abruptio placenta b-1 ppt
TRANSCRIPT
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ABRUPTIO PLACENTA
OBG B UNIT
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Definition A seperation of placenta from site of its
implantation before delivery.(latin-rendering placenta as under).
Incidence• Range of 0.52% - 1.29%.Increases with “increased
gestational age”.
• Perinatal mortality- 119/1000 live births Vs 8.2/1000 due to other causes.
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ETIOLOGY
• MATERNAL HYPERTENSION. • PROM. • CIGARETTE SMOKING,COCAINE ABUSE. • THROMBOPHILIAS. • SUDDEN UTERINE DECOMPRESSION
(polyhydramnios). • EXTERNAL TRAUMA. • UTERINE LEIOMYOMA. • PRIOR ABRUPTION.
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RISK FACTORS RISK FACTORS
increased age n parity preeclapmsia chronic hypertension PROM
multifetal gestation hydramnios chronic smoking thrombophilias cocaine abuse prior abruption uterine leiomyoma
RELATIVE RISK 1.3-1.5 2.1-4.0 1.8-3.0 2.4-4.9 2.1 2.0 1.4-1.9 3-7 NA 10-25 NA
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PATHOLOGY Haemorrhage into decidua basalisdecidua
splits leaving a thin layer adherent to myometriumdecidual haematomaseparation,compression & destruction of placenta.
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PATHOLOGY Decidual spiral artery
ruptureretroplacental haematomathe area of separaton becomes more extensive upto marginuterus unable to contractblood dissects membrane from utrine wall & escapes out or remains concealed
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Pathological classification
REVEALED CONCEALED CONCEALED
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Causes of concealed haemorrhage
• Effusion of blood behind placenta but margin adherent.
• Placenta separeted but membrane still retain their attachment.
• Blood gains access through amniotic cavity.
• Fetal head closely applied to lower segment that prevents blood escape.
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CLINICAL FEATURES Vaginal bleeding 78%
utrine tenderness 66% fetal distress 60% preterm labour 22% high frequency of contraction17% hypertonus 17% dead fetus 15%
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CLINICAL CLASSIFICATION
GRADE 1- not recognised clinically & diagnosed by retroplacental
clots after delivery.
GRADE 2-intermediate,classical signs present but fetus still alive.
GRADE 3-severe, fetus is dead. 3a-without coagulopathy. 3b-with coagulopathy.
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DIFFERENTIAL DIAGNOSIS
WITH VAGINAL BLEEDplacenta praevia, uterine rupture, vasa praevia.
WITHOUT VAGINAL BLEEDrectus sheath haematoma, retro peritoneal haemorrhage, rupture of appendicular abcess, acute degeneration or torsion of uterine fibroid.
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COMPLICATION
• Hypovolemic shock.
• Acute renal failure.
• DIC.
• Couvelaire uterus.
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Couvelaire uterus
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MANAGEMENT OF ABRUPTIO• ROLE OF IMAGING
Poor sensitivity
• When clot visualized,PPV high
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IUD with abruption
• Blood for grouping,crossmatching
• Hb%,PCV
• DIC Profile
• LFT,RFT
• Urine routine
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• Replace blood loss
• Correct coagulopathy
• Deliver the baby
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Evaluation and replacement of blood loss
• Aggressive correction despite normal vitals & Hct
• Insert CVP catheter,Foley’s catheter
• Transfuse packed cells
• Expand volume with RL/NS
• 1 FFP after every 4U packed cells
• Maintain PCV 30%,urine O/P of 30 ml/hr
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Management of coagulopathy
Normal values of DIC profileFibrinogen -150 to 600 mg/dl
PT -11 to 16 sec
PTT -22 to 37 sec
Platelet count -1.2 to 3.5 lak/ cmm
D-dimer - <0.5 mg/l
FDP - <10 microgram/dl
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• Clot retraction test- For function of platelets
• Clot lysis- Gross measure of fibrinolytic system
• Transfuse 10-20 U of cryoppt if fibrinogen <100 mg/dl
• Transfuse platelets if count <40,000
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Termination of pregnancy
• Vaginal delivery unless no CI
• Early amniotomy
• Oxytocin infusion
• Time for obtaining delivery upto 24 hrs
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Live fetus but in distress
• Emer LSCS
• Evaluate hemostatic system
• Speed of delivery important
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Live fetus ,FHS normal
• Induce and allow for vaginal delivery
• Continuous CTG
• If CTG abnormal,LSCS
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Expectant Mx in preterm
• Only in mild cases
• To await lung maturity
• Hospital stay a must
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