What is dangerous premature detachment of a normally located placenta. Premature detachment of a normally located placenta, symptoms, causes, signs
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Premature detachment of a normally located placenta
What is Premature detachment of a normally located placenta -
Premature abruption of a normally located placenta (PONRP)- this is an untimely separation of the placenta that occurs during pregnancy or in the first and second stages of childbirth. This complication occurs with a frequency of 0.5-1.5% of observations.
In 1/3 of cases, PONRP is the cause of massive bleeding, hemorrhagic shock and DIC. Maternal mortality ranges from 1.6 to 15.6% due to bleeding and hemorrhagic shock.
PONRP is distinguished as partial, which in turn qualifies as progressive and non-progressive, and complete.
What provokes / Causes of Premature abruption of a normally located placenta:
Factors leading to PONRP can be conditionally divided into two groups.
Factors directly contributing to the development of this complication:
- gestosis (often long-term, untreated or insufficiently treated);
- extragenital diseases (arterial hypertension, arterial hypotension, heart defects, kidney disease, diabetes mellitus, thyroid disease, adrenal cortex disease, tuberculosis, syphilis, etc.);
- isoserological incompatibility of the blood of the mother and fetus according to the ABO system and the Rh factor;
- autoimmune conditions (APS, systemic lupus erythematosus);
- blood diseases (congenital and acquired coagulopathy);
- degenerative-dystrophic changes in the uterus due to inflammation, surgical interventions, multiple complicated births;
- malformations of the uterus;
- the location of the placenta in the projection of the myomatous node (intermuscular node with centropetal growth, submucosal node);
- delayed pregnancy.
Factors provoking PONRP against the background of already existing pathomorphological disorders:
- overstretching of the walls of the uterus due to polyhydramnios, multiple pregnancy, the presence of a large fetus;
- sudden, rapid and copious outflow of amniotic fluid with polyhydramnios;
- trauma (fall, blow to the stomach);
- external rotation of the fetus;
- gross obstetric examination;
- short umbilical cord;
- discoordination of the contractile activity of the uterus;
- irrational use of uterotonic drugs in childbirth;
- the birth of the first fetus with monochorionic twins.
Pathogenesis (what happens?) during Premature abruption of a normally located placenta:
Premature detachment of a normally located placenta often develops in nulliparous women. In preterm birth, placental abruption is observed 3 times more often than in timely ones.
PONRP should first of all be considered from the point of view of the transition of chronic FPI to its acute form.
The development of premature detachment of a normally located placenta, as well as FPI, causes a number of interrelated pathogenetic mechanisms.
Insufficiency of cytotrophoblast invasion leads to the formation of a narrow lumen of the spiral arteries, their increased resistance and sensitivity to the action of vasopressor factors. The created conditions prevent the development of normal uteroplacental circulation, which leads to a decrease in the blood supply to the placenta and ischemia of the villi. A significant role in reducing the intensity of blood flow in the uteroplacental vessels is played by hypovolemia (with preeclampsia), arterial hypotension, and heart defects.
Violation of the outflow of blood from the intervillous space in cardiovascular and pulmonary diseases, with uterine hypertonicity also negatively affects the nature of the BMD. During uterine contractions, pressure in the myometrium, amniotic cavity and in the intervillous space increases significantly. At the same time, in the uteroplacental arteries, the blood pressure does not change significantly, and the venous outflow practically stops. Against this background, there is a significant slowdown in blood circulation in the intervillous space. The balance between intra-amniotic, myometrial pressure and pressure in the intervillous space is also disturbed. The progressive increase in pressure in the latter to a level exceeding systemic arterial pressure serves as an obstacle to blood flow through the spiral arteries. The immaturity of the villous tree also has a significant impact on the creation of conditions for PONRP, in which, first of all, the process of formation of terminal villi and their vascularization is disturbed.
A decrease in blood flow velocity in the intervillous space, especially in combination with a violation of the synthesis and balance of prostaglandins (prostaglandins E2 and F2a, prostacyclin and thromboxane A2) leads to thrombosis, hypercoagulation, increased blood viscosity, fibrin deposition, decreased microcirculation and the development of placental ischemia, increased vascular permeability.
Thus, the interconnected pathogenetic prerequisites for PONRP are:
- structural disorders in the walls of the vessels of the subplacental zone;
- complete or partial obstruction of the spiral arteries due to atherosclerotic changes;
- decrease in the elasticity of the vascular wall and increase its permeability;
- pathological immaturity of the villous tree;
- violation of the venous outflow of blood from the intervillous space;
- increased pressure in the intervillous space;
- disorders of the vascular-platelet link, thrombosis or microembolism.
These factors lead to disruption of the links between the placenta and the uterine wall, rupture of blood vessels with the formation of hematomas, which gradually merge with each other, destroying the decidua, and form an increasing retroplacental hematoma at the site of placental abruption.
With detachment of the placenta closer to its central part, the resulting retroplacental hematoma, increasing, swells along with the placenta towards the amniotic cavity and, with a whole fetal bladder, contributes to an increase in intrauterine pressure. There is no external bleeding, and the massiveness of internal bleeding depends on the area of detachment, the rate of blood flow, the initial state of the hemostasis system, and the contractile activity of the uterus.
If the site of placental abruption is small, then after the formation of a retroplacental hematoma, thrombosis of the uterine vessels is possible against the background of compression of the villi. Further placental abruption stops. At the site of detachment, heart attacks and salt deposits are formed, which are recognized when examining the placenta after childbirth.
With significant placental abruption, massive bleeding and extensive retroplacental hematoma, the outflowing blood diffusely permeates the myometrium up to the visceral peritoneum. Multiple hemorrhages in the thickness of the myometrium lead to damage to the neuromuscular apparatus of the uterus and a violation of its contractility. This condition is a utero-placental apoplexy and was called "the uterus of Couvelaire" by the name of A. Couvelaire, who first described such a picture.
Pain detachment of the placenta is formed closer to its edge, then the blood, penetrating between the fetal membranes and the wall of the uterus, pours into the vagina, which is manifested by external bleeding. When bleeding occurs soon after placental abruption, the blood flowing from the vagina is usually scarlet. Dark blood with clots is noted if some time has passed from the moment of detachment to the onset of bleeding.
An important pathogenetic aspect in the development of PONRP is the features of previous disorders of the hemostasis system.
It is known that chronic DIC occurring in gestosis, in which, in turn, PONRP is most often noted, leads to prolonged consumption of coagulation factors (fibrinogen, other procoagulants, platelets) and depletion of the fibrinolysis system. The longer and more severe the course of preeclampsia, the more pronounced these violations. DIC with gestosis does not develop against the background of placental abruption, but passes from a chronic form to an acute one. At the same time, the depleted fibrinolysis system cannot ensure the dissolution of a huge number of circulating microcoagulations, which leads to severe damage to the microcirculation. Clinically, against the background of bleeding, this is expressed in the development of cerebrovascular accident, coma, acute renal-hepatic and pulmonary insufficiency. It should be emphasized that PONRP should be considered as an extremely unfavorable outcome of preeclampsia.
Against the background of other complications with significant activation of fibrinolysis, which contributes to increased bleeding, the prognosis of PONRP is also very unfavorable. At the same time, microcirculation disorders are significantly aggravated and, as a result, irreversible changes in vital organs develop. In cases of bleeding during PONRP in patients without preeclampsia, DIC develops a second time as a result of successive changes in microcirculation due to hemorrhagic shock. With the retroplacental hematoma formed in the process of detachment, a huge amount of active thromboplastins enters the maternal circulation, which causes DIC with the consumption of coagulation factors.
With the same volume of recorded blood loss in surviving and deceased women as a result of PONRP, in the latter case, a more pronounced coagulopathy of consumption was noted with a slight activation of fibrinolysis.
Symptoms of Premature detachment of a normally located placenta:
Clinical course of PONRP depends on:
- degree of detachment;
- severity of comorbidities;
- state of the hemostasis system.
PONRP may be mild. In this case, clinical symptoms will be scarce. The patient's condition is satisfactory (hematoma volume 50-100 ml does not affect hemodynamics). The uterus is in normal tone or somewhat tense. The fetal heart rate is not affected. From the genital tract observed bloody discharge in a small amount.
In severe cases, detachment, as a rule, occurs acutely and is characterized by pronounced clinical signs of hemorrhagic and painful shock.
PONRP may be accompanied by external bleeding from the vagina or be latent (blood accumulates between the placenta and the uterine wall with the formation of a retroplacental hematoma). Amniotic fluid is often stained with blood.
In the area of the uterus where the placenta is located (when the placenta is localized on the anterior or lateral walls of the uterus), due to the presence of a retroplacental hematoma, local swelling and pain occur, which quickly increase and gradually spread to the rest of the uterus. When the placenta is located on the back wall, the pain is diffuse and unclear. Local pain may be mild or not expressed at all when blood flows out.
Hypertonicity of the uterus develops: it becomes tense, painful on palpation, does not relax, acquires an asymmetric shape. Small parts of the fetus are not defined. The presence of uterine hypertonicity indicates that the size of the retroplacental hematoma reaches 150 ml or more. Belly swollen.
Pain in the abdomen and hypertonicity of the uterus due to its stretching, impregnation of the myometrium with blood, irritation of the peritoneum.
The patient has weakness, dizziness, vomiting. The skin and visible mucous membranes are sharply pale. The skin is cold and damp. There is cyanosis of the lips. Breathing quickened. The pulse is frequent, weak filling and tension. Arterial pressure is reduced. Hemodynamic disorders develop when the volume of retroplacental hematoma is 300 ml.
At the same time, signs of increasing hypoxia and fetal asphyxia appear. The suffering of the fetus and its death are due to a pronounced reduction in gas exchange due to a decrease in the active area of the placenta during its detachment and a decrease in the BMD. With a size of retroplacental hematoma of 500 ml or more and / or an area of detachment of more than 1/3, as a rule, the fetus dies in all cases.
