Premature placental abruption
Premature placental abruption is a complication that manifests itself during pregnancy or during childbirth. Normally, the separation of the placenta from the uterine wall should occur after the birth of the child. Premature detachment occurs in about one percent of cases. A third of these complications are accompanied by severe bleeding. As a result, a woman may develop disseminated intravascular coagulation syndrome or hemorrhagic shock. Such situations pose a danger to the life of both the mother and the fetus.
The content of the article:
Types of premature placental abruption
Causes of premature placental abruption
Symptoms of premature placental abruption
Diagnosis of premature placental abruption
Treatment of premature placental abruption
Prognosis and prevention of premature placental abruption
Premature placental abruption
According to statistics, premature placental abruption occurs:
during pregnancy — in almost 57 percent of cases;
in the first two stages of labor (disclosure and expulsion) — in 43.5 percent of cases.
In the presence of premature detachment during the previous pregnancy, the risk of recurrence of the complication increases.
If premature placental abruption was not accompanied by bleeding, then its presence becomes known only after the birth of a viable fetus. In this case, either a blood accumulation is detected in the space between the uterine wall and the placenta, or a retroplacental hematoma.
Types of premature placental abruption
Premature placental abruption is classified by severity.
A mild degree is characterized by premature detachment of a small fragment of the placenta. At the same time, the general condition of the pregnant woman practically does not change. Ultrasound examination may show the presence of retroplacental hematoma, however, if there is a small discharge from the genitals, then it will not be. After childbirth, a small clot forms on the placenta.
With moderate severity, premature placental abruption occurs on a quarter (and sometimes a third) of the surface. Blood is secreted from the genital tract in clots and in large quantities. Retroplacental hematoma causes abdominal pain, possible hypertonicity of the uterus, as well as its soreness and asymmetry. The mother develops symptoms of pain and hemorrhagic shock. The fetus can die from hypoxia if it does not cause premature birth.
The severe form is characterized by detachment of half of the placental surface. External bleeding is preceded by internal bleeding, the woman feels severe abdominal pain. Examination of the uterus reveals its asymmetry and tension. The symptoms of acute hypoxia are obvious, and the risk of fetal death is great.
Another common classification is according to the form of placental abruption:
marginal (peripheral) detachment — accompanied by bleeding;
central detachment — accompanied by accumulation of blood between the uterine wall and the placenta, as well as concomitant deterioration of the pregnant woman;
combined detachment — combining the features of the two previous ones.
In addition, premature placental abruption can be progressive and non—progressive, depending on whether the area of placental discharge from the uterine wall increases over time.
Causes of premature placental abruption
In such a violation as premature placental abruption, the causes can be very different.
During pregnancy, risk factors may include:
late toxicosis (gestosis);
nephropathy of pregnant women;
vascular extragenital pathology;
autoimmune conditions;
vascular inflammation of infectious and allergic genesis;
allergic reactions to blood transfusion;
endocrine diseases;
genetic disorders of blood clotting;
tendency to thrombosis;
instability of blood pressure;
kidney diseases;
rh-conflict of mother and fetus;
placental insufficiency;
finding the placenta in the projection of the myomatous node.
During childbirth, the causes of premature placental abruption can be such phenomena as:
the birth of the first fetus in a multiple pregnancy;
excessive stimulation of the uterus;
discoordination of uterine contractions;
late rupture of the fetal bladder;
short umbilical cord;
polyhydramnios and outpouring of amniotic fluid;
postponed pregnancy;
a large fruit.
In addition, premature placental abruption can be triggered by mechanical effects:
the fall of a pregnant woman;
punch in the stomach;
careless actions of doctors;
external obstetric rotation of the fetus.
The mother’s bad habits can also complicate the situation.
Symptoms of premature placental abruption
In such a complication as premature placental abruption, the symptoms vary in severity. However, the most common of them are:
bleeding;
hypertonus of the uterus;
stomach pain;
the threat of fetal hypoxia.
It is worth talking about bleeding separately. It can be internal or external, depending on the degree and shape of the detachment.
Marginal detachment in a mild form causes a slight discharge of blood from the genital tract.
Marginal detachment in more severe degrees is accompanied by profuse bleeding. Pregnant women have to change the pad or tampon about once an hour.
The central detachment does not entail visible bleeding, in other words, it is internal. Blood permeates the uterine wall and forms a retroplacental hematoma.
It is necessary to pay attention to one more important detail — the color of the secreted blood. If the blood is bright red, it means that it comes from the uterine wall, and if it is dark, it comes from a hematoma.
