(a.k.

a Accidental Hemorrhage or Ablatio Placenta) -

Premature separation of the implanted placenta before the birth of the fetus
Hemorrhage can be either occult (difficult to detect) or apparent (obvious). With an occult hemorrhage, the placenta usually separates centrally, and a large amount of blood is accumulated under the placenta. When the apparent hemorrhage is present, the separation is along the placental margin, and blood flows under the membranes and through the cervix.

If the placenta begins to detach during pregnancy, there is bleeding from these vessels. The larger the area that detaches, the greater the amount of bleeding.

Incidence: second leading cause of bleeding in the 3rd Trimester; occurs in 1:300* pregnancies.

1:700-750*

Types a. Type I: concealed, covert, or central type; the classic type Placenta separates at the center causing blood to accumulate behind the placenta. External bleeding not evident. Signs of shock not proportional to the signs of external bleeding.

Concealed Abruption

Types b. Type II: Marginal, overt, or external bleeding type. Placenta separates at the margins. Bleeding is external, it is usually proportional to the amount of internal bleeding. May be incomplete or complete depending on the degree of detachment.

External External Abruption

Relatively Concealed Abruption

*predominantly/relatively concealed, the membrane gradually separate from the uterine wall and blood escapes through the cervix.

Determine the amount and type of bleeding and the presence or absence of pain. Monitor maternal and fetal vital signs, especially maternal BP, pulse, FHR, and
FHR variability or alterations.

Palpate the abdomen oNote the presence of contractions and relaxations between contractions (if
contractions are present).

oIf contractions are not present assess the abdomen for firmness. Measure and record fundic height to evaluate the presence of concealed bleeding. Prepare for possible delivery.

Destruction of the placental tissues

a. Painful vaginal bleeding in the 3rd trimester. b. Rigid, board-like, and painful abdomen. c. Enlarged uterus due to concealed bleeding; signs of shock not proportional to the degree of external bleeding (classic type). d. If in labor: tetanic contractions with the absence of alternating contraction and relaxation of the uterus.

Signs of Shock*

Destruction of the placental tissues

Grade 0

Criteria No symptoms of separation were apparent from maternal or fetal signs; the diagnosis that a slight separation did occur is made after birth, when the placenta is examined and a segment of the placenta shows a adherent clot on maternal surface. Minimal separation, but enough to cause vaginal bleeding and changes in the maternal vital signs; no fetal distress or hemorrhagic shock occurs, however. Moderate separation; there is evidence of fetal distress; the uterus is tense and painful on palpation. Extreme separation; without immediate interventions, maternal shock and fetal death will result.

2 3

Grade 1 Mild Separation (10-20%) General Findings Total Amount of Blood Loss Color of blood Shock Coagulopathy Uterine Tonicity Tenderness (pain) <500 cc Dark Red Rare: none Rare: none Normal Usually absent

Grade 2 Moderate Separation (20-50%) 1,000-5,000 cc Dark Red Mild Occasional DIC Increased Present

Grade 3 Severe Separation (>50%) >1,500 cc Dark Red Common, often sudden Frequent DIC Tetanic Agonizing pain

Coagulopathy* and Uterine Tonicity*

Grade 1 Mild Separation (10-20%)

Grade 2 Moderate Separation (20-50%)

Grade 3 Severe Separation (>50%)

Ultrasonographic Findings Location of placenta Normal, Upper Uterine segment Variable to engaged Usual variations Normal, Upper Uterine segment Normal, Upper Uterine segment

Station of presenting part Fetal position

Variable to engaged Usual variations

Variable to engaged Usual variations

A. B. C.

Clinical Diagnosis Signs and symptoms Ultrasound detects the retro placental defects. Clotting- reveal DIC, clotting defects. The thrombosplastia from retroplacental clots enter maternal circulation and consumes maternal free fibrinogen resulting in:

DIC (disseminated intravascular coagulation): small fibrin clots Hypofibronozenia: normal fibronogen results in absence of normal blood coagulation.

Symptoms: Vaginal bleeding (Light or moderate) Abdominal pain Back pain A uterus that hurts or is sore. It might also feel hard or rigid. Signs: Physical examination reveals uterine tenderness and/or increased uterine tone. Hemorrhage or heavy bleeding in pregnancy may be visible or concealed.

Tests include: CBC, may note decreased hematocrit or hemoglobin and platelets Prothrombin time test Partial thromboplastin time test Fibrinogen level test Abdominal ultrasound (may be done)

Destruction of the placental tissues

Predisposing Thrombolphlibitic Factors: conditions Advance Age PIH (Pregnancy(> 35y.o) induced HPN) Gender (Female) Renal Disease Heredofamilial Chorioamnionitis* High Parity Anemia Previous abruptio Uterine Fibroid placenta Polydamnios* Short umbilical cord* CHD Trauma (Injury) Fibrin Defects

Damage in small arterial vessels in the basal layer of decidua*

Contributing Factors: Smoking/ Cocaine use Diet Socio-economic status (Low)

Bleeding
OCCULT APPARENT

Splits decidua, leaving a thin layer attached to the placenta

Hematoma formation

Obliteration of the intervillous space*

Compression of the basal layer*

Destruction of the placental tissues

Concealed Bleeding

Visible Bleeding

Impaired exchange of respiratory gases and nutrients

Blood passes through the membranes of amniotic sac

Blood reaches the edge of the placenta

Blood passes through the membranes of amniotic sac

Port wine discoloration

of discharges
( PATHOGNOMONIC SIGN)

