ABRUPTION PLACENTA INTRODUCTION Medical disorders, associated with pregnancy, increase as women delay childbearing.

They become more at risk with increasing age. ANTEPARTUM HAEMMORHAGE: Antepartum haemmorhage is defined as bleeding from the genital tract after 28 week of pregnancy and before the birth of the baby. TYPES OF ANTEPARTUM HAEMMORHAGE: 1. PLACENTAL BLEEDING A.PLACENTA PREVIA B.ABRUPTIO PLACENTA 2.EXTRA PLACENTAL BLEEDING(Due to extra placental bleeding) ABRUPTIO PLACENTA: DEFINITION: Abruptio placenta is defined as premature separation of a normally situated placenta after 28 weeks gestation and before birth of the baby. -ANNAMMA JACOB It is one form of antepartum haemorrhage where the bleeding occurs due to premature separation of normally situated placenta. -D.C.DUTTA. INCIDENCE: The overall incidence is about 1 in 200 deliveries. Depending on the extent (partial or complete) and intensity of placental separation, it is a significant causes of perinatal mortality(15-20%) and maternal mortality (2-5%).More and more cases of placental abruption are being diagnosed in the recent years.
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TYPES OF ABRUPTIO PLACENTA: REVEALED: Following separation of the placenta, the blood escapes from the placental site, seperates the membranes from the uterine wall and drains through the vagina. CONCEALED: The blood collects behind the separated placenta or between the membranes and decidua. The collected blood is prevented from coming out of the cervix by the presenting part, which presses on the lower segment. Sometimes it is retained behind the placenta and forced into the myometrium where it infiltrates between the muscle fibres of the uterus, resulting in a condition known as couvelaire uterus. MIXED In this type, some portion of the blood collects inside (concealed)and a portion is expelled out (revealed).Usually one type predominates the other. CAUSES: The exact cause is unknown , but several factors have been considered as causes: Spasm of the uterine vessels followed by flooding into the choriodecidual space. Malnutrition Folic acid deficiency Traction of short cord Trauma from cephalic version. Abruptio placentae is seen associated with the following conditions: Multiparity ,5 th pregnancy and over Major congentiaal malformations Abruption in previous pregnancy Pregnancy induced hypertension
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GRADING OF PLACENTAL ABRUPTION: GRADE-I Mild separation of the placenta Slight vaginal bleeding and some uterine irritability are present. Maternal blood pressure is unaffected .Fibrinogen level is unaffected . The fetal heart rate is normal. GRADE-II Moderate separation of the placenta. External bleeding is mild- to-moderate. The uterus is irritable. Tetanic contractions may be present.Maternal blood pressure may be normal. The fetal heart rate shows signs of distress. The maternal fibrinogen level is decreased. GRADE-III Severe separation of the placenta The bleeding may be severe and may be concealed. Uterine contractions are titanic and painful. Maternal hypotension may be present. The fibrinogen level is greatly reduced with resultant coagulation problems

SIGNS AND SMPTOMS: Small to moderate amount of bright or dark red vaginal bleeding. Acute abdominal pain associated with vaginal bleeding. Acute abdominal pain associated with vaginal bleeding. Uterine tenderness and high uterine tonicity often described as board-like abdomen. Increase in the size of the uterus ,particularly if the bleeding is concealed. Failure of the uterus to relax between contractions. Fetal heart sounds absent with concealed or mixed type.
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 Urine output usually diminished. DIAGNOSIS: Ultrasonography to visualize the location of the placenta and presence of clot or hematoma. Coagulation profile to rule out disseminated intravascular coagulation Clotting time bleeding time fibrinogen level platelet count prothrombin and partial prothrombin time fibrin degradration products Renal function tests MANAGEMENT Fluid and blood replacement Vaginal delivery if bleeding is minimal, the mothers condition is stable, the labor is progressing and the presenting part is in the pelvis. Labor may have to be augmented(induced)if it not progressing well. Caesarean delivery if hemorrhage is severe,fetal heart tones are present, the presenting part is not in the pelvis, the cervix is closed or it is anticipated that birth is not imminent. If the fetus is dead , a cesarean section is performed only if the bleeding is life-threatening .A cesarean hysterectomy may be necessary if the bleeding cannot be controlled. POSSIBLE COMPLICATIONS: Severe shock may cause renal failure with first hematuria, then oliguria or anuria due to necrosis of the nephrons. Coagulation defect if not treated successfully can lead to castrophic bleeding due to disseminated intravascular coagulation.

 Heavy blood loss and shock can cause pituitary necrosis leading to Sheehans disease. Postpartum haemmorhage may occur as a result of the couvelaire uterus and disseminatedintravascular coagulation. NURSING CARE All maternal and fetal vital signs should be monitored frequently and recorded carefully. The amount and nature of bleeding to be assessed and recorded. Contraction pattern and cervical status to be monitored if the woman is in active labor. Urinary output and skin color should be observed and recorded. The woman should be grouped and cross-matched for packed red blood cells. If the pain is extreme , an analgesic such as morphine is given, as pain can exacerbate shock, which must be avoided. An intravenous line must be set up with a 16-guage intra catheter to administer plasma expander and blood. Blood is collected for investigations. A central venous line is usually inserted in order to monitor the central venous pressure two hourly or more frequently. Physical comfort and emotional support must be provided. The woman must be assisted to rest in left lateral position, which relieves occlusion of venacava and compression of aorta by the gravid uterus. Fundal height and abdominal girth are to be measured hourly. An increase indicates continued bleeding behind the placenta. If the fetus is alive, the fetal heart rate should be monitored continuously and oxygen to be administered to relieve hypoxia. Once the womans condition is stabilized cesarean section may be indicated. Observations must be made for any developing complications such as hypotension, hypovolemia, shock and DIC. PROGNOSIS:
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The prognosis of the mother and the baby depends on the clinical types (revealed, mixed, or purely concealed),degree of placental separation , the interval between the separation of the placenta and delivery of the baby and the efficacy of treatment. Bleeding in placental abruption is almost always maternal . Fetal bleeding is observed only with traumatic variety of abruption placenta.