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Placental abruption

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun M.D., PhD.

Synonyms and keywords: Premature separation of placenta; ablatio placentae; abruptio placentae; placenta abruptio

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun M.D., PhD. Rana aljebzi, M.D.[2]

Overview

Placental abruption is a complication of pregnancy, where the placental lining has separated from the uterus of the mother after 20 weeks of gestation and prior to second stage of labor.Placental abruption is a relatively rare but serious complication of pregnancy and placed the well-being of both mother and fetus at risk.[1]

Epidemiology and Demographics

It occurs in 1% of pregnancies world wide with a fetal mortality rate of 20-40% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality. The heart rate of the fetus can be associated with the severity.[2]

References

  1. ↑ Workalemahu T, Enquobahrie DA, Gelaye B, Thornton TA, Tekola-Ayele F, Sanchez SE; et al. (2018). “Abruptio placentae risk and genetic variations in mitochondrial biogenesis and oxidative phosphorylation: replication of a candidate gene association study”. Am J Obstet Gynecol. 219 (6): 617.e1–617.e17. doi:10.1016/j.ajog.2018.08.042. PMC 6497388. PMID 30194050.
  2. ↑ Usui R, Matsubara S, Ohkuchi A; et al. (2007). “Fetal heart rate pattern reflecting the severity of placental abruption”. doi:10.1007/s00404-007-0471-9. PMID 17896112.

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Historical Perspective

Historical Perspective

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun M.D., PhD.

References

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Classification

Classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun M.D., PhD.

Classification

Abruptions are classified according to severity in the following manner:

  • Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta.
  • Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus.
  • Grade 2: The mother is symptomatic but not in shock. Some evidence of fetal distress can be found with fetal heart rate monitoring.
  • Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.

References

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Pathophysiology

Pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun M.D., PhD. Rana aljebzi, M.D.[2]

Pathophysiology

Trauma, hypertension, or coagulopathy, contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into the decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption.

Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death.

Lasting Effects[1]

On the Mother

  • A large loss of blood or hemorrhage may require blood transfusions and intensive care after delivery.
  • The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract.
  • The mother may have problems with blood clotting for a few days.
  • If the mother’s blood does not clot (particularly during a caesarean section) and too many transfusions could put the mother into disseminated intravascular coagulation (DIC), the doctor may consider a hysterectomy.
  • A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland.
  • In some cases where the abruption is high up in the uterus, or is slight, there is no bleeding, though extreme pain is felt and reported.

On the Baby

  • If a large amount of the placenta separates from the uterus, the baby will probably be in distress until delivery.
  • The baby may be premature and need to be placed in the newborn intensive care unit. He or she might have problems with breathing and feeding.
  • If the baby is in distress in the uterus, he or she may have a low level of oxygen in the blood after birth.
  • The newborn may have low blood pressure or a low blood count.
  • If the separation is severe enough, the baby could suffer brain damage or die before or shortly after birth.

References

  1. ↑ Pitaphrom A, Sukcharoen N (2006). “Pregnancy outcomes in placental abruption”. J Med Assoc Thai. 89 (10): 1572–8. PMID 17128829.

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Causes

Causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun M.D., PhD., Rana aljebzi, M.D.[2]

Causes[1][2]

  • The exact cause of placental abruption may be hard to determine, But some factors may raise a woman’s risk for it:
  1. History of placental abruption in a previous pregnancy
  2. Long-term high blood pressure
  3. Sudden high blood pressure in pregnant women who had normal blood pressure in the past
  4. Heart disease
  5. Smoking
  6. drugs like Alcohol or cocaine use
  7. twins pregnancy or more
  8. Being older than 35
  • Direct causes are rare, but include:
  1. Injury to the belly area (abdomen) from a fall, hit to the abdomen, or automobile accident
  2. Sudden loss of uterine volume (can occur with rapid loss of amniotic fluid or after a first twin is delivered)

References

  1. ↑ Anderson E, Raja EA, Shetty A, Gissler M, Gatt M, Bhattacharya S; et al. (2020). “Changing risk factors for placental abruption: A case crossover study using routinely collected data from Finland, Malta and Aberdeen”. PLoS One. 15 (6): e0233641. doi:10.1371/journal.pone.0233641. PMC 7289359 Check |pmc= value (help). PMID 32525937 Check |pmid= value (help).
  2. ↑ Workalemahu T, Enquobahrie DA, Gelaye B, Thornton TA, Tekola-Ayele F, Sanchez SE; et al. (2018). “Abruptio placentae risk and genetic variations in mitochondrial biogenesis and oxidative phosphorylation: replication of a candidate gene association study”. Am J Obstet Gynecol. 219 (6): 617.e1–617.e17. doi:10.1016/j.ajog.2018.08.042. PMC 6497388. PMID 30194050.