With an increase in the time interval from the moment of placental abruption to delivery, clinical symptoms of increasing consumption coagulopathy with thrombocytopenia are noted, which is manifested by a petechial rash on the skin of the face and upper extremities, the formation of hematomas, prolonged bleeding from injection sites, etc. With a retroplacental hematoma of 1000 ml or more, it is necessary clinical signs of coagulopathy are observed. With the development of DIC, the blood flowing from the genital tract forms loose clots or does not coagulate. Hematuria is noted.
The clinical symptoms of PONRP may be accompanied by signs of insufficiency of vital organs caused by preeclampsia: oligoanuria, cerebrovascular accident, etc. The severity of these signs in preeclampsia in some cases can mask the true picture of PONRP, especially in the absence of external bleeding.
Profuse bleeding may occur after the birth of the fetus, due to uterine atony in combination with acute coagulopathy. The uterus, soaked in blood, loses its ability to contract. The gaping vessels of the subplacental zone become a constant source of bleeding. The outflowing blood is unable to clot. It contains only a small amount of procoagulants due to their long-term prior intravascular consumption. Fibrinolytic activity increases and DIC progresses rapidly. Bleeding becomes very intense, takes on a generalized and indomitable character. There is profuse bleeding from the uterus, from soft tissue wounds, surgical wounds, injection sites. Widespread hematomas and small hemorrhages are found in the parauterine (parametric) tissue, fallopian tubes, ligamentous apparatus of the uterus, on the skin of the neck, trunk, and extremities. The duration of clinical signs of coagulopathy during treatment reaches 3-6 hours. Shock progresses rapidly, the severity of which is aggravated due to the development of hypovolemia, peripheral circulatory disorders and damage to vital organs.
Another variant of the clinical course of PONRP against the background of depletion of the fibrinolysis system (most often with gestosis) is also possible. At the same time, uterine bleeding is insignificant and can be dealt with relatively easily. Generalization of bleeding may not be. Sometimes there is a petechial rash on the face, neck, chest (signs of thrombocytopenia), "marbling" of the skin. At the same time, oliguria or anuria, a violation of the function of external respiration are noted. Perhaps the development of coma. The results of laboratory studies confirm the consumption of blood clotting factors and the depletion of fibrinolysis. It is very difficult to save such patients. The cause of their death is extensive irreversible changes in vital organs due to previous disorders, which are aggravated by bleeding.
Diagnosis of Premature detachment of a normally located placenta:
When establishing a diagnosis, the most important is the correct assessment of the general condition of the patient and the amount of blood loss.
The patient's complaints, anamnesis data, clinical course of the complication, as well as the results of objective, instrumental and laboratory studies should be taken into account. Women with preeclampsia deserve special attention.
Diagnosis of PONRP is primarily based on the detection of blood discharge from the genital tract during pregnancy or childbirth against the background of hypertonicity and asymmetry of the uterus, abdominal pain, combined with signs of increasing hypoxia and fetal asphyxia. Signs of internal bleeding will be indicated by a frequent, soft, easily compressible pulse, arterial hypotension.
In the event of PONRP during labor, contractions weaken, become irregular, and the uterus does not relax between contractions.
Increasing hypoxia and asphyxia of the fetus during auscultation is characterized by tachycardia, followed by bradycardia, and heart rhythm disturbance. According to CTG data, there is a decrease in basal rate variability, the appearance of deep and prolonged late decelerations, incomplete recovery of the heart rate after the end of decelerations, and the appearance of a sinusoidal rhythm.
Diagnosis can be somewhat complicated in cases where there is no external bleeding, and the patient's condition is caused not only by placental abruption, but also by other aggravating circumstances with damage to vital organs and systems, which is manifested by preeclampsia and / or eclampsia, anuria, impaired respiratory function . In this case, the clinical picture of these conditions will dominate over the symptoms of placental abruption.
Significant assistance in the diagnosis of PONRP is provided by ultrasound, which allows you to determine the location and volume of retroplacental hematoma. In the absence of external bleeding, retroplacental hematoma is visualized as a hypoechoic formation of various sizes, located between the wall of the uterus and the placenta. Most clearly, this picture is observed when the placenta is located on the anterior or lateral walls of the uterus.
According to laboratory studies of the hemostasis system, in patients with severe placental abruption, hypocoagulation is noted due to the consumption of blood clotting factors. Revealed a decrease in the number of platelets, the concentration of fibrinogen and the level of antithrombin III.
In pathomorphological diagnosis, PONRP is judged by the macroscopic appearance of the maternal part of the placenta: the presence of facets and depressions. According to microscopic examination, extensive microinfarcts of the placenta, fibrin thrombi, sclerosis of the villi, thinning or absence of decidual tissue are revealed.
In the presence of Kuveler's uterus, the myometrium is imbibed with blood up to the serous membrane. Microscopic signs of uteroplacental apoplexy are: edematous swelling of muscle fibers, dystrophic and necrotic changes in the myometrium, multiple, sometimes confluent hemorrhages into the thickness of the myometrium.
In dead women, widespread hemorrhages are found in the pericardium, under the endocardium, in the pleura, the mucous membrane of the stomach, esophagus, and mouth. Acute anemia, pulmonary edema, atelectasis, severe dystrophic and necrotic changes in parenchymal organs are revealed.
The differential diagnosis of PONRP should be made with imminent and/or ongoing rupture of the uterus or vestigial uterine horn.
In patients with uterine rupture, certain features of the obstetric and gynecological history are noted, indicating the possibility of degenerative changes in the myometrium (a scar on the uterus, curettage of the uterus, inflammatory diseases of the reproductive system, complicated previous births, etc.). Real pregnancy is complicated by overstretching of the uterus (polyhydramnios, multiple pregnancy, large fetus), breech presentation of the fetus. During this pregnancy, there are constant or prolonged irregular pains in the lower abdomen, in the lower back, in the area of the scar on the uterus, or without a clear localization. Childbirth is complicated by a pathological preliminary period, untimely discharge of amniotic fluid, discoordination of labor, signs of a discrepancy between the size of the presenting part of the fetus and the mother's pelvis.
The appearance of external bleeding during pregnancy and at the beginning of labor may also be associated with previously undiagnosed placenta previa. However, in these cases, as a rule, there is no tension and local soreness of the uterus. There are also some differences in history. So, PONRP more often develops in young primiparous (primiparous) women with preeclampsia, who have various predisposing extragenital diseases (cardiovascular pathology, kidney disease, diabetes mellitus, etc.). Placenta previa is more typical for multiparous women with burdened obstetric and gynecological history.
Treatment of Premature detachment of a normally located placenta:
The sequence of actions for PONRP:
- analyze the patient's complaints;
- assess her general condition and the severity of the complication;
- determine hemodynamic parameters and the severity of hemodynamic disorders;
- perform an external obstetric examination (the condition of the uterus, its tone, the presence of contractions, local swelling, soreness);
- determine the condition of the fetus, whether he is alive or not;
- to perform a vaginal examination to clarify the obstetric situation, the presence of labor, to resolve the issue of amniotomy;
- determine the next course of action.
With progressive PONRP, its severe course and the absence of conditions for urgent delivery through the birth canal (during pregnancy, regardless of the term, or during childbirth), only urgent caesarean section is indicated, providing immediate delivery. In the absence of labor, early amniotomy should not be performed, since a decrease in intrauterine pressure may aggravate the onset of PONRP.
In this situation, it is necessary to quickly empty the uterus, since over time from the moment of placental abruption to delivery:
- bleeding progresses;
- retroplacental hematoma increases;
- thromboplastic substances enter the gaping uterine vessels;
- aggravated violations in the hemostasis system with the development of DIC;
- fetal hypoxia increases (danger of his death);
- there is an imbibition of the myometrium with blood with damage to the neuromuscular apparatus of the uterus, which further leads to the development of atonic bleeding;
- conditions are created for the rapid development of shock.
In this regard, a caesarean section is performed according to vital indications both from the side of the mother and from the side of the fetus. Abdominal delivery allows not only to eliminate the complication that has arisen, but also to provide fast and reliable hemostasis.
The sequence of actions of the previous operations:
- transfer the pregnant woman to the operating room and place a permanent catheter with the determination of hourly diuresis;
- determine the state of the blood coagulation system;
- arrange the introduction of fresh frozen plasma and blood substitutes;
- start a caesarean section.
Features of caesarean section with PONRP are as follows:
- it is advisable to perform a lower median laparotomy (the possibility of revision of the abdominal organs and a wide examination of the uterus) under endotracheal anesthesia;
- after removing the fetus and placenta, it is necessary to bring the uterus into the wound and carefully examine its walls (in particular, its back surface);
- if petechial rashes are detected on the serous membrane of the uterus, starting hypocoagulation (loose blood clots, increased bleeding of tissues), hemorrhagic impregnation of the walls of the uterus (Kuveler's uterus), indicating the presence of DIC, the uterus should be extirpated (if necessary - with ligation of the internal iliac arteries).
Performing supravaginal amputation of the uterus cannot be considered justified in this situation, since the likelihood of resumption of bleeding from the cervical stump is very high, which will require relaparatomy.
After the operation, the puerperal should be in the operating room until the stabilization of hemodynamic and coagulation parameters. To prevent possible bleeding in the postoperative period, uterotonic agents are administered intravenously. Monitor the parameters of the hemostasis system.
With a slight non-progressive placental abruption during pregnancy, a satisfactory condition of the patient, the absence of anemia and signs of fetal hypoxia, it is possible to use expectant management with prolongation of pregnancy in a hospital. At the same time, careful monitoring of the state of the fetoplacental system (ultrasound, dopplerometry, echographic functional assessment of the fetus, CTG), assessment of the hemostasis system, treatment of background diseases and complications of pregnancy, therapy of FPI, correction of the hemostasis system are necessary. However, it should be remembered that PONRP can begin to progress rapidly at any time, and, in addition, it usually occurs against the background of preeclampsia, FPI and other obstetric complications and extragenital diseases that worsen the prognosis of the outcome of pregnancy and childbirth. If there are repeated, even slight bleeding, indicating the progression of placental abruption, even if the pregnant woman is in a satisfactory condition, expectant management should be abandoned and the issue resolved in favor of an emergency caesarean section for health reasons.
