Premature detachment of a normally located placenta: symptoms, diagnosis, treatment

Premature detachment of the normally located placenta - premature (before the birth of the child) separation of the placenta from the wall of the uterus.

Epidemiology of premature detachment of the normally located placenta

The frequency of premature detachment of a normally located placenta varies from 0.4 to 1.4%. Maternal mortality in this pathology is 1.6-15.6%, perinatal mortality - 20-35.0 ‰.

Classification of premature detachment of a normally located placenta

There is no uniform classification of premature detachment of a normally located placenta.

With a detachment of normally located placenta distinguish:

• detachment with external or visible bleeding - discharge of blood from the vagina;
• detachment with internal or hidden bleeding - blood accumulates between the placenta and the uterine wall, forming a retrocolar hematoma;
• detachment with combined or mixed bleeding - there is both hidden and visible bleeding. On the area detachments are distinguished:
• partial (progressive or non-progressive);
• complete.

According to the degree of severity of the clinical picture, the detachment is divided into:

• light (detachment of a small portion of the placenta);
• middle (detachment 1/4 of the placenta surface);
• heavy (detachment more than 2/3 of the surface of the placenta).

Diagnosis of premature detachment of a normally located placenta

Anamnesis and physical examination

The pregnant woman is often diagnosed with a long sluggish gestosis, hypertension, kidney disease, acute infectious diseases. Less often, premature detachment occurs after external obstetric fetal turn, amniocentesis, abdominal injuries of various etiologies, rapid changes in the volume of the uterus due to the outflow of amniotic fluid during polyhydramnios.

• With premature detachment of normally located placenta of mild degree during pregnancy, the state of the pregnant is satisfactory. Visible mucous membranes and skin are normal or slightly pale, the pulse is rapid, but satisfactory filling, there is a slight pain in the uterine region, often there are no signs of external bleeding, sometimes there are scarce blood discharge from the genital tract. Fetal condition is satisfactory. During pregnancy, the diagnosis can be made with the help of ultrasound (detection of retroplacental hematoma, if the blood is not released to the outside). The final diagnosis is established after childbirth, when on the mother's surface the placenta is determined by a crater-like depression and a blood clot.
• With a premature detachment of a normally located placenta of medium degree during pregnancy, the condition of a pregnant woman is of moderate severity. There are symptoms of hemorrhagic shock: visible mucous membranes and skin pale, the skin is cold to the touch, moist. The pulse is frequent, weak filling and tension, blood pressure is lowered, breathing is quickened. The uterus is tight, of a dense consistency, of an asymmetric shape due to a retropacental hematoma, and is sharply painful on palpation in a certain area. Often determine the local bulge and tension over the place of placental abruption when it is located on the front wall of the uterus. Because of the soreness of the uterus, it is impossible to palpate the small parts of the fetus. The motor activity of the fetus is expressed or weakened, while auscultation is marked tachy- or bradycardia in the fetus. Possible its death as a result of acute hypoxia. Determine blood discharge (bright or dark) from the genital tract.
• With premature detachment of severe severity, the onset of the disease is sudden. There are sharp pains in the abdomen, severe weakness, dizziness, often fainting. Skin and visible mucous membranes are pale, the face is covered with cold sweat. The pulse is rapid, weak filling and tension. Blood pressure is decreased. The abdomen is sharply inflated, the uterus is tense, painful on palpation, with local swelling, small parts of the fetus and palpitation are not determined due to pronounced tone and soreness of the uterus. External bleeding from the genital tract is absent or mild, it is always secondary and, compared with the internal one, is less abundant. Of great importance for diagnosis is the placental abruption option.
• With an edge detachment, external bleeding is observed, usually not accompanied by pain syndrome. With central detachment of the placenta and formation of a hematoma, external bleeding is absent even in severe pain syndrome. This is an extremely dangerous form, leading to the death of the fetus, severe hypovolemic disorders in the mother. A classic picture of premature detachment of a normally located placenta is observed in only 10% of women. In 1/3 of pregnant women there is no pain syndrome as one of the important diagnostic signs of this pathology. The leading clinical symptoms of detachment are bloody discharge from the genital tract and signs of intrauterine fetal hypoxia.

Special research methods

Assessment of the severity of hemorrhage.

• Biochemical blood test (protein less than 60 g / l).
• Hemostasiogram:
  • phase of hypercoagulation - increased the amount of thromboplastin and prothrombin, clotting time less than 4 min, paracoagulation tests (ethanol, b-naphthol, protamine sulfate) are not changed;
  • transitional phase - the amount of fibrinogen is less than 2 g / l, paracoagulation tests are positive, the number of fibrin degradation products is increased, thrombin time is more than 30-35 s, prothrombin time is more than 20 s, the amount of antithrombin III is less than 75%;
  • phase of hypocoagulation: the amount of fibrinogen is less than 1.5 g / l, paracoagulation tests are often negative, the content of fibrin degradation products is more than 2 × 10 ^-2 g / l, thrombin time is more than 35 s, prothrombin time is more than 22 s, the amount of antithrombin III is 30-60 %, the number of platelets decreased.
• Ultrasound (determine the location of placental abruption, the size of the retrocolar hematoma, its structure). With an edge detachment of the placenta with external bleeding, it is not always found.
• CTG.
• Doppler.

Differential diagnosis of premature detachment of a normally located placenta

Differential diagnosis should be carried out with the following conditions.

