Abruptio Placentae

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Abruptio Placentae, also known as placental abruption, refers to the premature separation of a normally implanted placenta from the uterine wall before the delivery of the fetus. This condition can lead to significant maternal and fetal morbidity and mortality.

Aetiology

Abruptio placentae can result from various factors, including:

• Hypertension: Chronic hypertension or preeclampsia increases the risk of placental abruption.
• Trauma: Abdominal trauma, such as from a motor vehicle accident or domestic violence, can cause placental separation.
• Sudden Uterine Decompression: Rapid loss of amniotic fluid (e.g., following rupture of membranes) may precipitate placental abruption.
• Substance Abuse: Cocaine use is strongly associated with an increased risk of placental abruption.
• Multiparity: Women with multiple previous pregnancies are at higher risk.
• Previous Placental Abruption: A history of placental abruption significantly increases the risk of recurrence in subsequent pregnancies.

Pathophysiology

Abruptio placentae occurs when the placenta separates from the uterine wall, leading to bleeding between the placenta and the uterine lining. This separation can compromise the exchange of oxygen and nutrients between the mother and fetus, potentially leading to fetal hypoxia and death. The degree of separation, location of the abruption, and amount of bleeding determine the severity of the condition.

Risk Factors

• Hypertension or preeclampsia.
• Abdominal trauma.
• Sudden uterine decompression (e.g., rapid loss of amniotic fluid).
• Substance abuse, particularly cocaine.
• Advanced maternal age.
• Multiparity.
• Previous history of placental abruption.
• Smoking during pregnancy.

Signs and Symptoms

• Sudden onset of severe abdominal pain.
• Vaginal bleeding, which may be minimal or absent if the bleeding is concealed.
• Uterine tenderness and contractions.
• Fetal distress, which may manifest as abnormal fetal heart rate patterns.
• Maternal hypotension and signs of shock, particularly in severe cases.

Investigations

• Clinical Assessment: Immediate assessment of maternal and fetal status, including monitoring of vital signs and fetal heart rate.
• Ultrasound: Used to assess placental location and the presence of retroplacental haematoma, although it may not always detect placental abruption.
• Full Blood Count (FBC): To evaluate for anaemia and assess platelet levels.
• Coagulation Profile: To check for coagulopathy, particularly in cases with significant bleeding.
• Kleihauer-Betke Test: May be used to detect fetal cells in the maternal circulation, indicating fetal-maternal haemorrhage.

Management

• Rapid ABCDE Assessment and Resuscitation: Immediate assessment and resuscitation are crucial, with maternal resuscitation prioritised over determining fetal viability.
• Definitive Management: Management depends on gestation and the presence of fetal distress:
  • Fetal Distress: Emergency caesarean section is indicated.
  • No Fetal Distress < 36 Weeks: Close observation, administration of steroids, no tocolysis, and gestational age guides delivery timing.
  • No Fetal Distress > 36 Weeks: Vaginal delivery is typically recommended.
  • In-Utero Fetal Death: Induced vaginal delivery or caesarean section may be required depending on maternal condition.
• Anti-D Immunoglobulin: Administer within 72 hours of the onset of bleeding if the woman is rhesus D negative.
• Maternal Stabilisation: Administer intravenous fluids to manage shock, and monitor maternal vital signs and fetal heart rate continuously. Blood transfusion may be required in cases of significant haemorrhage.
• Fetal Monitoring: Continuous electronic fetal monitoring is essential to assess fetal well-being.
• Delivery: If the fetus is at term or if there is significant maternal or fetal distress, prompt delivery is indicated. This may involve an emergency caesarean section, particularly if there is fetal distress or if vaginal delivery is not imminent.
• Expectant Management: In cases where the abruption is minor, the fetus is preterm, and both mother and fetus are stable, expectant management may be considered with close monitoring in a hospital setting.
• Management of Coagulopathy: In severe cases with coagulopathy, fresh frozen plasma or platelets may be required.
• Postpartum Care: Monitor the mother closely for postpartum haemorrhage, which can occur after delivery in cases of placental abruption.

References

1. NHS (2024) Placental Abruption. Available at: https://www.nhs.uk/conditions/placental-abruption/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Management of Antepartum Haemorrhage. Available at: https://cks.nice.org.uk/topics/antepartum-haemorrhage/ (Accessed: 24 June 2024).
3. British Medical Journal (2024) Diagnosis and Management of Placental Abruption. Available at: https://www.bmj.com/content/350/bmj.h491 (Accessed: 24 June 2024).
4. Royal College of Obstetricians and Gynaecologists (2024) Green-top Guideline No. 63: Antepartum Haemorrhage. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg63/ (Accessed: 24 June 2024).

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