Placental_Abruption_Flashcards
What is placental abruption?
Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space.
What is the epidemiology of placental abruption?
Occurs in approximately 1/200 pregnancies.
What are the associated factors for placental abruption?
Proteinuric hypertension, cocaine use, multiparity, maternal trauma, increasing maternal age.
What are the clinical features of placental abruption?
Shock out of keeping with visible loss, constant pain, tender and tense uterus, normal lie and presentation, fetal heart: absent/distressed, coagulation problems, beware pre-eclampsia, DIC, anuria.
A 33-year-old woman who is 35 weeks pregnant presents to the Emergency Department with severe continuous abdominal pain. She had some vaginal bleeding an hour ago but this has mostly stopped now, with only a small amount of bloody discharge remaining. She is pale and clammy and obstetric examination reveals a firm, woody uterus which is very tender. Her pulse is 102bpm and her blood pressure is 98/65 mmHg. What is the most likely diagnosis?
Labour
Placenta praevia
Placental insufficiency
Placental abruption
Uterine rupture
Placental abruption
This patient has had a placental abruption. Important signs and symptoms to think about when suspecting placental abruption are:
continuous abdominal pain
shock disproportionate to the amount of blood loss (20% of placental abruptions are ‘concealed’ - the blood is trapped behind the placenta and does not drain)
the uterus may be in spasm and feel firm or ‘woody’
the fetus may be hard to feel
the fetal heart may be hard to auscultate
Remember that most women giving birth are young and fit - they may not show signs of shock until they have lost a considerable amount of blood as they are able to compensate well.
The pain felt in labour comes in waves with each contraction. You would not expect a woody, tender uterus or low blood pressure.
Placenta praevia is another important cause of antepartum haemorrhage but is typically painless.
Uterine rupture in pregnancy is very rare and is often catastrophic. Risk factors include a scarred uterus - e.g. multiple previous caesarian sections.
Placental insufficiency means the blood flow to the placenta is insufficient for the baby to develop as it should, and can result in intrauterine growth restriction.
References and resources:
Royal College of Obstetricians and Gynaecologists: Antepartum Haemorrhage Guideline
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg63.pdf
BMJ ABC of Labour Care: Obstetric Emergencies
Chamberlain G, Steer P. ABC of Labour Care: Obstetric Emergencies. BMJ (1999) 15;318(7194):13421345. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg63.pdf
Patient UK - placenta and placental problems
http://patient.info/doctor/placenta-and-placental-problems
buzz words
Emergency Department
severe continuous abdominal pain
mild vaginal bleeding
bloody discharge
pale and clammy
obstetric examination reveals a firm, woody uterus which is very tender.
Tachycardia
Low blood pressure (haemodynmaically unstable)
A 35-year-old, 12 week pregnant, female presents to the emergency department with abdominal pain. The pain has been constant for the past 2 hours but she has had no vaginal bleeding.
What are the factors associated with an increased risk of placental abruption?
Maternal trauma and young maternal age
Maternal trauma, multiparity and increased maternal age
Maternal trauma, nulliparity and increased maternal age
Nulliparity and young maternal age
Multiparity and increased maternal age
Maternal trauma, multiparity and increased maternal age
Increased risk of placental abruption is associated with increasing maternal age, multiparity and maternal trauma
All 3 of these factors are associated with an increased risk of placental abruption.
In addition, proteinuric hypertension is a risk factor; this is another term for pre-eclampsia, which is defined as the presence of protein in the urine, along with hypertension.
A primigravida 25-year-old woman at 31 weeks gestation presents with vaginal bleeding and severe abdominal pain. The abdominal pain started suddenly in the night (awoke her from sleep), about 4 hours previously. It is a severe dull pain in the suprapubic region and doesn’t radiate anywhere. The pain has not settled at all since onset (she has not taken any medications) and is not positional. She says it is a 10/10 severity. She passed about 2 cupfuls of blood 1 hour previously. She says the bleeding has since soaked through 2 sanitary pads. She also complains of back pain and is exquisitely tender on suprapubic palpation. She has not noticed any decreased foetal movements, although says that her baby is not particularly active usually. Which is the most likely diagnosis?
Placenta increta
Miscarriage
Placenta abruption
Placenta accreta
Placenta praevia
Placenta abruption
Placenta abruption presents with painful vaginal bleeding, whereas placenta praevia is usually painless. A woody, hard uterus may be palpable in placenta abruptio - this is because retroplacental blood tracks into the myometrium. The fetal heart is often absent and the woman may be shocked. Resuscitation is vital in these cases and the baby will need urgent delivery when stable. There is an increased risk of postpartum haemorrhage.
