References:
- Dr. RPS Maternal and Newborn Care: A Comprehensive Guide and Source Book for Teaching and Learning, 2nd Edition, ISBN 978-971-98-2265-3, by Rosalinda Parado Salustiano (pp. 117-195)
- Lecturer (V)
An abruptio placenta is a complication of late pregnancy or labor characterized by premature partial or complete separation of a normally implanted placenta; also termed as accidental hemorrhage and ablatio placenta. This is the second leading cause of bleeding in the third trimester; occurring in 1:300 pregnancies second only to placenta previa. Risk factors for abruptio placenta include:
- Maternal hypertension; PIH (#1), renal disease
- Sudden uterine decompression such as in polyhydramnios and multiple gestation.
- Advanced age
- Multiparity
- Short umbilical cord: double cord-coil
- Trauma (#2); fibrin defects
- Inappropriate use of oxytocin
- Infection
| Types | Description |
|---|---|
| Type I | Classic concealed, covert, central type. The placenta separates at the center (schultz), causing blood to accumulate behind the placenta, hiding the presence of bleeding. External bleeding does not appear to match the severity of shock. |
| Type II | Marginal, overt, external bleeding type. The placenta separates at the margins (duncan), allowing old blood (dark red, brown) to spill out. In this type, external bleeding matches the severity of shock. |
| Type III | Mixed. Some part of the blood remains concealed, while some are expelled. |
Assessment Findings and Diagnosis
- Painful vaginal bleeding in the third trimester.
- Rigid, board-like, and painful abdomen.
- Enlarged uterus from concealed bleeding; signs of shock that may be disproportional to external bleeding.
- Tetanic contractions if in labor— alternating contraction and relaxation does not occur.
Diagnosis is based on clinical signs and symptoms and an ultrasound to image retroplacental bleeding.
| Areas of Major Differences | Placenta Previa | Abruptio Placenta |
|---|---|---|
| Placental Location | Lower uterus | Upper uterus |
| Bleeding | Painless, vaginal, fresh, bright red | Painful, often concealed, dark, old blood if external |
| Abdomen | Soft/flaccid; during labor with intermittent hardening and softening corresponding with uterine contractions. | Hard, board-like; during labor, No characteristic intermittent hardening and softening of the abdomen. |
| Major Complications | Hemorrhage Prematurity Obstruction of the birth canal | Hemorrhage Couvelaire Uterus Disseminated Intravascular Coagulation (DIC) |
| PIH as a risk factor | PIH is not a risk factor | PIH is a major risk factor |
Clotting studies reveal the presence of DIC and clotting defects. The thromboplastin from the retroplacental clot enters maternal circulation and consumes maternal free fibrinogen, resulting in DIC and hypofibrinogemia.
Management for both Placenta Previa and Abruptio Placenta
- No Internal Examination; external fetal monitoring
- Watchful Waiting
- Cesarean Section. AP may result in fetal distress faster than PP.
- Coomb’s Testing