Placental abruption is a complication of pregnancy, wherein the placenta

Placenta

The placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply. "True" placentas are a defining characteristic of eutherian or "placental" mammals, but are also found in some snakes and...

l lining has separated from the uterus

Uterus

The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...

 of the mother

Mother

A mother, mum, mom, momma, or mama is a woman who has raised a child, given birth to a child, and/or supplied the ovum that grew into a child. Because of the complexity and differences of a mother's social, cultural, and religious definitions and roles, it is challenging to specify a universally...

. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies

Pregnancy

Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...

 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.

Lasting effects

On the mother:

• A large loss of blood or hemorrhage may require blood transfusions and intensive care after delivery. 'APH
  Antepartum haemorrhage
  In obstetrics, antepartum haemorrhage , also prepartum hemorrhage, is bleeding from the vagina during pregnancy from the 24th , week gestational age to term....
  
   weakens for PPH
  Postpartum hemorrhage
  Hemorrhage after delivery, or postpartum hemorrhage, is the loss of greater than 500 ml of blood following vaginal delivery, or 1000 ml of blood following cesarean section...
  
   to kill'.
• 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
  Caesarean section
  A Caesarean section, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus...
  
  ) and too many transfusions could put the mother into disseminated intravascular coagulation
  Disseminated intravascular coagulation
  Disseminated intravascular coagulation , also known as disseminated intravascular coagulopathy or consumptive coagulopathy, is a pathological activation of coagulation mechanisms that happens in response to a variety of diseases. DIC leads to the formation of small blood clots inside the blood...
  
   (DIC) due to increased thromboplastin
  Thromboplastin
  Thromboplastin is a plasma protein aiding blood coagulation through conversion of prothrombin to thrombin.Although sometimes used as a synonym for tissue factor, this is a misconception. Historically, thromboplastin was a lab reagent, usually derived from placental sources, used to assay...
  
  , the doctor may consider a hysterectomy
  Hysterectomy
  A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...
  
  .
• A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland. Diffuse cortical necrosis in the kidney is a serious and often fatal complication.
• 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 and may die in utero, thus resulting in a stillbirth.
• 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.

Symptoms

• contractions that don't stop (and may follow one another so rapidly as to seem continuous)
• pain in the uterus
• tenderness in the abdomen
• vaginal bleeding (sometimes)
• uterus may be disproportionately enlarged
• pallor

Clinical Manifestation

• Class 0: asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.
• Class 1: mild and represents approximately 48% of all cases. Characteristics include the following:
  • No vaginal bleeding to mild vaginal bleeding
  • Slightly tender uterus
  • Normal maternal BP and heart rate
  • No coagulopathy
    Coagulopathy
    Coagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
    
    
  • No fetal distress
    Fetal distress
    In medicine , the term fetal distress refers to the presence of signs in a pregnant woman—before or during childbirth—that suggest that the fetus may not be well...
    
    
• Class 2: moderate and represents approximately 27% of all cases. Characteristics include the following:
  • No vaginal bleeding to moderate vaginal bleeding
  • Moderate-to-severe uterine tenderness with possible tetanic contractions
  • Maternal tachycardia with orthostatic changes in BP and heart rate
  • Fetal distress
  • Hypofibrinogenemia (i.e., 50–250 mg/dL)
• Class 3: severe and represents approximately 24% of all cases. Characteristics include the following:
  • No vaginal bleeding to heavy vaginal bleeding
  • Very painful tetanic uterus
  • Maternal shock
  • Hypofibrinogenemia (i.e., <150 mg/dL)
  • Coagulopathy
  • Fetal death

Pathophysiology

Trauma

Physical trauma

Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...

, hypertension

Hypertension

Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...

, or coagulopathy

Coagulopathy

Coagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...

 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

Fetal distress

In medicine , the term fetal distress refers to the presence of signs in a pregnant woman—before or during childbirth—that suggest that the fetus may not be well...

 or death.