With a mild form of PONRP, vaginal delivery is possible only if the obstetric situation is favorable:
- head presentation of the fetus;
- the presence of a "mature" cervix;
- full proportionality of the fetal head and the mother's pelvis;
- with normal biomechanism of childbirth;
- coordinated uterine contractions.
In the process of conducting childbirth through the natural birth canal, it is necessary:
- conduct constant monitoring of the condition of the fetus and the contractile activity of the uterus;
- organize medical supervision;
- carry out infusion therapy.
If regular labor activity has developed, then an early amniotomy is performed. At the same time, a decrease in the volume of the uterus after the discharge of amniotic fluid reduces the tone of the myometrium.
Labor induction and labor stimulation with uterotonic drugs are contraindicated in PONRP.
To maintain the coordinated nature of the contractile activity of the uterus in the first stage of labor, intravenous drip administration of antispasmodics (no-shpa) is used.
With aggravation of detachment during childbirth, an increase in the intensity of bleeding, the development of uterine hypertonicity and a deterioration in the condition of the fetus, a caesarean section is indicated.
Immediately after extraction of the fetus in the case of vaginal delivery, manual separation of the placenta and removal of the placenta should be performed with a simultaneous revision of the walls of the uterine cavity for:
- removal of parietal blood clots;
- exclusion of uterine rupture;
- prevention of hypotonic bleeding and hypocoagulation.
It is also necessary to examine the cervix and vaginal walls with mirrors to exclude possible damage and eliminate them if detected. At the same time, uterotonic drugs are prescribed to prevent bleeding in the postpartum period.
If placental abruption occurred in the second stage of labor and there are conditions for their immediate completion (complete opening of the cervix, fetal head in the pelvic cavity), then with a live fetus, obstetric forceps should be applied, and with a dead fetus, a fruit-destroying operation should be performed. Otherwise, a caesarean section is performed.
In the event of uterine atony or the development of coagulopathic bleeding following PONRP after vaginal delivery or after caesarean section, one should not unduly delay the time in an attempt to stop bleeding with conservative measures. In the absence of their effect, it is necessary to start extirpation of the uterus in a timely manner (in some cases with ligation of the internal iliac arteries) with simultaneous replenishment of blood loss.
Important components of treatment for PONRP are adequate replacement of blood loss and the fight against disorders in the hemostasis system. In this regard, it is necessary to puncture the main vein and perform transfusion-infusion therapy (introduction of agents that help restore peripheral hemodynamics, replenish bcc), treatment of functional insufficiency of vital organs and body systems.
Prevention of premature detachment of a normally located placenta:
Preventive measures aimed at preventing PONRP include the following activities.
- From the early stages of pregnancy in the antenatal clinic, a careful selection and monitoring of pregnant women at high risk for the occurrence of obstetric bleeding is carried out.
- In this contingent of pregnant women, a thorough (informal) examination and treatment of concomitant diseases and complications is carried out with monitoring of the effectiveness of the therapy.
- Particular attention should be paid to pregnant women with preeclampsia.
- Timely hospitalization in the hospital in the absence of the effect of the treatment on an outpatient basis, as well as mandatory prenatal hospitalization at the 38th week of pregnancy.
- Compliance with the principle of continuity between the tactics of managing pregnant women in the antenatal clinic and in the hospital.
- The choice of the optimal method of delivery and rational management of childbirth.
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A serious complication that a woman in position may face is placental abruption during pregnancy.
This condition requires urgent medical attention, as delay can cost the life of an unborn baby.
The organ that occurs during pregnancy in the uterus and connects the mother and fetus is connected by the placenta (children's place). Its significance is very great. The organ is responsible for the biological processes by which the baby develops normally in the tummy. The life of the child depends on the placenta. Deviations, pathologies associated with it, can lead to his death.
The following functions of the placenta can be distinguished:
- gas exchange. The baby in the womb needs oxygen: it enters the blood of the fetus from the mother's blood through the placenta. Through it, carbon dioxide is also transferred from the child to the mother. A small detachment of the placenta can disrupt gas exchange;
- nutritional and excretory. For the normal development of the baby, vitamins, nutrients, and water are required. All this he receives through the placenta. Through it, waste products are removed;
- hormonal. The placenta can be compared to an endocrine gland. It produces very important hormones (chorionic gonadotropin, placental lactogen, prolactin, progesterone, etc.), without which the normal course of pregnancy is impossible;
- protective. The placenta provides the fetus with immunological protection. Mother's antibodies passing through the child's place protect the baby from various diseases.
Placental abruption: what is it, what does it look like and what happens?
Placental abruption is its separation (partial or complete) from the uterine mucosa. At the same time, blood accumulates between the child's place and the wall of the uterus, which repels the placenta from the uterus. The placenta should not pass during pregnancy. Its separation from the uterus should occur in the third birth period. However, there are cases when the placenta departs prematurely.
What threatens placental abruption during childbirth? This process is dangerous for the baby, as it can deprive him of oxygen and nutrients.
Causes of premature detachment of a normally located placenta
Women experience premature delivery of the placenta in 0.4-1.4% of cases. It can occur both during pregnancy and during childbirth in the first or second period. Why does placental abruption occur? The reasons for this process are different.
Child seat separation can be called disorders in the vascular system. The capillaries of the uterus and placenta may become more fragile and brittle. Because of this, a violation of the patency of the blood is possible. Similar changes in the female body can occur with. They are also observed in the presence of certain diseases: cardiovascular pathology, hypertension, kidney disease, obesity, diabetes, etc.
The threat of placental abruption may come from inflammatory, degenerative and other pathological processes flowing in the children's place and uterus. Violations can be observed with uterine fibroids, malformations of its development, overwearing.
predispose to premature delivery of the placenta bad habits: excessive consumption of drinks containing alcohol, addiction to cigarettes, drugs. The situation may worsen with anemia (anemia, a decrease in the number of red blood cells, low hemoglobin).
Most often, the symptoms of placental abruption in early pregnancy or later are observed in women for whom the upcoming birth is not the first. The reason for this lies in the change in the mucous membrane of the uterus.
The most rare cases of placental abruption due to autoimmune conditions in which the female body produces antibodies to its own cells. This can be observed with a disease such as lupus erythematosus.
Allergy to drug therapy is another reason for placental abruption in the later or early stages. Usually, pregnant women experience an allergic reaction during the transfusion of donor blood and its components, the introduction of protein solutions.
Abdominal trauma resulting from a fall, impact, or accident can lead to complications. Placental abruption can also contribute to sudden changes in blood pressure that occur during stress and other neuropsychic influences.
Symptoms of placental abruption
In early and late pregnancy, symptoms of placental abruption may include:
- bleeding;
- tension of the uterus and pain with placental abruption;
- baby's heart failure.
Bleeding can be external (visible), internal (hidden) or mixed. External bleeding is easy to notice, as it appears from the vagina during placental abruption brown discharge. It is observed with detachment of the edges of the placenta. If the child's place is detached from the uterus in the center, and the edges remain attached to its wall, then the bleeding in this case will be called internal. Fluid will accumulate between the uterus and the placenta.
When detaching a child's place, one feels uterine tension. On palpation, one feels pain. It can be dull, paroxysmal. Sometimes the pain gives in the thigh and womb, as well as in the lumbar region. It is most strongly felt with internal bleeding.
A fetus with placental abruption may have cardiac dysfunction. His condition depends on the volume of blood that the woman has lost, and on the size of the placental abruption. Signs of intrauterine suffering begin to appear with detachment of 1/4 of the area of the placenta. If 1/3 of its part departs, then the child begins to experience severe oxygen deficiency. His death occurs when 1/3-1/2 of the placenta is exfoliated.
Placental abruption at different stages of pregnancy
The separation of the child's place from the uterus manifests itself in different ways depending on the gestational age. Quite often, doctors are faced with premature detachment of the placenta. in the first trimester. With timely diagnosis and proper treatment, terrible consequences can be avoided. Pregnancy can continue further, and there will be no discharge. In the future, the lost area of contact between the placenta and the uterine wall can be compensated by the growth of the placenta (its increased area).
Placental abruption in the second trimester characterized by such signs as high muscle tone and tension. The actions of medical workers are directly dependent on the duration of pregnancy. For example, the placenta may continue to grow until the middle of the second trimester and compensate for the area lost earlier.
The most dangerous is the separation of the children's place in 3 trimester, because all her compensatory possibilities are completely exhausted, and she can no longer grow. Signs of placental abruption in the later stages are typical: the presence of abdominal pain, tension and soreness of the uterus, bleeding, fetal suffering.
The only way out is delivery. However, it is worth noting that if the area of detachment is not large, there is no bleeding and the process does not progress, then it is possible to bring the child to the term prescribed by nature, while being in the hospital under close medical supervision.
Premature placental abruption in childbirth is a fairly common occurrence. Ideally, this should happen at the third stage of this natural process. However, it also happens that detachment occurs at the first or second stage. In such a situation, doctors either perform labor induction or begin a caesarean section.
Diagnosis of premature detachment of the placenta
In the presence of pronounced symptoms, it is not at all difficult to find out that the placenta exfoliates. If the symptoms are not fully manifested, for example, there is no pain factor, there is no external bleeding, then the diagnosis is made, excluding the presence of other diseases that can cause similar symptoms. Assists in the diagnosis of placental abruption by ultrasound. Thanks to him, it is possible to determine the area of the placenta, which has moved away from the wall of the uterus, the size of the retroplacental hematoma.
During the examination, one of three possible diagnoses of the discharge of a child's place can be made:
- non-progressive partial;
- progressive partial;
- total.
The placenta may partially move away from the uterine wall in a small area. In such situations, damaged blood vessels are often clogged. Bleeding stops and no further detachment occurs. Pregnancy can proceed completely without any complications, and the baby will be born healthy.
