, Jharkand
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