Unpredictable Placental Abruption: Case Series

Background: The diagnosis of placental abruption is primarily clinical, but findings from imaging, laboratory, and postpartum pathologic studies can be used to support the clinical diagnosis. In patients with classic symptoms, fetal heart rate abnormalities, intrauterine fetal demise, and/or disseminated intravascular coagulation strongly support the clinical diagnosis and indicate extensive placental separation. In a few cases, placental separation has not been recognized and was only identified upon cesarean section as an incidental finding. Objectives: To describe the clinical presentations and pregnancy outcomes of placental abruption cases that are not diagnosed before cesarean delivery, termed “unpredictable placental abruption” and also cases diagnosed before cesarean delivery, termed “predictable placental abruption”. Methods: A retrospective analysis of 100 cases of placental abruption was identified by cesarean delivery at Tu Du hospital from September 2018 to May 2019. Clinical variables were compared between the unpredictable and predictable groups. The unpredictable group consists of cases that are not diagnosed before cesarean delivery, while the predictable cases were identified placental separation before cesarean delivery. The maternal and fetal outcomes were also studied. Results: In 100 cases of placental, abruption by gross clinical examination of the placenta at the time operation revealed that, 33% were unpredictable. Placental abruption attributed to maternal complications included one case of total hysterectomy (1%) with no cases of disseminated intravascular coagulation (DIC), shock or maternal death;specifically, this case of total hysterectomy appeared with predictable one. There were two cases of stillbirths. Among the 98 live neonates, 15 cases (14.7%) experienced severe birth asphyxia resulting in eight neonatal deaths;two of which were caused by heart disease and necrotizing enterocolitis. Sixty-three neonates were delivered prematurely (61.74%), with mean gestational age of 34.64 ± 3.32 weeks. Among the 33 unpredictable cases, there were no stillbirths but 60.6% and 12.1% experienced moderate and severe asphyxia, respectively. All unpredictable cases had obvious indications of cesarean section but the basic symptoms and signs of acute placental abruption included the onset of preterm labor, unspecified intrapartum hemorrhage, hypertonic uterine contractions and fetal distress for emergency caesarian section;however there were also cases where there were no symptoms and signs. Conclusions: Unpredictable placental abruption cases—not suspected of having abruption, termed—“concealed” or “chronic” placental abruption, may have variable clinical manifestations and better pregnancy outcomes.

Placental abruption

Placental abruption(also termed accidental haemorrhage) refers to the separation of a normally sited placenta from the uterine wall resulting in maternal haemorrhage into the interventing space. If this space communicates with the external os of the cervix, the haemorrhage will be revealed. If not,the haemorrhage may result in delay in diagnosis, and underestimation of blood loss,which in turn increases the likelihood of coagulopathy and maternal morbidity. In the presence of massive abruption, blood tracks under pressure back into the myometrium, and may be visible beneath the uterine serosa at caesarean section. This appearance is referred to as a ’Couvelaire uterus’. Fetal bleeding can occur with placental abruption , though it is rare. It can be detected by a Kleihauer test which detects fetal haemoglobin in the maternal circulation and can be a clue to retroplacental bleeding in cases of trauma.

Management and Maternal-Fetal Prognosis of Placental Abruption: A Retrospective Study of 130 Cases

Objective: To describe the epidemiological, clinical and prognostic factors and assess treatment of placental abruption in the obstetrics gynecology department of the Dakar Principal Hospital. Patients and Method: We carried out a retrospective observational study of 130 successive cases of placental abruption, which occurred from January 2015 to December 2017 at the Level 3 Maternity Unit of the Dakar Principal Hospital. Data were collected from non-computerized obstetric records and analyzed using Excel and Epi info software. Results: There were 130 cases of placental abruption, that is a prevalence of 1.5%. The average age of onset of placental abruption was 30 years. The history of hypertension concerned 32.3% of patients, the average gestational age of 32.5 weeks at the time of diagnosis, grade 3 of Sher was found in 48.5% of cases. The outcome of the pregnancy was a caesarean section in 79.2% of cases, the average weight of newborns was 2058 g. The management of the complications required a blood transfusion and intensive care. A haemostasis hysterectomy was performed in 6.2% of cases. Stillbirth rate was 53.7% and maternal mortality was zero. Discussion and Conclusion: Placental abruption, a severe complication of pregnancy, is associated with high perinatal morbidity and mortality linked to the severity of the clinical picture, despite an improved maternal prognosis.