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. There is 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
  Disseminated intravascular coagulation
  Disseminated intravascular coagulation , also known as disseminated intravascular coagulopathy or consumptive coagulopathy, is a pathological activation of coagulation mechanisms that happens in response to a variety of diseases. DIC leads to the formation of small blood clots inside the blood...
  
  . Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus
  Couvelaire uterus
  Couvelaire uterus is a life threatening condition in which loosening of the placenta causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity....
  
  .

Risk factors

• Maternal hypertension
  Hypertension
  Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
  
   is a factor in 44% of all abruptions.
• Maternal smoking is associated with up to 90% increased risk.
• Maternal drinking of alcoholic beverages within a year before conception and during pregnancy can increase the risk by a factor 3 to 4
• Maternal trauma, such as motor vehicle accidents, assault
  Assault
  In law, assault is a crime causing a victim to fear violence. The term is often confused with battery, which involves physical contact. The specific meaning of assault varies between countries, but can refer to an act that causes another to apprehend immediate and personal violence, or in the more...
  
  s, falls or nosocomial infection.
• Short umbilical cord
  Umbilical cord
  In placental mammals, the umbilical cord is the connecting cord from the developing embryo or fetus to the placenta...
  
  
• Prolonged rupture of membranes (>24 hours)
• Retroplacental fibromyoma
  Uterine fibroids
  A uterine fibroid is a benign tumor that originates from the smooth muscle layer and the accompanying connective tissue of the uterus.Fibroids are the most common benign tumors in...
  
  
• 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.
• some infections are also diagnosed as a cause
• cocaine intoxication
  Cocaine intoxication
  Cocaine intoxication refers to the immediate effects of cocaine on the body. Although cocaine intoxication and cocaine dependence can be present in the same individual, they present with different sets of symptoms....
  
  

The risk of placental abruption can be reduced by maintaining a good diet

Diet (nutrition)

In nutrition, diet is the sum of food consumed by a person or other organism. Dietary habits are the habitual decisions an individual or culture makes when choosing what foods to eat. With the word diet, it is often implied the use of specific intake of nutrition for health or weight-management...

 including taking folic acid

Folic acid

Folic acid and folate , as well as pteroyl-L-glutamic acid, pteroyl-L-glutamate, and pteroylmonoglutamic acid are forms of the water-soluble vitamin B9...

, regular sleep

Sleep

Sleep is a naturally recurring state characterized by reduced or absent consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, and is more easily reversible than...

 patterns and correction of pregnancy-induced hypertension

Pregnancy-induced hypertension

Gestational hypertension or pregnancy-induced hypertension is defined as the development of new arterial hypertension in a pregnant woman after 20 weeks gestation without the presence of protein in the urine.-Conditions:...

.

Intervention

Placental abruption is suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The fundus

Fundus (uterus)

The fundus of the uterus is the top portion, opposite from the cervix.Fundal height, measured from the top of the pubic bone, is routinely measured in pregnancy to determine growth rates...

 may be monitored because a rising fundus can indicate bleeding. An ultrasound may be used to rule out placenta praevia

Placenta praevia

Placenta praevia is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum haemorrhage...

 but is not diagnostic for abruption. The mother may be given Rhogam if she is Rh negative.

Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36 weeks and neither mother or fetus is in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first.

Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother is in distress. Blood volume replacement to maintain blood pressure and blood plasma

Blood plasma

Blood plasma is the straw-colored liquid component of blood in which the blood cells in whole blood are normally suspended. It makes up about 55% of the total blood volume. It is the intravascular fluid part of extracellular fluid...

 replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over caesarean section

Caesarean section

A Caesarean section, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus...

unless there is fetal distress. Caesarean section is contraindicated in cases of disseminated intravascular coagulation.
Patient should be monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy if family size is completed.

External links

• Emergency medicine: Abruptio Placentae, emedicine.com, April 5, 2005
• Obstetrics/Gynecology: Abruptio Placentae, emedicine.com, August 31, 2005