A placental abruption: - pre-mature separation of normally situated

placenta after 22 weeks of pregnancy.- etiology unclear

- associated factors.

sever pre-eclampsia, not chronic HTN.2. after delivery of 1st twins ,and occurrence ROM .3. direct trauma to the abdomen RTA.4. seat belt injury5. violence.6. previous c.s7. High parity.8. cigarette smoking.9. ECV. - incidence 0.4-1.8 %

* partial separation:

- bleeding from maternal venous sinus. apparent bleeding from vaginal due to .retained bleeding behind placenta and

forced into the myometrium, and infiltrate between muscle fibers [bruised, edematous uterus]

-couvelaire uterus-uterine apoplexy

-clp-no vaginal bleeding.-Signs of hypovolemic shock (concealed Hge )uterine enlargement.Extreme pain.

3) Mixed Hge:- bleeding per vagina.- concealed Hge. In the uterine muscle.- revealed , concealed , mixed.

* according to mother and baby condition

mildmoderate.sever Hge.assessing mother condition.

Hx: pre eclampsia.\recent hx of N ,V headache , blurred vision.

Physical domestic violence appear .ECV - RTA.Delivery of first twinsLoss of copious amount of amniotic fluid .Slight localize pain – revealed.- concealed (sever abd. pain.)

General examination:Anxious , abd pain, palloredema of the face, fingers, pretibial area.Alteration of v/s, except Bp in case of PIH Respiration & pulse within normal. Temp. :normal – air hunger if sever infection developed fever.Brown dark blood .Fresh bright.

Abd examination.More than expected gestational age

concealed .Hard uterus.Rigid uterus, painful.Gaurading on palpation of abdomenUs CTG Fetal death is common out come

assessing fetal condition :-fetal movement-CTG-U\s

management:I Vcanula , CBC , blood group , cross

match ,clotting factors.psychological care.analgesic for pain morphine 15 mg , pethidine

100-150mg.differentiate between pain from concealed

hemorrhage, or pain from uterine contraction.

source of pain:

bleeding between muscle and membrane of placenta

labor pain sub capsular hemorrhage ( pre -eclampsia)management of shock (hypovolemic

shock ,hemorrhagic plasma or blood transfusion haemacele :-doesn't alter platelet functions ,improve

renal function position left side ,sever shock elevate legs ,semi

recumbent position

-midwifery role :

Resuscitate mother before surgery Check v\s regularly CvpCanula in place I&o recorded by indwelling catheter Urinanalysis for proteinuria Fluid requirement should record Fundal height checked regularly Continuous CTG if baby living Anti D for mother RH –ve

*management of different degree of placental abruption 1-mild (incidental ):Mild separation of placenta ( partial )Slight vaginal bleeding Mother &fetus in stable condition

-no signs of shock -abdomen lax -soft uterus-??ppDx: u/s Rx:u/s -v/s -fetal condition monitoring by CTG -if mother not in labor ,< 37 weeks follow up->37 weeks IOL

*IOL:done in case of :1-mild episode of bleeding 2-no evidence of fetal compromise Nb: anemic mother with mild abruption

placenta need more concern

Moderate:

Separation of placenta 1\4-vaginal bleeding -formation of retro placental blood clot C/p:-uterine tenderness-increase pulse rate -decrease blood pressure -hypoxic baby -IUFD

Management :-manage shock -analgesic -fluid & blood transfusion -cvp monitoring-continuous CTG -vaginal birth : contracted & stop bleeding after birth -psychological support * augmentation of labor :1-amniotomy ROM 2-oxytocin infusion

- sever type :

-acute emergency condition -detachment of placenta 2\3 -life threatening condition -most of blood concealed -sever shock decrease blood pressure ,if

normal suspect pre-eclampsia cases -fetus almost died -sever abdominal pain -board like abdomen

* ComplicationsDIC -RF Pituitary dysfunction -The same as moderate treated by blood

transfusion, cs delivery in case of sever bleeding

cvppain relief

*Care of the baby:Asphyxia (pediatrician, equipment well

prepared)may need neonatal ICU physical care :full information and explanation to the family.

Partner support.If baby go neonatal ICU "visit her"Let mother to handle her baby before going

to nursery.N.B abruption placenta has a risk factor for

recurrence in the next pregnancy.

Complications

DIC is a complication of moderate to severe placental abruption.

• Postpartum hemorrhage may occur as a result of the Couvelaire uterus and disseminated intravascular coagulation, or both. Intravenous ergometrine 0.5 mg is given at birth as a prophylactic measure.

• Renal failure may occur as a result of hypovolaemia and consequent poor perfusion of the kidneys.

Pituitary necrosis is another possible consequence of prolonged and severe hypotension (also known as Sheehan's syndrome; see medical texts for details of this rare condition).

• The maternal mortality rate due to placental abruption is 1%

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