Progressive partial detachment placenta poses a risk to the fetus. The size of the hematoma increases. If most of the placenta leaves the uterine wall, the fetus will die. In such a situation, the fair sex herself, who is carrying a baby, suffers very much, because she loses a large amount of blood. Blood loss can lead to hemorrhagic shock. You can cope with this situation thanks to urgent delivery.
It may also be observed total(complete) detachment of the child's place. This happens in very rare cases. The fetus dies almost immediately, as gas exchange between it and the mother stops.
Treatment of placental abruption
The question of how to treat placental abruption causes a lot of anxiety. When diagnosing premature discharge of a child's place, the doctor faces a difficult task - to choose a method of careful and quick delivery. You also need to take additional actions aimed at increasing blood clotting, combating shock and blood loss.
The choice of treatment for placental abruption in early pregnancy and later depends on several parameters:
- The moment of detachment (during pregnancy or childbirth);
- The volume of blood loss and severity of bleeding;
- The general condition of the future mother and fetus.
Doctors may refuse the option of early delivery if:
- the placenta exfoliated in a small area, and this condition does not progress;
- the gestation period is not more than 36 weeks;
- the discharge has stopped during placental abruption and the amount of blood loss is small;
- there are no signs of oxygen starvation in the fetus;
- the pregnant woman feels well and will be in the hospital under the supervision of doctors.
The patient must comply bed rest. The condition of the future mother and baby should be monitored. It is necessary to regularly undergo an ultrasound examination, cardiotocography, dopplerography, monitor blood clotting (it is determined on the basis of special laboratory tests).
With placental abruption, the following drugs can be used:
- medicines that relax the uterus;
- antispasmodics;
- hemostatic agents;
- medicines to fight anemia.
If there are any concomitant diseases and complications, then appropriate therapy must be carried out.
Expectant tactics will have to be abandoned if, during the stay in the hospital, spotting begins to appear after placental abruption. They may indicate that the detachment is progressing. In such cases, most often they decide to conduct. Childbirth can be conducted through natural ways. It already depends on the condition of the pregnant woman and the fetus.
Childbirth in any case should take place under the close supervision of medical professionals for the child's cardiac activity. If a woman gave birth naturally, then after the birth of the baby, a manual examination of the uterine cavity is required.
After a caesarean section, the uterus is also examined to assess the condition of its muscular layer. If it is saturated with blood, then the uterus is removed, since in the future it can become a source of bleeding.
Pregnancy after placental abruption
Women who have had placental abruption during a previous pregnancy are interested in the question of whether a similar situation will recur during the next gestation. It is worth noting that the probability of leaving a child's place is high. In 20-25% of the fair sex, the situation repeats itself again.
Unfortunately, modern medicine is not yet able to completely eliminate the possibility of placental abruption during pregnancy during subsequent gestations.
You can try to avoid placental abruption without the help of doctors. To do this, you need to prevent the occurrence of risk factors in early pregnancy:
- control your blood pressure;
- be required to attend scheduled check-ups;
- periodically undergo an ultrasound examination, thanks to which even a small hematoma of placental abruption can be detected;
- observe a healthy lifestyle (refuse alcohol, tobacco products, drugs, junk food);
- protect yourself from injury, wear seat belts in the car;
- in case of exacerbation of chronic diseases, the occurrence of inflammatory processes, one should not turn a blind eye to them, but proceed to treatment;
- prevent allergic reactions.
In conclusion, it is worth noting that placental abruption is a very serious condition that threatens the life of the child. Any representative of the fair sex can face it.
If the first signs of placental abruption occur (vaginal bleeding or discharge of the corresponding color, uterine pain, pain in the back or lower abdomen, no movement of the baby in the womb), you should immediately seek help from doctors. If nothing threatens the health of the mother and baby, then the pregnancy will continue, but under the supervision of specialists.
If placental abruption progresses, then immediate delivery by caesarean section or naturally is required, since the consequences of placental abruption in early pregnancy or later can be very sad if not given due attention to this.
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Sometimes detachment occurs in a very small area of the placental site. In such cases, this complication is asymptomatic or is so mild that it goes unnoticed; they learn about it only after childbirth by the characteristic appearance of the maternal surface of the placenta.
In almost half of pregnant women with placental abruption, pregnancy ends in premature birth.
The placenta usually attaches itself to the top of the uterus and does not peel off until the baby is born. This helps the baby continue to receive oxygen from his mother until he can breathe on his own. If the placenta separates from the walls of the uterus before the baby is born, it is called placental abruption. This condition is dangerous for both the child and you.
Normally, the placenta should begin to exfoliate in the III stage of labor, after the baby has already been born and she has fulfilled all her “duties” in relation to him. But sometimes, for various reasons, it can happen earlier.
Premature from the puff of the placenta is a complication of the course of pregnancy, which manifests itself in the untimely separation of the placenta from the uterus.
Normal detachment of the placenta should occur in the third stage of labor, after the baby was born.
Causes of premature detachment of a normally located placenta
The occurrence of premature detachment of the placenta can occur with severe courses of diseases such as:
- preeclampsia;
- heart defects;
- hypertonic disease;
- kidney disease;
- diabetes;
- thyroid disease;
- Rhesus conflict;
- APS (antiphospholipid syndrome);
- inflammatory diseases of the uterus, etc.
Also, risk factors for the development of premature placental abruption can be:
- multiple pregnancy;
- polyhydramnios, large fruit;
- prolongation of pregnancy;
- serious injury to the abdomen (fall, blow to the stomach);
- great physical activity, etc.
To try to avoid such a complication of pregnancy, it is very important to undergo a preventive examination in order to identify diseases leading to such a pathology.
The cause of premature abruption of the placenta is very diverse. Numerous causes of this complication can be divided into two groups: the causes predisposing to premature detachment of the placenta, and the causes directly causing it.
Predisposing reasons include the following. Changes in the vascular system of the mother's body, as a result of which the vessels that bring blood to the placenta and take blood away from it become either fragile and brittle, or difficult for blood to pass. This condition is observed in severe forms of toxicosis of pregnancy, especially with nephropathy and eclampsia, with chronic nephritis, with some chronic infections (tuberculosis, syphilis, malaria, chronic sepsis, etc.), with heart defects, thyrotoxicosis, prolonged hypertension in a pregnant woman, with a tendency to pregnant to thrombophlebitis, etc. In all these cases, there are changes in the vascular walls and their rupture in the spongy layer of the decidua.
Inflammatory, degenerative and other pathological processes in the uterus and placenta, as a result of which the connection between these organs becomes insufficiently strong and at the same time the contractility of the uterus decreases in certain parts of its walls. This can be observed with chronic inflammation of the uterus (metro-endometritis), with submucosal fibromyomas of the uterus, some malformations of its development, with significant overpregnancy, hypovitaminosis (vitamin E deficiency), etc.
Excessive stretching of the uterus during pregnancy, as a result of which its walls become thinner, and the size of the placental site increases, the placenta itself increases and becomes thinner. This is noted in multiple pregnancies, polyhydramnios, large fetuses, etc.
These predisposing causes are usually not enough for premature detachment of a normally located placenta. In order for this complication to occur, some immediate cause is often necessary.
The causes that directly cause premature detachment of a normally located placenta most often include direct and indirect trauma and neuropsychic effects.
Immediate trauma- a fall on the stomach, especially from a height, a blow to the stomach, for example, with a hoof or horns of an animal, roughly performed manipulations during external rotation of the fetus to the head, etc.
Indirect injury- the shortness of the umbilical cord (absolute and relative), the density of the membranes, the sudden outflow of water during polyhydramnios, the rapid birth of the first twin with twins, etc. With polyhydramnios and multiple pregnancy, for example, at the time of rapid outpouring of water or the birth of the first twin, the spread placenta cannot follow a reduced placental site, as a result of which its detachment occurs to a greater or lesser extent. Detachment is facilitated, in addition, by a sudden drop in intrauterine pressure, as a result of which the placenta exfoliating from its bed is not properly counteracted by the uterine cavity.
Neuro-psychic effects (fright, excitement during sexual intercourse, etc.).
pathogenosis this process is not complicated. Detachment begins in a small area of the placental site, which causes a violation of the integrity of the uteroplacental vessels and associated bleeding. Blood begins to accumulate between the placenta and the walls of the uterus, as a result of which a retroplacental hematoma forms at the site of placental abruption, which, gradually increasing, increases the detachment.
Blood, accumulating under the placenta, may not find a way out. This occurs when the periphery of the placenta is firmly connected to the uterus. Retroplacental hematoma, growing in such cases, more and more protrudes the fetal surface of the placenta towards the amniotic sac and thereby increases the intrathecal pressure, and hence the intrauterine pressure, with the whole fetal bladder. The walls of the uterus are overstretched due to an increase in the volume of fluid contained in it (amniotic fluid and blood), and the placental site is also stretched. The stretching of the latter can be so significant that cracks form in the underlying sections of the uterine wall, penetrating to the serous membrane and even extending to it. In this case, the entire wall of the uterus is saturated with blood, which penetrates into the periuterine fiber, and in some cases through cracks in the serous membrane and into the abdominal cavity. In the latter, a serous-bloody fluid can be found, and sometimes pure blood, in especially severe cases in a significant amount. There is no external bleeding.
In other cases, blood makes its way through a narrow gap between the membranes of the amniotic sac and the wall of the uterus into the vagina, from where it begins to stand out.
Sometimes the integrity of the membranes is broken and blood enters the amniotic fluid. This increases the tension in the amniotic cavity, which is transmitted to its lower pole - the fetal bladder.
However, very often placental abruption, which began in a small area, does not receive further distribution for one reason or another; the blood clot gradually thickens and partially resolves, and heart attacks and salt deposits form at the site of placental abruption, which can easily be detected after childbirth with a careful examination of the placenta. Pregnancy and childbirth proceed normally.
In acute cases, when a significant amount of blood pours out or accumulates in the uterus, and also penetrates into the thickness of the uterine wall, the course of pregnancy and childbirth takes on a pronounced pathological character. With detachment of more than a third of the maternal surface of the placenta, the fetus dies from asphyxia. In very rare cases, detachment of the entire placenta occurs, which leads to rapid death of the fetus. If at the same time there is sufficient disclosure of the uterine pharynx and the fetal bladder is opened, prolapse of the placenta (prolapsus placentae) may occur before the birth of the fetus. This is usually observed in the transverse and oblique positions of the fetus.