• Bleeding during presentation of the placenta rarely combines with vascular pathology (gestosis, hypertension), pyelonephritis. Hemorrhagic shock is not typical. Typical repetitive, not accompanied by painful symptoms of bleeding. The uterus is painless on palpation, of normal shape and size. Fetal position often pelvic, oblique, transverse. The present part is located high above the entrance to the small pelvis. The fetus suffers insignificantly.
• Bleeding after rupture of the marginal sinus of the placenta occurs suddenly at the end of pregnancy or the first stage of labor. Usually stops for 10 minutes. Blood flowing scarlet. There may be a second bleeding. Pregnant women with this pathology often have gestosis, multiple pregnancies. The prognosis for the fetus is favorable. The final diagnosis is established after delivery, when the disturbed sinus and blood clots, fixed to the edge of the placenta, are determined.
• Rupture of the umbilical cord with a pleural attachment. Bleeding (of fruit origin) develops suddenly with spontaneous or artificial dissection of the fetal bladder, a mild, scarlet color, quickly leads to the death of the fetus. The dead fruit is pale white (anemia). This pathology should be assumed if the fetal heart rate begins to suffer immediately after the opening of the membranes and the beginning of bleeding. The final diagnosis is established after the examination of the afterbirth: the broken vessels of the umbilical cord are attached to the membranes or to an additional lobe of the placenta.
• Rupture of the uterus during pregnancy (by rumen). The uterus after the rupture decreases in volume, the fetus is dead, palpable under the abdominal wall. Pregnant in a state of shock (skin is pale, pulse is thready, blood pressure is sharply reduced). An emergency abdominal incision is shown, and, as a rule, removal of the uterus.
• Bleeding from varicose veins of varicose veins of the vagina, ectopia, polyps, cervical carcinoma can be ruled out by examining the vagina and cervix using heated mirrors.

Indications for consultation of other specialists

• Anesthesiologist: the need for abdominal delivery.
• Neonatologist resuscitator: the need for resuscitation at birth of a child in a state of moderate or severe asphyxia.

Treatment of premature detachment of a normally located placenta

The purpose of treatment

Stop bleeding.

Indications for hospitalization

Bleeding from the genital tract of any intensity.

Non-drug treatment

Bed rest.

Drug therapy

The choice of the treatment method for premature detachment of the placenta is determined by the severity of the bleeding, the state of the mother and the fetus.

With detachment of the placenta during pregnancy (with a period of up to 34-35 weeks), if the condition of the pregnant and fetus does not suffer much, there is no pronounced external and internal bleeding, expectant tactics are possible.

Therapy is aimed at treating the disease that caused the detachment (hypertension, gestosis, etc.), a decrease in the tone of the uterus, correction of hemostasis, the fight against anemia and shock.

Treatment is carried out under the supervision of ultrasound, Doppler, KTG; it includes bed rest, the introduction of antispasmodics, disaggregants, multivitamins, antianemic drugs:

• drotaverina 2% solution 2-4 ml IM, in / in;
• etamzilate IV, in / m 2-4 ml, then every 4-6 hours, 2 ml each. With detachment of the placenta, β-adrenomimetics can not be used.

Basic principles of treatment of hemorrhagic shock.

• Stop bleeding.
• Maintain macro- and microcirculation (controlled hemodilution).
• Correction of concomitant metabolic acidosis (4% sodium bicarbonate solution at the rate of 2 ml / kg body weight).
• Administration of glucocorticoids (0.7-0.5 g of hydrocortisone or equivalent doses of prednisolone or dexamethasone).
• Maintaining adequate diuresis at 50-60 ml / h with low doses of furosemide (10-20 mg) after the administration of each liter of fluid.
• Transfer of patients to artificial lung ventilation with increasing hypercapnia (increased RCO2 to 60 mm Hg), the presence of symptoms of respiratory failure.
• The use of antibiotics starting with cephalosporin drugs.
• Adequate anesthesia.

Surgery

With moderate and severe forms of premature detachment of the normally located placenta during pregnancy, delivery is indicated by cesarean section surgery in an emergency in the interest of the pregnant woman, regardless of whether the fetus is still alive. In the presence of multiple hemorrhages in the wall of the uterus (uterus of Kuveler), the extirpation of the uterus without appendages is shown in connection with the danger of bleeding in the postoperative period against the background of coagulopathy and hypotension of the uterus.

Patient education

A pregnant woman should be informed of immediate hospitalization in the hospital with the appearance of even minor blood discharges from the genital tract.

Further management

On 2-3 days continue the infusion therapy and correction of electrolyte balance, put a cleansing enema, conduct respiratory gymnastics. On the 5th-6th day, ultrasound is performed to assess the size of the uterus, its cavity, the condition of the sutures, the presence of hematomas. On the 6-7th day, seams are removed from the anterior abdominal wall.

Forecast

The prognosis regarding the life of the mother and fetus is mixed. The outcome of the disease depends on the etiologic factor, the severity of the detachment, the timeliness of the diagnosis, the nature of the bleeding (external, internal), the choice of an adequate method of treatment, the state of the pregnant body, the degree of maturity of the fetus.

Prevention

Timely diagnosis and treatment of pregnant women with diseases leading to placental abruption (arterial hypertension, gestosis, etc.), a decrease in the tone of the uterus, correction of hemostasis.

[1], [2], [3], [4], [5], [6]