Abruptio de placenta, clasificación

Placental Abruption

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What is placental abruption?

Placental abruption is the premature detachment of the placenta, it is divided into a total or partial detachment of the insertion of the placenta before delivery. This disease can occur from 0-4% -1.29% of all pregnancies and has a perinatal mortality of up to 30%. The abrupt placenta can recur between 5.5% and 16.6%.

What are the causes of the detachment of the placenta?

Until today we still do not know exactly what is the etiology of this disease, it is believed that there is an alteration of the decidual and uterine vessels, which adds an arterial hypertension in the mother (occurs in 44% of pregnant women ), generate the rupture of these vessels and triggering a series of steps that are explained later, until the total detachment of the placenta is reached.

There is also a relationship of this entity with the presence of uterine myomatosis, as other risk factors that can be seen in the following image:

Risk factors for placental abruption
Risk factors for placental abruption

What is the pathophysiology of placental abruption?

The detachment of placenta normoinserta occurs in the third trimester of pregnancy, for this reason it is listed as one of the causes of vaginal bleeding in the third trimester (Placenta Previa, Abruptio placenta and placental accreta). It has been described that the cause of this entity is due to the rupture of small vessels that are mostly decidual, this rupture generates a hemorrhage in the basal decidua forming a clot or retroplacental hematoma not evident that causes the placental tissue necrosis, limiting the area of blood exchange between the mother and the fetus, and finally dissecting the placenta until it generates the complete detachment of it.

It must be taken into account that because of the limitation of the blood exchange area, 80% of newborns are preterm and have intrauterine growth restriction (IUGR).

What are the signs and symptoms of placental abruption?

It is important to know that the premature detachment of the placenta is classified as an obstetric emergency, so you must know how to diagnose and treat.

Cardinal abruption of the placenta is a vaginal hemorrhage in the third trimester together with severe pain. This pain occurs because the myometrium contracts to be able to counteract the bleeding but the presence of fetal parts prevents hemostasis, which increases bleeding and this generates more hypertonia (increased tone of the uterus) and tachysystolia (Increased frequency of uterine contractions) becoming a vicious circle.

It must be borne in mind that this retroplacental hemorrhage can be hidden or not hidden, and this depends on the place of the insertion site where the rupture of the vessels occurred as we can see in the following image.
Abruptio de placenta, clasificación

After the hematoma or clot exceeds 500 cc, it extravasates and dissects and infiltrates the myometrium, compromising the uterine tone, forming the so-called Couvelaire Uterus, which can be complicated by disseminated intravascular CID.

How is it classified?

Placental abruption in pregnancy is classified as follows:

  1. Mild, light or grade I: It is characterized by having a detachment of 30% and the fetus is alive.
  2. Moderate, intermediate or grade II: The detachment is between 30-50% and the fetus is still alive.
  3. Severe, severe or grade III: There is a> 50% detachment of the placenta, and a dead fetus
    1. The latter can be divided into a severe placental abruption without disseminated intravascular coagulation or a Abruptio of severe placenta with disseminated intravascular coagulation.

How is placental abruption diagnosed?

Just like everything in medicine, the diagnosis of the premature detachment of the placenta must be initiated through the clinical history where severe pain of sudden onset will be evident, constant that may or may not be accompanied by vaginal bleeding, the latter depends if there is a occult bleeding (20% of patients present, Utero de Couvaliare and irreversible uterine atony) or not.

At the physical examination we can find an increase in the size of the uterus with hypersensitivity, hypertonia and hypesthesia; The amniotic fluid is bloody or in Port Wine; an unsatisfactory fetal state is also present.

What are the complications?

The main complications of placental abruption are:

  1. Hemorrhagic shock
  2. CID
  3. Uterine atony
  4. Ischemic necrosis of distal organs (sd sheehan)
  5. Fetal hypoxia
  6. Fetal exanguination
  7. Prematurity
  8. Intrauterine growth retardation IUGR

How should the treatment be?

The following points must be taken into account for their treatment:

  • Channeling 2 peripheral veins once the patient is channeled, the laboratories should be taken.
  • Perform a typing and tracking, maintain.
  • Have continuous maternal-fetal monitoring.
  • Pass a bladder catheter for the Glomerular Filtration Rate count.
  • Two special conditions that must be taken into account depending on the number of weeks of gestation of each patient is the realization of an amniotomy and clearing.

Bibliography

  • Obstetrica de Williams, Edición 22. Capítulo 35. Hemorragias del tercer trimestre.
  • Texto de Obstetricia y Perinatologia. Universidad Nacional de Colombia. 1999. Dr Jorge Rubio, Dr Heliodoro Ñañez. Capitulo 17, Desprendimiento de la placenta normalmente insertada.
  • James Alexander, Alison Wortman, Intrapartum Hemorrhage. Obstet Gynecol Clin N Am 40 (2013) 15–26.