Risk factors for premature placental abruption
Placental abruption occurs in 1 in 200 cases and is due to high blood pressure, cocaine addiction, preeclampsia, abdominal trauma, and a woman's history of previous placental abruptions during previous pregnancies.
Symptoms and signs of premature placental abruption
Premature placental abruption may be accompanied by profuse bleeding, slight spotting is possible, and detachment can also occur without visible external bleeding.
If the site of placental abruption is small, then vascular thrombosis is quite possible, after which placental abruption stops.
If the placenta is located closer to the cervix (not in the bottom of the uterus) (see Fig. 8, 9), the blood gradually drains and pours into the vagina. In this case, the woman sees external bleeding, which is scarlet. Bleeding can also be brown (dark blood) if some time has already passed since the onset of detachment and (or) this blood has drained from a high placenta (from the bottom of the uterus) (see Fig. 6).
If premature detachment of the placenta proceeds in a mild form (a small section of the child's place has exfoliated, the vessels have thrombosed, a small hematoma has formed), the woman's condition may not change, she will see only slight spotting.
A severe form of placental abruption occurs with the following symptoms:
- severe bleeding;
- significant pain (diffuse acute pain of unclear localization);
- tense uterus (stomach becomes tight);
- dizziness;
- pallor of the skin;
- rapid breathing;
- cardiopalmus;
- low blood pressure.
The fetus has intrauterine asphyxia.
If blood flows between the placenta and the uterine wall, there may not be visible external bleeding.
It is impossible to judge the real blood loss of a woman by external bleeding!
It is very important to see a doctor if you experience symptoms such as bleeding from the vagina, severe pain in the abdomen or back, relaxation of the uterus, or strong contractions every minute. In most cases of premature detachment of the placenta, only part of it is separated from the walls of the uterus. In some cases, the placenta exfoliates completely, and the child usually dies. If medical assistance is not provided in time, a woman may suffer from severe hemorrhage, organ failure, and even die. If you start bleeding after the 24th week, you will be taken to the hospital to check if the placenta has detached. The doctor will take your blood pressure and pulse, as well as your baby's heart rate, perform an ultrasound scan, and perform a pelvic exam. How and when you give birth depends on your health and the health of the baby; you can give birth naturally or by caesarean section, it is possible that you will give birth immediately, and maybe in a few hours or even days.
Clinical course of pregnancy and childbirth with premature detachment
The clinical course of pregnancy and childbirth with premature detachment of a normally located placenta depends on a number of reasons, of which the main ones are: the reactivity of the pregnant woman to blood loss and anoxia, and the fetus to anoxia, the size of the exfoliated surface of the placenta, the amount of blood lost and the rate at which blood loss occurs . The course of childbirth is very significantly affected by the cause that caused this complication of toxicosis, trauma, etc.
Detachment of a small area of the placenta, under other favorable conditions, may go unnoticed. It is recognized in such cases only after childbirth, when examining the placenta: an impression formed by a blood clot and the clot itself are found on its maternal surface. The type and density of the clot depend on how much time has passed since the detachment. This area of the placenta quite often has a whitish or yellowish color, is dense and rough to the touch - signs indicating calcification processes. In other cases, if a slight detachment occurred during childbirth, contractions (attempts) intensify or weaken, sometimes become irregular; there are signs of fetal asphyxia; at the end of the period of disclosure or in the period of expulsion with a whole fetal bladder, bloody discharge often appears. In such cases, childbirth usually ends spontaneously or with the help of obstetric forceps, which have to be resorted to only in the interests of the fetus.
If the beginning detachment is accompanied by nephropathy, trauma, or some other no less serious complication, the disease is more severe. Detachment of a significant part of the placenta occurs suddenly and immediately takes on an extremely severe character - a picture of collapse and shock develops: after excruciating acute pain in the abdomen, vomiting appears, pallor of the skin, slowing of the pulse, soon followed by its increase, and a drop in blood pressure (weak, easily compressed pulse); the stomach swells and becomes tense; cold sweat breaks out. If the uterus can be felt through the tense abdominal wall, its solid consistency, the soreness of its surface, arising from hemorrhage into the thickness of its wall, attracts attention. The unevenness of the uterine wall turns into a hillock of elastic consistency, corresponding to the area where placental abruption occurred.
The picture of internal bleeding can be supplemented by external bleeding. The latter always comes a second time and, in comparison with the internal, is less abundant.
The fetus quickly dies from anoxia, its heart tones are not heard.
With complete abruption, the placenta is born after the dead fetus. Its maternal surface is covered with a large tightly pressed blood clot. When separating a clot on the placenta, a plate-shaped depression from the pressure of a retroplacental hematoma is found.
Recognized this pathology is usually without much difficulty on the basis of the presence in the anamnesis of one of the indicated predisposing and directly causing causes, and most importantly, according to the characteristic clinical picture.
At vaginal examination, blood discharge is determined, although not always; with an open throat, the fetal bladder is tense both during contractions and outside them. However, with a tense uterus, its cramping contractions, even if they exist, are difficult to determine.
If the placenta has exfoliated in a small area (less than a third), and there is also external bleeding, it is necessary to differentiate with placenta previa.
In such cases, the most valuable differential diagnostic sign is the nature of bleeding: with detachment of a normally located placenta, it is constant, and with presentation - periodic (bleeding increases after contractions). The data obtained by vaginal examination of the woman in labor are characteristic: with placenta previa, the tissue of the latter is usually found within the uterine os, but this does not happen with detachment of a normally located placenta. The correctness of the diagnosis can be verified after the end of childbirth by examining the placenta that has given birth: with placenta previa, the membranes are torn at the very edge of the placenta, and the edge of the placenta adjacent to the torn area is often crushed and covered with blood clots; with detachment of a normally located placenta, the rupture of the membranes is much further from its edge.
Treatment of premature detachment of a normally located placenta
Treatment of women in labor with premature detachment of a normally located placenta depends on the clinical picture and on the preparedness of the natural birth canal. With symptoms of severe internal bleeding and unpreparedness of the birth canal, a caesarean section is indicated. With extensive and multiple hemorrhages in the thickness of the uterine wall, especially with damage to its serous membrane, supravaginal amputation of the uterus is performed to avoid postoperative atony and suppuration. The same should be done when there is significant internal bleeding, the uterus is tuberous and during the study it is sharply painful even with full opening of the pharynx.
With full or almost complete opening of the pharynx and the absence of signs of extensive hemorrhages in the walls of the uterus, the fetus is shown to be pedunculated and removed if the fetus remains mobile. The subsequent head of a dead fetus should be perforated to avoid trauma to the birth canal.
If placental abruption occurred during the period of exile with a live fetus, childbirth is completed under appropriate conditions by the imposition of output or cavity forceps. With a dead fetus, perforation of the head is performed, followed by cranioclasia.
Opening the fetal bladder usually slows down placental abruption and reduces, and sometimes even stops, bleeding. Therefore, with mild or moderate symptoms of premature detachment of the placenta, an opening of the fetal bladder is indicated.
In all cases of delivery through the natural birth canal after the removal of the fetus, manual removal of the placenta (if its detachment was incomplete) and examination of the uterine cavity are necessary to remove possible remnants of the placenta and exclude violation of the integrity of the uterus. Manual examination of the uterine cavity, in addition, contributes to its good reduction. It is also necessary to examine the cervix and vagina with the help of mirrors in order to exclude their damage. At the same time, drugs that reduce the uterus (pituitrin, ergotine, etc.) are prescribed to prevent bleeding in the early postpartum period, and in order to prevent infection that easily develops in these cases, antibiotics. To combat anemia, repeated blood transfusions are performed.
Prediction for the mother and for the fetus, the worse the earlier placental abruption occurred during pregnancy or during childbirth, the more blood loss and the weaker the protective adaptations of the body of the pregnant woman and the fetus, in particular their resistance to oxygen starvation. Fatal outcomes depend on the late delivery of patients to the hospital. The cause of death is usually acute anemia or shock. Maternal mortality, which until recently, according to E. I. Povolotskaya-Vvedenskaya, was 4.35%, is declining from year to year and can be practically brought to zero.
Significantly worse prediction for the fetus. With detachment of a significant part of the placenta during pregnancy, fetal death almost always occurs; with detachment in the period of opening, the mortality rate of the fetuses reaches 85.7%, and in the period of expulsion - 35.7%.
If risk factors have been identified in a pregnant woman, then the doctor will monitor and treat these diseases as needed.
A severe form of premature placental abruption requires emergency surgical intervention - a caesarean section to save the life and health of a woman and a child.
Any bleeding of a pregnant woman requires urgent hospitalization of a woman in a hospital to find out the causes of her condition and carry out therapeutic measures! The degree of severity of violations can only be established by a doctor based on the results of the examination of the expectant mother!
Prevention of premature detachment of a normally located placenta
Prevention of premature detachment of a normally located placenta is reduced to the prevention of causes predisposing to this complication of pregnancy and childbirth or causing it. A special place in this regard is occupied by the fight against toxicosis of pregnancy, infection, especially chronic, the fight against miscarriages, etc., as well as protecting the pregnant woman from any injury - physical and mental.
Prophylaxis is also the correct management of childbirth in case of polyhydramnios, multiple pregnancy and other conditions when there is overstretching of the uterus.
2. Premature detachment of a normally located placenta. Etiology, classification, pathogenesis, clinic, diagnosis, treatment, delivery.
Premature detachment of a normally located placenta - detachment of the placenta before the birth of the fetus (during
during pregnancy, in the first and second stages of labor).
ICD-10 CODE
O45 Premature placental abruption ( abruption placentae).
O45.0 Premature placental abruption with bleeding disorders.
O45.8 Other placental abruption.
O45.9 Premature abruption of the placenta, unspecified.