Uterine hypertonus and pain syndrome are increasing in parallel. When examining the uterus , it is found:
tension;
soreness during palpation;
asymmetry;
increase in size;
protrusion of retroplacental hematoma on the lateral or anterior wall.
The pain is caused by stretching of the serous lining of the uterus and is more pronounced with central detachment.
In addition, a woman may have the following symptoms of premature placental abruption:
back pain;
increased diastolic pressure;
tachycardia;
dizziness;
pallor of the skin;
general weakness.
The fetus also reacts in its own way to premature placental abruption. In some cases, his heartbeat slows down (less than 120 beats per minute), in some cases, on the contrary, it accelerates (more than 160 beats per minute).
The state of hypoxia occurs when a third of the placental surface is detached. If the detachment is non-progressive, the child can be saved if the placenta has no functional or morphological defects. If the area of placental abruption exceeds a third of the surface, then in most cases the fetus dies.
Diagnosis of premature placental abruption
The diagnosis of “premature detachment of a normally located placenta” is based on the results:
interviewing the patient for complaints;
general examination of a woman;
obstetric and gynecological examination;
ultrasound diagnostics of the uterus and fetus;
cardiotocography;
laboratory research.
During a gynecological examination, the doctor pays attention to the cervix and the external pharynx. When the fetal bladder is opened, bloody impurities may be contained in the amniotic fluid with premature detachment of the placenta.
Ultrasound shows:
where is the retroplacental hematoma located;
what are its dimensions and structure;
what is the area of placental abruption.
It is impossible to overlook the fact that a slight form of marginal detachment cannot be detected using ultrasound.
Cardiotocography allows you to objectively assess the condition of the fetus, based on the dynamics of its cardiovascular system. Another important test to clarify the condition of the child is the Kleihauer—Bethke test, which reveals whether he is bleeding.
In order to determine whose blood is secreted — the mother or the child, its sample is mixed with tap water and sodium hydroxide. If the blood belongs to the fetus, then the mixture will remain pink, if not, it will change color to yellowish-brown.
Treatment of premature placental abruption
Premature placental abruption requires immediate hospitalization of the pregnant woman. The purpose of treatment is to stabilize the patient’s condition, which implies stopping bleeding and maintaining the viability of the fetus.
If the degree of detachment is light, delivery should not be accelerated, but a woman needs close medical supervision. The main task in this case is to identify the causes of premature detachment of the normally located placenta and their elimination. In addition, a number of related problems need to be solved:
from the hematopoietic system — dissolve blood clots;
from the cardiovascular system — to normalize blood pressure;
on the part of the reproductive system — to relieve muscle tension of the uterus.
The condition of the fetus should be under continuous monitoring. In general, with a mild degree of placental abruption, they adhere to wait-and-see tactics.
In more severe forms of this disorder, as well as in the case of progressive detachment, stimulation of labor or cesarean section is indicated.
The average severity of the detachment allows for childbirth through the natural birth canal. To do this, the following conditions must be met::
cervical maturity;
proportionality of the fetal head and the mother’s pelvis;
head presentation of the child;
sufficient intensity of labor activity.
The doctor’s actions include the following procedures:
mothers get an epidural;
a catheter is connected to the central vein of the mother for timely infusion therapy;
an artificial rupture of the fetal bladder is carried out in order to reduce the intensity of bleeding and accelerate the birth process;
uterine contractions are stimulated with oxytocin.
The whole process should be carried out under the control of the fetal heartbeat, contractile activity of the uterus and hemodynamics of the mother.
If it is not possible to carry out natural childbirth, or the mother’s condition is assessed as severe, it is recommended to perform a cesarean section.
In case of intrauterine fetal death, childbirth should be called immediately.
Sometimes, in order to save the patient’s life, it is necessary to perform surgical removal of the uterus. This is done in the case of impregnation of the uterine wall with blood (this phenomenon is called the Kuveler uterus). An organ can be saved if a method of binding the vessels feeding it is available.
Prognosis and prevention of premature placental abruption
Prevention of premature placental abruption requires, first of all, a careful attitude of a pregnant woman to herself:
treatment of gynecological diseases in the framework of pregnancy planning;
timely treatment of pregnancy in a women’s consultation;
visits to an obstetrician-gynecologist on schedule during pregnancy;
prevention of physical and mental overload.
The doctor leading the pregnancy should timely identify pathologies such as:
placental insufficiency;
gestosis;
arterial hypertension.
As for the prognosis for premature placental abruption, everything depends on the timely provision of qualified care to the patient.