NOTE:
Small amount of blood goes out to the vagina (not an indication of the severity of condition)

Ineffective tissue perfusion (placental) related to excessive bleeding, hypotension, and decreased cardiac output, causing fetal compromise

Evaluate amount of bleeding by weighing all pads. Monitor CBC results and VS. Position in the left lateral position, with the head elevated to enhance placental perfusion. Administer oxygen through a snug face mask at 8-12L per minute. Evaluate fetal status with continuous external fetal monitoring. Prepare for possible CS delivery if maternal or fetal compromise is evident.

Acute Pain related to increase uterine activity

Instruct patient on the cause of pain to decrease anxiety . Instruct and encourage the use of relaxation technique to augment analgesics. Administer pain medications as needed and as prescribed.

Fluid volume deficit related to excessive bleeding

Establish and maintain a large-bore IV line, as prescribed and draw blood for type and screen for blood replacement. Evaluate coagulation studies. Monitor maternal VS and contractions. Monitor vaginal bleeding and evaluate fundal height to detect an increase in bleeding.

Risk for infection related to excessive blood loss

Use aseptic technique when providing care. Evaluate temperature q4h unless elevated; then evaluate q2h. Evaluate WBC and differential count. Teach perineal care and hand washing techniques. Assess odor of all vaginal bleeding or lochia.

Fear related excessive bleeding procedures and unknown outcome

Inform the woman and her family about the status of herself and the fetus. Explain all procedures in advance when possible or as they are performed. Answer questions in a calm manner, using simple terms Encourage the presence of a support person .

Maternal shock Anaphylactoid syndrome of pregnancy* Postpartum hemorrhage or Hemorrhagic shock Acute respiratory distress syndrome Sheehans syndrome* Renal tubular necrosis* Rapid labor and delivery Maternal and fetal death Prematurity, fetal distress/demise (IUSD)

COUVELAIRE UTERUS: the bleeding behind the placenta may cause some of the blood to enter the uterine musculature causing the uterine muscles not to contract well once the placenta is delivered. Disseminated Intravascular Coagulation (DIC) Hypofibrogenemia Infection

MEDICAL MANAGEMENT

SURGICAL MANAGEMENT

IV administration of fibrinogen or cryoprecipitate Laboratory examinations CS

Fibrinogen is a protein produced by the liver. This protein helps stop bleeding by helping blood clots to form. A blood test can be done to tell how much fibrinogen you have in the blood.

Blood Component Therapy Cryoprecipitate (CRYO)Cryoprecipitate is prepared from plasma and contains fibrinogen, von Willebrand factor, factor VIII, factor XIII and fibronectin. Cryoprecipitate is the only adequate fibrinogen concentrate available for intravenous use. Indications for Cryoprecipitate Bleeding or immediately prior to an invasive procedure in patients with significant hypofibrinogenemia (<100 mg/dL)

CS During the procedure An average C-section takes about 45 minutes to one hour. Preparation. Before the C-section, a member of your health care team cleanses your abdomen. A tube (catheter) may be placed into your bladder to collect urine. IV lines are placed in a vein in your hand or arm to provide fluid and medication. A member of your health care team may also give you an antacid to reduce your risk of an upset stomach during the procedure.

After the procedure In the hospital. After a C-section, most mothers stay in the hospital for about three days. To control pain as the anesthesia wears off, you may use a pump that allows you to adjust the dose of IV pain medication. While you're in the hospital, your health care team will monitor your incision for signs of infection. They'll also monitor your appetite, how much fluid you're drinking, and bladder and bowel function. Before you leave the hospital, talk with your doctor about any preventive care you may need, including vaccinations. It's a good time to make sure your immunizations are up to date to help protect your health and the health of your baby.

a. Maintain bed rest, LLR b. Careful monitoring: Maternal v/s FHT Labor onset/progress I & O, oliguria/anuria Uterine pain Bleeding (not proportional to degree of shock)

c. Administer IV fluid, plasma, or blood as ordered.

d. Prepare for diagnostic examinations. e. Provide psychological support prepare for all

examinations, explain what is happening and inform or explain results. f. Prepare for emergency birth either per vagina or CS. g. Observe for ASSOCIATED PROBLEMS AFTER DELIVERY. Poorly contracting uterus (Couvelaire uterus) partal hemorrhage Disseminated Intravascular Coagulation (DIC) Post-

hemorrhage and possibly CVA

Maternal mortality is uncommon. Maternal death rates in various parts of the world range from 0.5 to 5%. Early diagnosis of the condition and adequate intervention should decrease the maternal death rate to 0.5 to 1%. Fetal death rates range from 20-35 %. 15% of cases - Upon hospital admission, no fetal heart tone is detectable in about. Approximately 50% of cases of fetal distress appears early in the condition . 40 to 50% incidence of illness in infants. Risk of maternal or fetal death: concealed vaginal bleeding in pregnancy, excessive loss of blood resulting in shock, absence of labor, a closed cervix, and delayed diagnosis and treatment are unfavorable factors .

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