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Abruptio Placenta

Abruptio placenta is defined as haemorrhage occurring in pregnancy due to the separation of a normally situated placenta. It is also called accidental haemorrhage or premature separation of placenta.

Risk Factors for Abruptio Placenta

  1. Increased age and parity
  2. Preeclampsia and chronic hypertension
  3. Preterm ruptured membranes
  4. Cigarette smoking and cocaine use
  5. Thrombophilia
  6. Prior abruption (risk of recurrence is 17% for patients with one abruption and 25% for patients with more than one abruption)
  7. Uterine leiomyoma
  8. Multifetal gestation
  9. Polyhydramnios
  10. External trauma

Signs and Symptoms of Abruptio Placentae


Signs and Symptoms

Frequency (%)

Vaginal bleeding


Uterine tenderness or back pain


Fetal distress


High-frequency contractions




Idiopathic preterm labor


Dead fetus


Page's Classification for Abruptio Placentae




Grade 0

Retrospective diagnosis (after delivery)

Grade 1

External bleeding, uterine tenderness, and no fetal distress

Grade 2

Fetal distress or IUFD

Grade 3

Maternal shock, with or without DIC

  1. With IUFD the placental detachment is usually greater than 50%.
  2. Approximately 30% patients will show evidence of coagulopathy.
  3. Pritchard has demonstrated that if abruption is severe enough to kill the fetus the average intrapartum blood loss is about 2500 mL.

Shers classification (1978)

Grade I     Diagnosis of abrptio made retrospectively


Grade II    Classical feature of abruptio are present. Fetus is alive


Grade III   Fetal death without (A) or with (B) coagulopathy


  1. Uncorrected DIC is a contraindication for vaginal delivery and LSCS (always correct DIC first, if present).
  2. Pritchard's rule for management of abruption: keep hematocrit (Hct) at least 30% and maintain urine output of at least 30 mL/h.
  3. Never wait and watch, and never give tocolysis in case of abruption.

Mode of Delivery


Fetus living

 - Fetal distress present – LSCS

 - No fetal distress and vaginal delivery is imminent

 Then vaginal delivery otherwise LSCS

Fetus dead

- Vaginal delivery

Consumptive Coagulopathy (DIC)

  1. One of the most common causes of clinically significant consumptive coagulopathy in obstetrics is placental abruption.
  2. Overt hypofibrinogenemia (less than 150 mg/ dL of plasma) along with elevated levels of fibrin degradation products, D-dimers (FDP), and variable decreases in other coagulation factors are found in about 30% of women with placental abruption severe enough to kill the fetus. Such severe coagulation defects are seen less commonly in those cases in which the fetus survives.
  3. Release of thromboplastin in placental abruption leads to DIC.
  4. Management:

Use fresh frozen plasma 1 unit of FFP raises 5-10 mg/dl of fibrinogen.

A fibrinogen level less than 100 mg/dl or sufficiently prolonged PT/PTT in a woman with surgical bleeding is an indication for FFP in doses of 10-15 ml/kg

  1. Cryoprecipitate – also increase fibrinogen but volume of blood lost is not replenished
  2. Platelet should be given may if count <50,000/ml. Single unit transfusion raises platelet by 5000 – 10,000 / ml.
  3. If female is Rh negative give 300 mcg of anti d after platelet transfusion.
  4. Side by side in abruptio delivery should be done
  5. Uncorrected DIC is a contraindication for vaginal delivery / LSCS.

Extra Edge: Normal Values of DIC Profile

  1. Fibrinogen 150 – 600 mg/dl
  2. PT – 11 -16 sec
  3. PTT 22 – 37 sec
  4. Platelet - 1.5 to 3.5 lac
  5. D dimer - <0.5 mg/l
  6. Fibrin degradation products (FD) <10 mcg/dl

In case of DIC: All clotting factors are consumed so levels of fibrinogen decrease; PT and PTT and FDP, D dimer all increase.

Couvelaire Uterus

  1. There may be widespread extravasation of blood into the uterine musculature and beneath the uterine serosa.
  2. This so-called uteroplacental apoplexy, first described by Couvelaire in the early 1900s, is now frequently called Couvelaire uterus. It is seen in cases of severe concealed abruption.
  3. Such effusions of blood are also occasionally seen beneath the tubal serosa, in the connective tissue of the broad ligaments, and in the substance of the ovaries, as well as free in the peritoneal cavity.
  4. These myometrial hemorrhages seldom interfere with uterine contractions sufficiently to produce severe postpartum hemorrhage and are not an indication for hysterectomy.

