It is one of the leading cause of vaginal bleeding and maternal death in the last three months of pregnancy (third trimester) and It can occur in any 9 mothers out of 1000. In addition to the maternal problems, this can seriously affect the fetus.This has around 20 – 40 % death rate for the fetus, even in the best units in the world, and accounts for around 6% maternal deaths.
Placental Abruption is more common in African American women in USA. Increased risk is observed in women less than 20 years and more than 35 years.
What causes it?
Multiple risk factors are identified like smoking prior and during pregnancy. Cocaine abuse is another risk factor.
Abdominal trauma is a well known cause of Placental Abruption. Especially by road traffic accidents. It can occur due to wearing of seat belts in the mid abdomen. Lower seat belt should extend across pelvis to prevent placental abruption.
Other more common causes are previous placental abruption, prolonged rupture of membranes, chorioamnionitis (infection in fetal membranes), hypertension in pregnancy, maternal age >35 and low socioeconomic status.There is also a relationship with thrombophilia (Increased blood clot formation) according to some literature.
What are the symptoms?
Symptoms are mainly vaginal bleeding (80%), severe abdominal pain, uterine contractions, uterine hardness and low fetal movements. During the clinical evaluation, doctors try to differentiate this with placental previa (placenta is situated lower than normal) and the normal labour.
What is a concealed hemorrhage?
Sometimes blood is pooled between placenta and the uterus. So the patient is only having a severe abdominal pain without vaginal bleeding. Rarely low fetal movements are the only presenting symptom.
The doctor will detect low blood pressure, high pulse rate, abdominal tenderness and reduced fetal heart sounds. Prolonged reduced fetal heart sounds usually carry a bad prognosis for the fetus.
What are the tests patient must undergo?
Ultra sound examination, is the best form of investigation. But it is dependent on the experience of the radiologist. In addition, negative ultra sound scan does not exclude placental abruption.
Management can continue only with the clinical judgement of the doctor. Possible ultra sound scan findings consistent with placental abruption include seeing a retroplacental clot (Blood clot between placenta and uterine wall), expanding hemorrhage and reduced fetal heart beat.
Fetal Cardiotocograph is a chart of fetal heart rate over time. It can reliably detect fetal compromise. In placental abruption Cardiotocograph will show reduced heart rate for longer time.
How placenta abruption is treated?
It depends on the degree of placental abruption. Treatment includes watchful waiting in mild abruptions, and caesarian section if the baby is alive. But if the mother is stable and baby has died vaginal delivery is the preferred option.
What are the complications?
Intra uterine fetal death is the most devastating complication other than the maternal death. Prolonged bleeding is the main cause of maternal deaths. Maternal death may be the outcome of disseminated intravascular coagulation (wide spread clot formation, which leads to consumption of clotting factors in blood) as well.
Termination of the pregnancy is the only treatment option in most of the time. It has to be done even the baby is premature to save the life of mother. Sometimes Hysterectomy (Removal of uterus) is the only option available to save the mother's life.
Further reading/Sources
1. www.emedicine.com
2. Obstetrics by Ten Teachers by Christoph Lees
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