EPIDEMIOLOGY
The frequency of PONRP tends to increase and currently occurs in 0.3-0.4% of births.
CLASSIFICATION
Depending on the area, partial and complete placental abruption is distinguished. With partial detachment of the placenta from
part of the uterine wall exfoliates, with complete - the entire placenta. Partial PONRP can be marginal when
the edge of the placenta exfoliates, or the central one - respectively, the central part.
Partial placental abruption can be progressive or non-progressive.
ETIOLOGY
The etiology of PONRP has not been definitively determined. Placental abruption is a manifestation of systemic, sometimes hidden
ongoing pathology in pregnant women. Among the causes of pathology, several factors are distinguished: vascular
(vasculopathy, angiopathy of the placental bed, superficial invasion of the cytotrophoblast into the defective
endometrium), hemostatic (thrombophilia), mechanical. Vasculopathy and thrombophilia relatively common
occur with preeclampsia, hypertension, glomerulonephritis.
Changes in hemostasis are the cause and effect of PONRP. In the development of PONRP, important importance is attached to APS,
genetic defects in hemostasis (mutation of the Leiden factor, angiotensin-II deficiency, protein C deficiency, etc.),
predisposing to thrombosis. Thrombophilia, which develops as a result of these disorders, prevents
complete invasion of the trophoblast, contributing to defects in placentation, PONRP.
Impaired hemostasis can occur due to PONRP, for example, an acute form of DIC, leading to
massive bleeding and development of PON. The situation is typical for a central detachment, when in the area
accumulation of blood pressure rises, conditions arise for the penetration of placental tissue cells,
with thromboplastic properties, into the maternal circulation.
In childbirth, PONRP is possible with a sharp decrease in the volume of the overdistended uterus, frequent and intense contractions.
The placenta, which is not capable of contraction, cannot adapt to the changed volume of the uterus, as a result of which
loses contact with the wall of the uterus.
Thus, the following conditions can be attributed to the predisposing factors of PONRP:
During pregnancy:
Gvascular extragenital pathology (AH, glomerulonephritis);
Gendocrinopathy (DM);
autoimmune conditions (APS, systemic lupus erythematosus);
Galergic reactions to dextrans, blood transfusion;
Ggestosis, especially against the background of glomerulonephritis;
G infectious-allergic vasculitis;
Genetic defects in hemostasis predisposing to thrombosis.
· During childbirth:
Gout of OB with polyhydramnios;
Ghyperstimulation of the uterus with oxytocin;
Gbirth of the first fetus with multiple pregnancy;
G short umbilical cord;
G belated rupture of the fetal bladder.
Violent detachment of the placenta is possible as a result of a fall and trauma, external obstetric turns,
amniocentesis.
PATHOGENESIS
Rupture of blood vessels and bleeding begins in decidua basalis. The resulting hematoma violates the integrity of all
layers of the decidua and exfoliates the placenta from the muscular layer of the uterus, which is adjacent to this area.
With a non-progressive variant of placental abruption, it may not spread further, hematoma
compacted, partially absorbed, salts are deposited in it. With a progressive variant, the detachment area
may increase rapidly. The uterus is stretched. Vessels in the area of detachment are not pinched.
Leaking blood can continue to exfoliate the placenta, and then the membranes and flow out of the genital tract. If
blood with ongoing placental abruption does not find a way out, then it accumulates between the wall of the uterus and
placenta with hematoma formation. Blood at the same time penetrates both into the placenta and into the thickness of the myometrium, which leads to
overstretching and impregnation of the walls of the uterus, irritation of the receptors of the myometrium. Stretching can be
so significant that cracks form in the wall of the uterus, extending to the serous membrane and even
on her. In this case, the entire wall of the uterus is saturated with blood, and it can penetrate into the periuterine tissue, and in a number
cases - through cracks in the serous membrane and into the abdominal cavity. The serous cover of the uterus at the same time has a bluish
color with petechiae (or with petechial hemorrhages). This pathological condition is called uterine
placental apoplexy; for the first time, pathology was described by A. Kuveler in 1911 and was called "womb
Kuveler". The condition disrupts the contractility of the myometrium, which leads to hypotension,
progression of DIC, massive bleeding.
CLINICAL PICTURE
The main symptoms of PONRP are:
Bleeding and symptoms of hemorrhagic shock;
· abdominal pain;
uterine hypertonicity;
Acute fetal hypoxia.
The severity and nature of the symptoms of PONRP are determined by the size and location of the detachment.
Bleeding in PONRP can be:
external;
internal;
Mixed (internal and external).
With marginal abruption of the placenta, external bleeding appears. Blood separates the membranes from the uterine wall and
quickly exits the genital tract. The blood is bright in color. If blood leaks from a hematoma located
high at the bottom of the uterus, the bleeding is usually dark in color. With external bleeding
the condition is determined by the amount of blood loss. With internal bleeding, which usually occurs with
central detachment, the blood does not find an outlet to the outside and, forming a retroplacental hematoma, impregnates the wall
uterus. The general condition is determined not only by internal blood loss, but also by pain shock.
Pain in the abdomen is due to imbibition of the uterine wall by blood, stretching and irritation of the peritoneum. painful
the syndrome occurs, as a rule, with internal bleeding, when there is a retroplacental hematoma. pain
can be intense. With PONRP located on the posterior wall of the uterus, the pain is localized in the lumbar
areas. With a large retroplacental hematoma on the anterior surface of the uterus, a sharply painful
local swelling.
Uterine hypertonicity is possible with internal bleeding and is due to the presence of retroplacental hematoma,
imbibition with blood and overstretching of the uterine wall. In response to a constant stimulus, the uterine wall contracts
and doesn't relax.
Acute fetal hypoxia occurs due to uterine hypertonicity, impaired uteroplacental blood flow and
placental abruption. The fetus may die with detachment of a third or more of the surface of the placenta. With complete detachment
immediate fetal death occurs. Sometimes intrapartum fetal death is the only symptom of detachment
placenta.
According to the clinical course, there are mild, moderate and severe degrees of severity of the condition of a pregnant woman with
placental abruption.
Easy form - Detachment of a small area of the placenta, minor discharge from the genital tract. General
state is not broken. With ultrasound, retroplacental hematoma can be determined, if blood is released from
external genital organs, then it is not detected by ultrasound. After childbirth, an organized clot is found on
placenta.
Medium degree gravity - detachment of the placenta on 1/3–/4 of the surface. Separation from the genital tract
blood with clots in a significant amount. With the formation of a retroplacental hematoma, pain occurs in
abdomen, uterine hypertonicity. If the detachment occurred during childbirth, the uterus does not relax between contractions. At
a large retroplacental hematoma, the uterus can become asymmetric, sharply painful on palpation. Without
premature delivery, the fetus dies. At the same time, symptoms of shock develop (hemorrhagic and
painful).
heavy form - Detachment of more than 1/2 of the surface area of the placenta. Sudden pain in the abdomen
bleeding (initially internal, and then external). Shock symptoms appear fairly quickly. At
examination and palpation, the uterus is tense, asymmetrical, in the area of retroplacental hematoma can be detected
bulging. Symptoms of acute hypoxia or fetal death are noted.
The severity of the condition, blood loss is further exacerbated by the development of DIC due to penetration into
maternal blood flow of a large number of active thromboplastins formed at the site of placental abruption.
DIAGNOSTICS
Diagnosis of PONRP is based on:
the clinical picture of the disease;
ultrasound data;
changes in hemostasis.
PHYSICAL EXAMINATION
Clinical symptoms suggestive of PONRP: spotting and abdominal pain; hypertonicity,
soreness of the uterus; lack of relaxation of the uterus in the pauses between contractions during childbirth; acute hypoxia
fetus or antenatal death; symptoms of hemorrhagic shock.
During vaginal examination during pregnancy, the cervix is \u200b\u200busually preserved, the external os is closed. IN
the first stage of labor with placental abruption, the fetal bladder is usually tense, sometimes moderate
the amount of bloody discharge with clots from the uterus. When opening the fetal bladder, the outflowing agents can
INSTRUMENTAL RESEARCH
Ultrasound should be performed as early as possible if PONRP is suspected. For longitudinal and transverse scanning
it is possible to determine the place and area of placental abruption, the size and structure of the retroplacental hematoma. In a number
cases with a slight detachment of the placenta along the edge with external bleeding according to ultrasound
fails to detect.
LABORATORY RESEARCH
Analysis of hemostasis indicators indicates the development of DIC.
SCREENING
Identification of latent thrombophilia in patients at risk for the development of PONRP.
DIFFERENTIAL DIAGNOSIS
Differential diagnosis is carried out with histopathic uterine rupture, placenta previa, rupture
umbilical cord vessels.
PONRP has identical symptoms with histopathic uterine rupture: abdominal pain, tension,
non-relaxing uterine wall, acute fetal hypoxia. Ultrasound reveals an area of exfoliated placenta. If
is absent, the differential diagnosis is difficult. Regardless of the diagnosis, urgent
delivery.
Detachment of the placenta previa is easily established, since in the presence of blood discharge from the genital tract,
other characteristic symptoms are absent. With ultrasound, it is not difficult to determine the location of the placenta.
It is extremely difficult to suspect a rupture of the umbilical cord vessels. This pathology is often observed in meningeal
attachment of blood vessels. It is characterized by the release of bright scarlet blood, acute hypoxia and antenatal
fetal death. Local pain and hypertonicity are absent.
The management of pregnancy in PONRP depends on the following indicators:
The amount of blood loss
condition of the pregnant woman and the fetus;
gestational age;
state of hemostasis.
During pregnancy and childbirth with a pronounced clinical picture (moderate and severe) PONRP
emergency delivery by CS is indicated, regardless of gestational age and fetal condition. During the operation
examination of the uterus is necessary to detect hemorrhage into the muscular wall and under the serous membrane (uterus
Kuvelera). When diagnosing the uterus of Kuveler at the first stage, after delivery, a dressing is performed
internal iliac arteries ( a. iliaca interna). In the absence of bleeding, the volume of the operation with this
is limited and the uterus is preserved. With continued bleeding, extirpation of the uterus should be performed.
