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Placental Abruption


(abruptio placentae, accidental haemorrhage)

  • premature separation of normally situated placenta
  • revealed, concealed or mixed
  • 0.4-3.5% pregnancies

Aetiology

  • spasm of uterine vessels followed by flooding into choriodecidual space
  • folic acid deficiency
  • trauma from external cephalic version / direct blow
  • sudden release of polyhydramnios
  • traction of short cord

Risk factors

  • multiparity
  • anaemia
  • previous abruption
  • pre-eclampsia
  • hypertension
  • cardiovascular disease
  • rheumatoid disease
  • cocaine

Symptoms and signs

  • vaginal bleeding
  • abdominal pain - greatest in concealed bleed
  • tense and tender uterus (Couvelaire uterus)
  • difficult to detect foetal heart or feel uterine contractions
  • evidence of hypovolaemia
  • foetal distress
  • dead foetus

Differential

Complications

Management

  • Minor degrees or uncertainty
    • bed rest
    • observation
    • clotting screen & FBC
    • Kleihauer test (indicating foetal cells in maternal circulation)
    • USS to exclude placenta praevia
  • Established abruption
    • Rapid assessment of maternal and foetal state
    • FBC, cross-match and clotting
    • analgesia
    • blood tranfusion - CVP monitoring
    • delivery
      • vaginal if foetus dead
      • Caesarean if live foetus
      • large doses ergometrine as likely to be atonic uterus

Expectant management

  • Hospital admission and bed rest
    • General assessment
    • Localise placenta
  • Speculum examination NOT vaginal
  • Mobilise when bleeding has stopped
  • anti-D immunoglobulin where necessary
  • Patient may go home if placenta praevia excluded and bleeding stopped
  • Continued supervision to exclude IUGR
  • Examination at 38 weeks in theatre
  • Careful examination of placenta and membranes after delivery
  • if bleeding does not stop - deliver!

 


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