Symptoms, complications and treatment of Abruptio placentae

Placental abruption is separation of the placenta from inner wall of the uterus that occurs before the onset of labor. Main symptoms of placental abruption are vaginal bleeding, severe abdominal pain and reduced fetal movements. It should be suspected in any woman who develops vaginal bleeding in the last three months of pregnancy.

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

Overview of common drugs prescribed for nausea and vomiting

Nausea and vomiting are very common symptoms in the day to day illnesses everyone get. Sometimes they can be symptoms of serious illnesses. Even though, it is a common symptom, it can become very troublesome one too. But there are effective drugs for this troublesome symptom. Some drugs are over the counter and others are prescription only.

 Although troublesome, vomiting is a natural defense against the toxins and germs. To induce vomiting, the brain has two dedicated parts. First one is called the Chemoreceptor trigger zone (CMTZ) and other is the vomiting centre. CMTZ detects certain chemicals in blood and sends the signal to the vomiting centre to induce vomiting. In addition to receiving impulses from CMTZ, the vomiting centre receives other inputs from various brain areas, including inner ear (cause for motion sickness). Some drugs acts on CMTZ and others acts directly on the vomiting centre. Few other drugs act in less understood ways.

 Usually doctors prescribe these drugs, when the diagnosis is sure. In addition, doctors usually do not prescribe vomiting medications in intestinal obstruction.

 Promethazine (Avomine 25mg®)

This is an anti histamine medication, that acts on the Vomiting centre. It is an effective in motion sickness as well as in other causes of vomiting. But the side effects are really troublesome E.g. drowsiness, dry mouth and blurred vision. This is an over the counter medication in some countries.

Metoclopramide (Emenil 10mg®)

This is a prescription only drug in Dopamine receptor antagonist family. This medication acts on CMTZ and in the gastrointestinal system. This drug inhibits CMTZ and increases the gastro intestinal transition. Main side effect is abnormal movements called the extra pyramidal symptoms. They are caused by widespread dopamine blockade inside the brain.

Domperidone (Domstal®)

This is a similar drug to Metoclopramide. But drug concentration in brain is low after administration. So abnormal movements are very much less. In USA this drug is not yet approved.

 Chlorpromazine (Largactil®) and Haloperidol

These drugs are primarily used in psychotic disorders, but they are effective in stopping vomiting as well. Due to their calming effect, it is used in patients with terminal illnesses. Action and side effects are similar to Metoclopramide.

 Dolasetron (Anzemet®), Granisetron (Kytril®) and Ondansetron (Zofran®)

 These prescription only drugs act on the serotonin receptors in brain and especially on the CMTZ. They are mainly used in cancer patients following chemotherapy.

 Aprepitant (Emend®) and Fosaprepitant (Ivemend®)

 These drugs act on Neurokinin 1 receptors. They are prescribed in cancer chemotherapy with other anti emetics medications.

Steroid Dexamethazone is also used in vomiting associated with cancer chemotherapy. Another drug used in vomiting in the condition called meniere’s disease is Betahistidine (Serc®).

 Sources
British National Formulary

Treatment of Heart attacks

Myocardial infarction or Heart attack is caused by the death of heart muscles. This is usually caused by decreased blood supply to the heart muscles. Although heart pumps blood, heart muscles cannot get oxygen/nutrients from the blood it pumps. So the heart is supplied by the coronary arteries. Coronary arteries are blocked by the accumulation of cholesterol. This leads to formation of blood clots inside the arterial lumen. Treatment includes removal of the block and to prevent future blocking. If the block cannot be removed then the doctors create a separate path for the blood to travel (bypass grafting).
 Myocardial infarction is a serious disease with high mortality. Death of  large part of the heart will arrest blood circulation in the body and lack of oxygen to the brain can cause death.
  Heart muscles cannot regenerate, so death of heart muscles causes permanent damage to the heart as well. This can leads to long term heart failure with ankle edema, difficulty to breathe and poor exercise tolerance.
 Symptoms
Left side tightening type chest pain, difficulty in breathing; sweating and apprehension are the main symptoms.
 Treatment
 Giving oxygen to the patient is usually the first step. Then patient is given Aspirin 75mg orally to prevent further clot formation. Glyceryl Tri Nitrate tablets are given sub lingual (under the tongue) to dilate the coronary arteries. These measures increase the oxygen level in heart muscles.
 Patient should rest in the bed to decrease the demand put on heart muscles as well. Then the doctor will give a shot of Morphine for pain relief. Morphine has some arterial dilatation properties as well.
 Clearing the blocked arteries and maintaining adequate blood supply to the brain are the main priorities in the first 24 hours. For that powerful thrombolytics (drugs that dilutes formed clots) are used. E.g. Streptokinase, Recombinant tPA. If above steps are failed, the doctor will dilate the coronary arteries by using a balloon inserted through skin (per cutaneous angioplasty).
 Once patient recovers from the initial ordeal, doctors try to find a cause for this heart attack. This can be due to increased fats and cholesterol in the diet, Diabetes mellitus, hypertension or stressful life style. Some people can have genetic predisposition for the heart attacks and increased cholesterol in the blood as well.
 Then doctors will try to correct above problems to prevent further damage to the heart. Patient needs life style modification like eating low cholesterol diet and regular exercises to prevent heart attacks in the future. After a myocardial infarction exercises should be undertaken with expert guidance.
 Sources
Clinical Medicine by Kumar and Clark