RBC reinfusion machines are used to collect and transfuse the patient's own blood.
autoblood (for example, "Cell saver", "Haemolit", etc.). With the help of these devices, the blood is sucked into the reservoir, where
it is cleared of free hemoglobin, clotting factors, platelets, and after that red blood cells
return to the body. At the same time, infusion-transfusion therapy is carried out (see "Hemorrhagic
With a mild form of the course of PONRP, if the condition of the pregnant woman and the fetus does not significantly suffer, there is no pronounced
external or internal bleeding (small non-progressive retroplacental hematoma according to
Ultrasound), anemia, with a gestational age of up to 34–5 weeks, expectant management is possible. Pregnancy management is carried out
under the control of ultrasound, with constant monitoring of the condition of the fetus (Doppler, CTG). Therapy involves
bed rest for a pregnant woman and consists in the introduction of b-agonists, antispasmodics,
antiplatelet agents, multivitamins, antianemic drugs. According to indications - transfusion of freshly frozen
If the condition of the pregnant woman and the fetus is satisfactory, there is no pronounced external or internal bleeding
(small non-progressive retroplacental hematoma according to ultrasound), anemia, with a gestation period of up to 34–36 weeks, expectant management is possible. Pregnant women are managed under ultrasound guidance, with constant
monitoring the condition of the fetus (Doppler, CTG). Treatment involves bed rest for a pregnant woman.
LABOR MANAGEMENT
With a slight detachment, a satisfactory condition of the woman in labor and the fetus, normal uterine tone, childbirth can be
lead through the natural birth canal. Perform early amniotomy to reduce bleeding and
receipt of thromboplastin in the maternal circulation, acceleration of labor (especially with a full-term fetus). childbirth
should be carried out under constant monitoring of the nature of maternal hemodynamics, contractile
uterine activity and fetal heart rate. Catheterization of the central vein is carried out, according to indications - infusion therapy. With weakness of labor activity after amniotomy, uterotonics are administered. expedient
epidural anesthesia. After eruption of the head, oxytocin is used to enhance uterine contractions
and reduce bleeding.
With the progression of detachment or the appearance of severe symptoms in the second stage of labor, tactics
determined by the location of the presenting part in the pelvis. With a head located in the widest part
pelvic cavity and above, CS is shown. If the presenting part is located in the narrow part of the pelvic cavity
and lower, then with head presentation, obstetric forceps are applied, and with breech presentation,
extraction of the fetus by the pelvic end.
In the early postpartum period, after separation of the placenta, a manual examination of the uterus is performed. For
to prevent bleeding, dinoprost is administered in physiological saline intravenously by drip for 2 hours.
Correction of hemostasis is important in the early postpartum and postoperative periods in PONRP. At
if there are signs of coagulation disorders, fresh frozen plasma is transfused,
platelet mass, blood transfusion according to indications (erythrocyte mass). In rare situations when
massive blood loss, phenomena of hemorrhagic shock, it is possible to transfuse fresh donor blood from
screened donors.
OUTCOME TO THE FETUS
In PONRP, the fetus usually suffers from acute hypoxia. If obstetric care is provided untimely and
not fast enough, antenatal fetal death occurs. In preterm delivery,
newborns may develop RDS.
PREVENTION
There is no specific prevention. The prevention of the PONRP consists in pre-gravid preparation,
treatment of endometritis and extragenital diseases before pregnancy, correction of identified
hemostasis defects.
The prognosis for PONRP is determined not only by the severity of the condition, but also by the timeliness of the provision
qualified assistance.__
Premature detachment Fine located placenta- this is the detachment of the placenta, located in the upper segment of the uterus, during pregnancy or in the I-II stages of childbirth. The frequency of detachment is from 0.3 to 0.5% of the total number of births, or 1-2% of all pregnancies, and up to 30% of the causes of maternal death, so this pathology refers to severe complications of pregnancy and childbirth.
Premature detachment of a normally located placenta is the second most common cause of obstetric bleeding during pregnancy and childbirth. Premature abruption of the placenta always poses a threat to the health, life of a pregnant woman, a woman in labor, and especially the fetus due to bleeding. Maternal mortality rates in premature placental abruption, according to the literature, remain quite high - from 1.6 to 15.6%. Perinatal mortality in premature placental abruption remains within 20-40%. Placental abruption, both during pregnancy and during the 1st and 2nd stages of labor, regardless of where it attaches to the walls of the uterus, is considered premature. The frequency of detachment requiring emergency care is 0.3-0.5%. Unlike placenta previa, placental abruption usually occurs later in pregnancy, with the onset of labor, over 90% of children weigh more than 1500 g.
Classification ( based on the degree of detachment of the placenta from the uterine wall and the localization of the detachment):
- 1. Complete detachment (abstraction of the entire placenta).
- 2. Partial detachment:
central.
Anatomical classification
In accordance with the localization of the hematoma from an anatomical point of view, there are five types of premature detachment of a normally located placenta:
- 1. Hemorrhage under the membranes, that is, subchorionic hematoma.
- 2. Hemorrhage in the region of the lower edge of the placenta - its first sign will be bleeding from the genital tract.
- 3. Hemorrhage into the amniotic cavity after rupture of the membranes.
- 4. Hemorrhage under the placenta - a large retroplacental hematoma is formed.
- 5. Hemorrhage into the thickness of the myometrium - infiltration of the intermuscular spaces with blood occurs, and in severe cases, the so-called Kuveler's uterus is formed.
Clinical classification
Page et al. allocate four degrees of severity of placental abruption (table 1).
The main links of pathogenesis:
spontaneous rupture of the vessels of the placental bed. The inability of the uterus to effectively contract as a result of the fact that the vessels are not clamped, and a retroplacental hematoma is formed.
Previously, the main cause of premature detachment of a normally located placenta was considered to be mechanical factors - trauma to the abdomen, an increase in the volume of the uterus, and then its rapid emptying (with polyhydramnios, multiple pregnancy, large or giant fetus), shortness of the umbilical cord, belated rupture of the membranes, dystrophic changes in the endometrium. Currently, vascular changes due to late toxicosis of pregnant women, hypertension or kidney disease are of great importance in the occurrence of premature detachment of a normally located placenta. Mechanical and stress factors are of some importance, especially if they are combined with this pathology.
Many modern authors believe that the trigger mechanism for premature placental abruption is an immunological conflict between the mother's body and the tissues of the fetoplacental complex, resulting in rejection.
The mechanism of detachment is the formation of basal hematomas as a result of pathological changes in the vessels of the decidua. Delimited hematomas, reaching a significant size, destroy the basal plate and break into the intervillous bloodstream. Placental abruption from the uterine wall and compression of the placental tissue by the formed hematoma occur. Macroscopically, with partial detachment, facets ("old" detachment) or blood clots ("acute" detachment) are found on the maternal surface of the placenta.
Microscopically, depending on the duration and area of placental abruption, various changes in the placenta are revealed, corresponding to the structure of acute and subacute hemorrhagic infarcts. A particularly favorable background for the emergence of this microscopic picture is severe late preeclampsia, in which there is a massive deposition of fibrin in the vessels of the placenta with the closure of the capillary lumen, proliferative endarteritis, and rupture of the decidual arteries.
Premature detachment of a normally located placenta is nothing more than the transition of a chronic form of insufficiency of the uteroplacental circulation into an acute one with certain clinical symptoms. This complication is always preceded by chronic disorders of the uteroplacental circulation in the form of sequential changes: spasm of arterioles and capillaries of the basal part of the decidua, which is part of the maternal part of the placenta, increased blood viscosity with erythrocyte stasis, their aggregation, lysis and release of blood thromboplastin, DIC syndrome . The deterioration of the microcirculation in the placenta leads to a decrease in the elasticity of the vascular wall, an increase in its permeability. This contributes to the rupture of arterioles, capillaries, the formation of microhematomas, gradually merging, destroying the basal plate of the decidual tissue, capturing intervillous spaces and forming an ever-increasing retroplacental hematoma at the site of placental abruption.
Clinical and diagnostic criteria for premature detachment of a normally located placenta
Premature detachment of a normally located placenta can be in pregnant women in the case of the following pathology:
preeclampsia;
kidney disease;
isoimmune conflict between mother and fetus;
overstretching of the uterus (polyhydramnios, multiple pregnancy, large fetus);
diseases of the vascular system;
diabetes;
connective tissue diseases;
inflammatory processes of the uterus, placenta;
developmental anomalies or tumors of the uterus (submucosal, intramural fibroids).
Rare causes:
physical injury;
mental trauma;
sudden decrease in the volume of amniotic fluid;
absolutely or relatively short umbilical cord;
pathology of the contractile activity of the uterus.
Clinical painting. The leading symptoms of premature placental abruption are bleeding and pain, the remaining symptoms are associated with these two: general and local soreness of the uterus on palpation, its hypertonicity, hypoxia or fetal death. Bleeding can be external, internal and combined. External bleeding is observed with marginal (lateral) placental abruption and an open cervix. Premature placental abruption with the formation of a retroplacental hematoma is characterized by internal bleeding. Combined bleeding occurs with lateral placental abruption with a slight opening of the cervical canal. Bleeding can be imperceptible, massive, and even accompanied by hemorrhagic shock. Depending on the volume of blood loss, hemodynamic disturbances of varying degrees develop, symptoms of coagulopathy, up to DIC. Pain is almost always present. Even a small detachment of the placenta is accompanied by an increase in the tone and soreness of the uterus. Generalized or local soreness of the uterus is always observed with placental abruption with the formation of "Cuveler's uterus". The clinical picture of premature placental abruption is also supplemented by symptoms characteristic of those diseases that preceded it: gestosis of pregnant women, hypertension, kidney pathology, etc. Fetal distress syndrome develops in proportion to the amount of blood loss in the mother. Primary disorders in the fetus are determined by the indications of uteroplacental blood flow in Doppler studies, their progression leads to fetal death.