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Differentiating Placental Abruption from other Diseases

Differentiating Placental Abruption from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief:Rana aljebzi, M.D.[2]

Overview

Bleeding during the second half of pregnancy is usually due to either placental abruption or placenta previa. Differentiating these 2 conditions is important to the care of the patient.

differential diagnosis

Placental abruption is an important cause of antenatal haemorrhage, Differential diagnoses to consider include:

  • Placenta praevia : where the placenta is fully or partially attached to the lower uterine segment.
  • Subchorionic Hemorrhage: is bleeding between the amniotic sac (membranes) and the uterine wall.This can occur by the placenta disconnecting from the original site of implantation, resulting in bleeding of the chorionic membranes, the outer layer of the amniotic sac.
  • Vasa praevia: which is extremely rare but devastating condition in which fetal umbilical cord blood vessels cross or run in close to the inner cervical os.
  • Uterine rupture : This usually occurs in labour with a history of previous caesarean section or previous uterine surgery such as myomectomy, where the full-thickness disruption of the uterine muscle and overlying serosa.
  • Local genital causes:
    • Benign or malignant lesions :e.g. polyps, carcinoma. cervical ectropion (common).
    • Infections : e.g. candida, bacterial vaginosis and chlamydia.


References

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Epidemiology and Demographics

Epidemiology and Demographics

Please help WikiDoc by adding more content here. It’s easy! Click here to learn about editing.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun M.D., PhD.

Overview

It occurs in 1% of pregnancies world wide with a fetal mortality rate of 20-40% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality. The heart rate of the fetus can be associated with the severity.[1]

References

  1. ↑ Usui R, Matsubara S, Ohkuchi A; et al. (2007). “Fetal heart rate pattern reflecting the severity of placental abruption”. doi:10.1007/s00404-007-0471-9. PMID 17896112.

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Risk Factors

Risk Factors

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun M.D., PhD. Rana aljebzi, M.D.[2]

Risk Factors[1]

  • Maternal hypertension is a factor in 44% of all abruptions.
  • Maternal trauma, such as motor vehicle accidents, assaults, falls, or nosocomial
  • Drug use is a factor, particularly tobacco, alcohol, and cocaine.[2]
  • Short umbilical cord
  • Prolonged rupture of membranes (>24 hours)
  • Retroplacental fibromyoma
  • Maternal age: Pregnant women who are younger than 20 or older than 35 are at greater risk.
  • Previous abruption: Women who have had an abruption in previous pregnancies are at greater risk.[3]

The risk of placental abruption can be reduced by maintaining a good diet including taking folic acid, regular sleep patterns and not smoking or drinking alcohol.

References

  1. ↑ Cheng WW, Lin SQ (2008). “[Analysis of risk factors for uteroplacental apoplexy complicating placental abruption]”. Zhonghua Fu Chan Ke Za Zhi. 43 (8): 593–6. PMID 19087494.
  2. ↑ Ananth CV, Savitz DA, Luther ER (1996). “Maternal cigarette smoking as a risk factor for placental abruption, placenta previa, and uterine bleeding in pregnancy”. Am J Epidemiol. 144 (9): 881–9. doi:10.1093/oxfordjournals.aje.a009022. PMID 8890666.
  3. ↑ Yang Q, Wen SW, Oppenheimer L, Chen XK, Black D, Gao J; et al. (2007). “Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy”. BJOG. 114 (5): 609–13. doi:10.1111/j.1471-0528.2007.01295.x. PMID 17355267.

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Screening

Screening

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief:Rana aljebzi, M.D.[2]

screeninig

  • First trimester (pregnancy-associated placental protein-A [PAPP-A])
  • second trimester (total hCG and alpha fetoprotein [AFP]) serum biochemistry were determined.The two screening periods were compared for the prediction of a range of severe adverse perinatal outcomes (intrauterine growth restriction [IUGR], abruption, severe pre-eclampsia/HELLP syndrome, delivery < 32 weeks, or stillbirth).[1]
  • MRI is a complementary technique that should be considered when ultrasound is inconclusive or incomplete.[2]

References

  1. ↑ Ananth CV, Wapner RJ, Ananth S, DʼAlton ME, Vintzileos AM (2017). “First-Trimester and Second-Trimester Maternal Serum Biomarkers as Predictors of Placental Abruption”. Obstet Gynecol. 129 (3): 465–472. doi:10.1097/AOG.0000000000001889. PMC 5367463. PMID 28178056.
  2. ↑ Leyendecker JR, DuBose M, Hosseinzadeh K, Stone R, Gianini J, Childs DD; et al. (2012). “MRI of pregnancy-related issues: abnormal placentation”. AJR Am J Roentgenol. 198 (2): 311–20. doi:10.2214/AJR.11.7957. PMID 22268173.

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Natural History, Complications and Prognosis

Natural History, Complications and Prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun M.D., PhD.

History

  • The pregnant comes with vaginal bleeding associated with abdominal pain and contractions ,in the second half of pregnancy. absence of bleeding doesn’t exclude the diagnosis some of the cases the Sometimes, blood gets trapped inside the uterus.

Complications

  • Excess blood loss may lead to shock and possible death in the mother or baby.

Prognosis

  • The mother does not usually die from this condition.
  • However, all of the following increase the risk for death in both the mother and baby:
  • Closed cervix
  • Delayed diagnosis and treatment of placental abruption
  • Excessive blood loss, leading to shock
  • Hidden (concealed) uterine bleeding in pregnancy
  • No labor
  • Fetal distress occurs early in the condition in about half of all cases.
  • Infants who live have a 40-50% chance of complications, which range from mild to severe.

References

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Diagnosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | CT | MRI | Ultrasound | Other Imaging Findings | Other Diagnostic Studies

Treatment

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case Studies

Case #1

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