PREMATURE PLACENTA SEPARATION

Premature placenta separation or bruptio placentae also known as placenta abruption is a significant cause of third-trimester vaginal bleeding. It is associated with poor health status of the mother and the unborn baby. It is defined as the premature partial or complete separation of a normally implanted placenta from the uterus after the period of viability (this varies between regions but is 28weeks in Nigeria and some African countries and is 24weeks in Europe) but before the delivery of the baby.  The overall incidence of abruption placentae is about 1 in 100 pregnancies

CAUSES OF PREMATURE PLACENTA SEPARATION

The exact cause of placenta abruption is unknown. It could probable be from abnormalities of the uterine blood vessels.  However, a number of risk factors are associated with its occurrence.  Risk factors for premature placenta separation include;

• Smoking
• Cocaine use during pregnancy
• Maternal age over 35 years
• Increasing number of birth
• Inherited or acquired thrombophilias (the blood abnormally form clots easily)
• Hypertensive disease in pregnancy (pregnancy induced hypertension, preeclampsia, eclampsia)
• Placenta abruption in a previous pregnancy
• Pregnancy with more than one baby
• High amniotic fluid level (baby water)
• Sudden uterine decompression from premature rupture of fetal membrane
• Short umbilical cord
• Trauma to the abdomen from motor vehicle accident, fall or violence resulting in a blow to the abdomen may lead to placental abruption.

CLASSIFICATION OF ABRUPTIO PLACENTAE

Abruptio placentae can be classified into four;

class 0: diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.

Class I:  manifest with no vaginal bleeding to mild vaginal bleeding, lightly tender womb, normal maternal blood pressure and heart rate, no bleeding disorder and baby not in distress.

Class 2: manifest with no vaginal bleeding to moderate vaginal bleeding, moderate to severe uterine tenderness with possible painful contractions, increase maternal heart beat with changes in blood pressure and heart rate on standing erect and the baby will be in distress.

Class 3: characteristics include the following; no vaginal bleeding to heavy vaginal bleeding, very painful contraction of the womb, maternal shock, bleeding disorder, death of the baby.

SYMPTOMS AND SIGNS OF ABRUPTIO PLACENTAE

Abruptio placentae could be the revealed type (blood is visible externally via the vagina), concealed type (blood not visible) or the mixed type where blood is concealed in the womb and also seen coming out of the vagina. The major clinical findings are vaginal bleeding which is preceded by a sudden abdominal pain, often accompanied by uterine contractions, uterine tenderness and the baby will be in distress. The mothers heart will beat too fast and her blood pressure becomes low.  

COMPLICATIONS OF ABRUPTIO PLACENTAE

The complication of placenta abruption to the pregnant woman are;

• Haemorrhage and the need for blood transfusions
• Hysterectomy (which is, removal of the womb)
• Bleeding disorder resulting from inability of the blood to form clot and stop bleeding
• kidney failure
• Sheehan syndrome (which is, damage to the pituitary gland from massive blood loss)
• Maternal death may occur.

Complication to the baby includes;

• The baby may be in distress
• The growth of the baby in the womb maybe restricted in cases of mild abruption placenta
•  Preterm birth with Low birthweight
• The baby maybe unable to initiate and sustain breathing after delivery called asphyxia
•  Death of the baby in the womb
• Death of the baby after birth

TREATMENT OF ABRUPTIO PLACENTAE

Abruptio placentae is an obstetrics emergency because it threatens the life of both mother and baby. Approach to it treatment will involve close observation by the doctor, continuous monitoring of the baby and oxygen administration. Blood loss will be replaced with drip and then blood when available; about four pints of blood maybe required. The mode of delivery whether via caesarean section or vaginal delivery depends on the hemodynamic status of the mother and whether the baby is alive or death in the womb. For a death baby, vaginal delivery is the preferred method when the maternal hemodynamic condition is stable. For a live baby the preferred option is caesarean delivery but this can be complicated by difficulty to stop bleeding.

PREVENTION OF ABRUPTIO PLACENTA

The prevention of abruption placenta is aimed at identification and elimination of known risk factors, optimization of maternal blood volume and prompt institution of therapy when it occurs to prevent complications.