Clinical symptoms
- 1. Pain syndrome: acute pain in the projection of the localization of the placenta, which then spreads to the entire uterus, back and becomes diffuse. Pain is most pronounced with central detachment and may not be pronounced with marginal detachment. With detachment of the placenta, which is located on the back wall, the pain can mimic renal colic.
- 2. Hypertonicity of the uterus up to tetany, which is not relieved by antispasmodics, tocolytics.
- 3. Bleeding from the vagina may vary depending on the severity and nature (marginal or central detachment) from minor to massive. If a retroplacental hematoma forms, there may be no external bleeding.
Premature detachment of a normally located placenta can be mild or severe. The severity of the pathology depends on the degree of blood loss, which is due to both the area of placental abruption (partial, complete) and its speed.
With mild severity, the general condition of the pregnant woman or the woman in labor does not suffer. Hemodynamic parameters remain within the normal range. The fetal heartbeat is not disturbed. A severe degree of placental abruption is accompanied by a deterioration in the patient's condition, up to the onset of symptoms of shock. Pallor of the skin, tachycardia, drop in blood pressure progress rapidly. Symptoms of intrauterine hypoxia of the fetus appear and rapidly increase, and its death quickly occurs.
Hemorrhage can be internal, external and combined. Even with the same blood loss, internal bleeding is considered the most dangerous and is often accompanied by hemorrhagic shock. The type of bleeding depends on the location of the hematoma (Fig. 3). If the hematoma occurs in the center of the placenta, then there may be no external bleeding or it appears later. A large uteroplacental hematoma, not finding an exit into the vagina, stretches the placental site, and uteroplacental apoplexy occurs, described by A. Kuveler. The walls of the uterus are saturated with blood, sometimes penetrating into the parametria, while the serous cover can be disturbed, the uterus ruptures with an outpouring of blood into the abdominal cavity.
Rice. 3. Premature detachment of a normally located placenta: a - central; b - edge
The uterus with massive hemorrhages looks like a "marble", its contractility is sharply reduced. Against this background, manifestations of DIC often occur due to the penetration of thromboplastic substances into the maternal bloodstream.
If placental abruption occurs along the periphery, blood, even with a small hematoma, can quickly exfoliate the fetal membranes and bleeding is external. The color of the blood flowing through the vagina in acute detachment is scarlet, in case of detachment of considerable age - brown, serous-bloody with dark clots. The condition of the patient, as a rule, corresponds to visible blood loss.
Pain is an extremely important sign of premature detachment of a normally located placenta. It occurs due to stretching of the serous membrane of the uterus. The nature of the pain varies from mild to intense.
Sometimes there is no pain if placental abruption occurs in a small area. The diagnosis in such cases is established retrospectively - when examining the placenta after childbirth.
A weak or moderate pain symptom accompanies detachment starting from the edge of the placenta.
In severe cases, strong, arching pains in the abdomen suddenly appear, the general condition deteriorates sharply, hemodynamics are disturbed: the pulse and respiration become more frequent, blood pressure drops rapidly, the skin turns pale. The abdomen is enlarged in volume, the uterus is in a state of hypertonicity, very painful on palpation. If the detached placenta is located on the anterior or anterolateral wall of the uterus, then a soft, painful bulge can be determined. The pain syndrome is often expressed to such an extent that the patient does not allow to touch the abdomen. The picture of hemorrhagic shock quickly develops. Bleeding is often internal. It is accompanied by the development of retroplacental hematoma.
The condition of the fetus depends primarily on the area and speed of placental abruption. Most authors believe that with acute detachment of less than 1/3 of the placenta, the fetus is in a state of hypoxia, with detachment of 1/3 or more, the fetus always dies. Fetal death can occur with detachment of a smaller area of the placenta, if it has morphological or functional signs of insufficiency.
Diagnostics
Premature placental abruption is diagnosed on the basis of clinical signs: abdominal pain, increased uterine tone, signs of internal and (or) external bleeding, impaired fetal heartbeat. The probability of an accurate diagnosis increases if these symptoms appear in pregnant women with late gestosis, hypertension, diseases of the kidneys, circulatory failure, and heart pathology.
- 1. Assessment of the state of the pregnant woman, which will depend on the size of the detachment, the volume of blood loss, the onset of symptoms of hemorrhagic shock or DIC.
- 2. External obstetric examination:
uterine hypertonicity;
the uterus is enlarged in size, it can be deformed with local protrusion if the placenta is located along the anterior wall;
pain on palpation;
difficulty or impossibility of palpation and auscultation of the fetal heartbeat;
the appearance of symptoms of fetal distress or death.
3. Internal obstetric examination:
tension of the fetal bladder;
with the outflow of amniotic fluid, their coloring with blood is possible;
bleeding from the uterus of varying intensity.
4. Ultrasound studies (echo-negative between the uterus and the placenta), but this method cannot be an absolute diagnostic criterion, since the hypoechoic zone can be visualized in patients without detachment.
The differential diagnosis is carried out with placenta previa and uterine rupture.
Similar symptoms sometimes have a syndrome of compression of the inferior vena cava. The absence of a pain symptom, an increase in the tone of the uterus, as well as a rapid improvement in the condition of the patient and the fetus with a change in body position help to exclude this pathology.
Tactics reference pregnancy And childbirth. In case of premature detachment of a normally located placenta, it is necessary to prevent the development of hemorrhagic shock and DIC, and, if they occur, to create conditions that increase the effectiveness of intensive care. Therefore, the main task of treatment is careful and rapid delivery. It is impossible to stop the progression of placental abruption and bleeding without emptying the uterus. This requirement is met by an abdominal caesarean section, which, after removing the fetus, makes it possible to diagnose uteroplacental apoplexy and, therefore, to amputate the uterus in a timely manner. In addition, in the case of the development of an acute form of DIC, cerebrotomy provides the possibility of immediate hysterectomy.
With premature detachment of a normally located placenta that occurred at the end of the 1st or 2nd stage of labor, especially if it is due to mechanical factors (shortness of the umbilical cord, outflow of amniotic fluid, etc.), childbirth can be completed through the natural birth canal. The principle of rapid emptying of the uterus remains unchanged in these cases. Depending on the obstetric situation, delivery is carried out using obstetric forceps or a vacuum extractor, extraction by the leg or using fruit-destroying operations. In all women, after the end of childbirth through the birth canal, the placenta is separated by hand; if it has already separated, then an examination of the uterus is carried out in order to exclude (or confirm) a violation of the integrity of the uterus and in a timely manner to diagnose and, therefore, treat hypotension of the muscles of the uterus.
The tactics of managing women with placental abruption is to implement measures aimed at reducing maternal and perinatal morbidity and mortality. The main should be considered the determination of the volume of blood loss and the implementation of replacement therapy. To compensate for blood loss, it is best to inject red blood cells. It is believed that more than 20% of women with placental abruption already have fetal death upon admission to the hospital.
Paramedic actions:
Medical intervention is needed to help.
With this pathology, it is necessary to quickly ensure hospitalization and deploy an operating room, adequate replacement of blood loss and the fight against clotting and hemodynamic disorders. Therefore, the woman is sent to the nearest maternity hospital, where she is informed about her admission, diagnosis and some information (for example, blood type and Rh factor).
Transportation on a stretcher with a lowered head end and ensuring contact with a vein and infusion therapy.
With minimal manifestations of detachment (when it is interpreted as the presence of placental insufficiency), conservative treatment is carried out if this does not threaten the life and health of the mother and fetus. Obstetric tactics is determined only by a doctor, treatment is carried out in a hospital.
Treatment
Unreasonably late delivery leads to the death of the fetus, the development of the Kuveler's uterus, massive blood loss, hemorrhagic shock and DIC, and loss of the woman's reproductive function.
- 1. In the case of progressive premature placental abruption during pregnancy or in the first stage of labor, with the appearance of symptoms of hemorrhagic shock, DIC, signs of fetal distress, regardless of the gestational age, urgent delivery by caesarean section is required. In the presence of signs of the uterus Cuveler - extirpation of the uterus without appendages.
- 2. Restoration of the amount of blood loss, treatment of hemorrhagic shock and DIC.
- 3. In the case of non-progressive placental abruption, the absence of late preeclampsia, dynamic monitoring is possible in preterm pregnancy up to 34 weeks (carrying out therapy for the maturation of the fetal lungs) in institutions where there is a round-the-clock duty of qualified obstetrician-gynecologists, anesthesiologists, neonatologists. Monitored monitoring of the condition of the pregnant woman and the fetus, CTG, ultrasound in dynamics.
Features of a caesarean section:
previous operation amniotomy (if there are conditions);
mandatory revision of the walls of the uterus (especially the outer surface) in order to exclude uteroplacental apoplexy;
in the case of diagnosing the uterus of Cuveler - extirpation of the uterus without appendages;
with a small area of apoplexy (2-3 foci with a diameter of 1-2 cm or one up to 3 cm) and the ability of the uterus to contract, there is no bleeding and signs of DIC, if necessary, to preserve the childbearing function (first birth, dead fetus), the council decides on the issue of preserving uterus. Surgeons observe for some time (10-20 minutes) with an open abdominal cavity the state of the uterus and, in the absence of bleeding, drain the abdominal cavity to control hemostasis. Such tactics, in exceptional cases, are allowed only in institutions that have a round-the-clock duty of an obstetrician-gynecologist, an anesthesiologist;
in the early postoperative period, careful monitoring of the condition of the woman in labor is necessary.
Tactics for placental abruption at the end of I or II period:
immediate amniotomy is necessary if the amniotic sac is intact;
with head presentation of the fetus - the imposition of obstetric forceps;
with breech presentation - extraction of the fetus by the pelvic end;
in the transverse position of the second fetus from twins, an obstetric rotation is performed with the extraction of the fetus by the leg. In some cases, a caesarean section will be more reliable;
manual separation of the placenta and removal of the placenta;
contractile agents - in / in 10 IU of oxytocin, in the absence of effect, 800 mcg of misoprostol (rectally);
careful dynamic observation in the postpartum period;
restoration of blood loss, treatment of hemorrhagic shock and DIC.
