Standard Treatment Guidelines For Abruptio Placenta

Abruptio placenta is the detachment of a normally located placenta from the uterus before the fetus is delivered. It is an obstetric emergency. Ministry of Health and Family Welfare, Government of India has issued the standard Treatment Guidelines for Abruptio Placenta. Following are the major recommendations :

Types:

It can be classified as-

 Revealed (separation of placenta with blood visible outside)

 Concealed (blood collects behind the separated placenta. Not visible outside)

 Mixed, (common type).

According to Sher clinical grading for placental separation

Grade 1: (Herald bleed) diagnosed retrospectively

1. Less than 100cc -150cc of uterine bleeding

2. Uterus non-tender

3. No Fetal Distress

Grade 2 ; Classical features of abruption

1. Uterus tender

2. Fetal Distress

3. Concealed hemorrhage

Grade 3

1. Fetal death

2. Maternal shock

3. Extensive concealed hemorrhage

4. Coagulopathy

Incidence : 1-2%

Perinatal mortality rate associated with placental abruption is high.

Causes: unknown

But following are risk factors:

o Increased age and parity

o Preeclampsia/ Chronic hypertension

o Preterm ruptured membranes

o Multifetal gestation

o Hydramnios

o Cigarette smoking

o Thrombophilias

o Prior abruption

o Uterine leiomyoma

o External trauma (Sudden jerk or assault over abdomen)

o Anaemia

o Short cord.

Complications:

Complications include the following:

o Maternal blood loss leading to shock, disseminated intravascular coagulation [DIC], mult-iorgan failure.

o Fetal distress or death

o IUGR if chronic and mild.

o In Rh negative mothers, chances of feto-maternal transfusion and Rh sensitization.

o Prematurity

Situation 1:

At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited.

a) Clinical Diagnosis:

Placental Abruption is a clinical diagnosis.

Severity of symptoms and signs depends on degree of separation and blood loss. Symptoms:

 Vaginal Bleeding

 Uterine tenderness

 frequent uterine contractions

Signs:

 Vital signs suggestive of cardiovascular compromise

1. Tachycardia

2. Orthostatic changes in blood pressure and pulse

 Abdominal examination:

1. Uterus may be larger than gestational age

2. Uterine hyper tonicity

3. Fetal demise(depending upon the severity)

 Hemorrhagic shock disseminated intravascular coagulation.

Diagnosis is made by clinical picture and confirmed by ultrasonography.

b) Investigations:

 Full blood count

 Blood grouping and typing, cross match

 Coagulogram for DIC screening

 Fetal heart monitoring

 Trans-abdominal ultrasonography done for evaluation of fetal presentation, size, fetal well-being and placental localization and separation.

c) Treatment:

1.Bed rest for mild symptoms

2.Prompt delivery for severe symptoms with aggressive supportive measures.

Prompt delivery is usually indicated if any of the following is present(grade 2 or 3 abruption)

a) Maternal hemodynamic instability

b) Non-reassuring fetal heart rate pattern on cardiotocography

c) Near-term pregnancy

3. Resuscitation:

1. Start IV Line with normal saline and refer to higher centre.

2. Blood transfusion: Explain the need of blood replacement and send the relatives blood donation.

3. Vaginal delivery may be tried if patient is in advanced labour and baby is either not compromised or IUD.

4. Definite management:

Stable patient (Grade I) management :

 Hospitalization

 Bed rest if the pregnancy is not near term and if mother and fetus are stable.

Patient is followed up if:

i. Bleeding does not threaten the life of the mother or fetus.

ii. The fetal heart rate pattern is reassuring.

iii. The pregnancy is not near term.

iv. No Coagulopathy

v. Optimal urinary output

This approach ensures close monitoring of mother and , if needed, rapidly treated. Corticosteroids should be considered (to accelerate fetal lung maturity) if gestational age is < 34 wk. Injection Betamethasone 12 mg. IM 12hrs.apart total of two injections.

If bleeding resolves and maternal and fetal status remains stable, ambulation may be allowed.

Patient may be discharged from hospital if pregnancy is not term. Patients are followed up in ante natal clinic.

If bleeding continues or if status deteriorates, prompt delivery is indicated.

Per vaginal examination is done in operation theatre and if findings are favourable, artificial rupture of membrane is done to augment the labor with syntocinon. If per vaginal findings are not favourable, caesarean section may be done.Complications and shift to grade 2 or 3 abruption can happen any time so patient should be referred to higher center for monitoring.

d) Complications:

Maternal complications

i. Hypovolemic shock

ii. Renal Cortical necrosis

iii. Coagulopathy

iv. Amniotic fluid embolism

v. Maternal Death

vi. Uteroplacental apoplexy (Couvelaire uterus) -

vii. Bleeding into myometrium results in hypotonic wall

viii. Risk of post partum hemorrhage

Fetal complications

 Intrauterine growth retardation

 Still birth

e)REFERRAL CRITERIA :

Shift to hospital where blood bank, neonatal and emergency cesarean section facilities and facility to treat multi organ failure and DIC are available.

Situation 2:

At Super Specialty Facility in Metro location where higher-end technology is available:

a) Clinical Diagnosis: Detailed history, physical examination and investigations, will be done to confirm the diagnosis.

b) Investigations: Blood count, Blood grouping and typing, cross match, Coagulogram for DIC screen.

c) Ultrasound: Evaluation of fetal presentation, size, fetal well-being and placental localization and separation.

d) Treatment:

 Admit

 History & examinations

 Assess blood loss .It is always more than revealed.

 Treatment for placental abruption varies depending on gestational age and the status of the mother and fetus.

 Begin continuous external fetal monitoring for both the fetal heart rate and contractions.

 Obtain intravenous access using 2 large-bore intravenous lines.

 Institute crystalloid fluid resuscitation for the patient.

 Type and cross match blood.

 Begin a transfusion if the patient is hemodynamically unstable after fluid resuscitation.

 Correct coagulopathy, if present.

 Administer Rh immune globulin if the patient is Rh-negative.

Management of coagulopathy

Indicators for prompt delivery:

a. Fetal distress (Non-reassuring fetal heart rate pattern).

b. Maternal hemodynamic instability.

c. DIC

d. Labor

e. Term

Vaginal delivery is acceptable as early as possible (generally preferred with DIC).

 If bleeding is heavy (revealed or concealed) deliver as soon as possible.

 Patient has to be delivered within 8 hours by Artificial rupture of membrane and Oxytocin 2.5units (not more than 5 units) in 500 cc of Dextrose.

 If cervix is fully dilated deliver by forceps or vaccum extractor.

 If vaginal delivery is not imminent or fetus is alive deliver by cesarean section.

 All precautions for the prophylaxis of third stage of labor. In every case of abruptio placentae, be prepared for postpartum haemorrhage.

FURTHER READING / REFERENCES.

1. Williams Obstetrics : 23rd edition

2. Practical guide to High Risk Pregnancy and Delivary by Fernando arias

3. RCOG Greentop guideline No: 27

RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (PATIENT WEIGHT 60 KGS)

(Units to be specified for human resources, investigations, drugs, and consumables and equipment. Quantity to also be specified)