Placenta Previa

#Definition: In placenta previa, the placenta is located over or very near the internal os. Four degrees of this abnormality have been recognized:

  1. Total placenta previa: The internal cervical os is covered completely by placenta.
  2. Partial placenta previa: The internal os is partially covered by placenta.
  3. Marginal placenta previa: The edge of the placenta is at the margin of the internal os.
  4. Low-lying placenta: The placenta is implanted in the lower uterine segment such that the placenta edge actually does not reach the internal os but is in close proximity to it.

Risk Factors

  1. Increasing age and increasing parity
  2. Past history (12 times risk of another placenta previa)
  3. Previous LSCS (probability of previa is four times greater than in patients without any uterine scar)
  4. Multiple pregnancy
  5. Prematurity
  6. Smoking
  1. In a case of placenta previa, one-third patients bleed before 30 weeks, one-third from 30 to 36 weeks, and one- third bleed after 36 weeks.
  2. In a case of placenta previa with previous one LSCS the incidence rate of placenta accreta is 25%, which increases to % with previous four LSCS.
  3. Frederiksen and coworkers reported a 25% hysterectomy rate in women undergoing repeat cesarean for a previa compared with only 6% in those undergoing primary cesarean for placenta previa.
  4. The simplest, most precise, and safest method of placental localization is provided by transabdominal sonography, which is used to locate the placenta with considerable accuracy. False-positive results are often a result of bladder distention. Therefore, ultrasonic scans in apparently positive cases should be repeated after emptying the bladder.
  5. Type 2 b = dangerous placenta previa.
  6. Stallworthy's sign (slowing of FHR on pressing the head down into the pelvis) is seen in placenta previa.
  7. Cesarean delivery is necessary in practically all women with placenta previa (even if the fetus is dead).

McAfee and Johnson Regimen (Conservative Management in Placenta Previa)

This consists of complete bed rest, tocolysis, and close observation of patient.


Steroids are generally given to enhance lung maturity.


To undertake this regimen (to wait and watch), all the three criteria should be fulfilled:

  1. Mother should be hemodynamically stable.
  2. There should be no fetal distress.
  3. Pregnancy should be less than 36 weeks of gestation.

If anyone of these criteria is not met, then the patient should be delivered by LSCS.

Management of placenta previa and preterm labour

  1. Tocolytic agent: “Uterine contractions are common in patients with placenta previa. Since uterine contractions have the potential to, disrupt the placental attachment and aggravate the bleeding, most obstetricians favor the use of tocolytic agents in the expectant management of patient with placenta previa”.
  2. Most common used tocolytics in case of placenta previa
    1. Nifedipine
    2. Magnesium sulphate
  3. Tocolytics which are not used –
    1. Terbutaline and Ritodrine: They cause tachycardia and make the assessment of patient pulse rate unreliable.
    2. Indomethacin: it cause inhibition of platelet cyclo oxygenase system and prolongs the bleeding time.
  4. Besides this – patient should be:
    1. Put on bed rest in left lateral position
    2. Glucocorticoids are given to hasten lung maturity

VASA Previa

  1. It occurs due to velamentous insertion of the cord (i.e. cord inserted onto the fetal membranes)
  2. Blood loss which occurs is fetal in origin and so there is increased fetal mortality – (75 to 90%), maternal mortality is not increased.
  3. Can be diagnosed antenatally by Doppler study
  4. When bleeding occurs: Sinusoidal fetal heart rate pattern seen
  5. Diagnosis made at the time of bleeding is by – Singers alkali denaturation test / Apt test
  6. Management – Emergency Cesarean section
  7. Wright Stain:
  8. On staining blood with Wright stain if RBC’s appear nucleated the blood is of fetal origin.

Extra Edge: Some other named classifications and Regimes

Named classification / Regine

Used in

Macaffee and Johnson Regime

Expectant management of placement previa

Page classification

Abruptio placenta

Sher classification

Abruptio placenta

Clarke’s classification

Classification of heart disease based on maternal mortality

Lytic cocktail regime (used 3 drugs – chlorpromazine, promethazine and pethidine)

Proposed by Menon for management of convulsion in eclampsia

Whites classification

Earlier used for classification of diabetes in pregnancy

Caldwell and Mohoy classification

Types of pelvis

Extra Edge:
Guide to adequate blood replacement

  1. Maintenance of central venous pressure at 10 cm of water
  2. Hematocrit = 30%
  3. Urinary output = 30 ml/hour

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