Premature placental abruption. Placental abruption. What is the placenta and why is it needed?

Complications during pregnancy and childbirth can lead to fatal consequences for the mother and fetus. These include the detachment of a normally or low-lying placenta from the wall of the uterus, with which it is connected by an extensive network of vessels.

The placenta (lat. placenta) is a very important organ during pregnancy. It produces hormones, and it is through it that oxygen and nutrients enter the child’s body. Premature placental abruption is the separation of the placenta before its time. That is, not after the child is born, but during childbirth (during contractions or pushing) or even during pregnancy.

Placenta previa

The placenta begins to form in the first weeks of pregnancy. But its exact location becomes clear closer to the second trimester of pregnancy. Normally, the placenta is located on the anterior or posterior wall of the uterus, or in its fundus (at the top point). Moreover, each type of location has its own characteristics. Thus, premature placental abruption as a result of a blow to the abdomen, resulting in premature birth, more often occurred if it was located on the anterior wall of the uterus. For the same reason, it is more difficult for doctors to listen to the baby's heartbeat with obstetric stethoscopes.

When the placenta is located in the fundus of the uterus, there are often problems with the regularity and intensity of uterine contractions during childbirth, and labor activity is discoordinated.

But on the back wall of the uterus the location is most favorable. But only if there is no scar after surgery (for example, after removal of uterine fibroids - myomectomy), or a myomatous node.

Early placental abruption occurs most often when it is low-lying or completely previa - this is when the placenta completely covers the internal os of the uterus (cervix). Complete presentation not only makes natural childbirth impossible for obvious reasons, but also provokes frequent placental abruption. And this threatens a large loss of blood from the mother and the death of the unborn child (if the detachment is large) as a result of acute oxygen deficiency.

Normally, the placenta migrates upward during pregnancy along with the growth of the uterus. Moreover, this growth is faster if it is located on the front wall. However, the placenta, located along the back wall of the uterus, also rises.

When deciding on the method of giving birth to a child, whether it is a natural process or a surgical intervention, the doctor pays attention to how much higher the placenta is than the internal os (you need at least 4 centimeters) and whether the baby’s head is located above or below the placenta before birth. For natural childbirth, you need a low position of the baby's head. Otherwise, there is a risk of severe bleeding.

Placenta previa often occurs in women who have undergone curettage (cleaning) of the uterus, abortion, or after multiple births. If there is a large uterine fibroid or in the past there was a severe inflammatory process in the uterus - endometritis. This pathology is more typical for women who are not giving birth for the first time.

Causes and symptoms of placental abruption

As for placenta previa, we have already listed the possible causes of this pathology. But not only the placenta, located in the lower segment of the uterus, can exfoliate, but also quite high from the internal os.

Possible causes of premature abruption of a normally located placenta are as follows.

1. Multiple pregnancy or large fetus. Because of this, tension occurs in the walls of the uterus.

2. Polyhydramnios. As a result of acute polyhydramnios, rupture of the amniotic sac occurs and immediate discharge of amniotic fluid, which entails placental abruption.

3. A blow, a fall, some kind of mechanical impact on the abdominal wall.

4. Violations of uterine contractility during childbirth. If the uterus is constantly tense, even between contractions.

5. The use of “Oxytocin” in large dosages to stimulate labor.

Risk factors for possible placental abruption include: nephropathy (preeclampsia), surges in blood pressure (in both directions), diseases of the heart and blood vessels, kidneys, incompatibility of blood groups and Rh factors of mother and child, anatomical features of the development of the uterus, post-term pregnancy .

The main symptom of detachment is bloody discharge from the vagina.. They can be abundant or not very abundant, with bright red blood and in the form of a so-called smear. Depends on where in the placenta, on the side or closer to the center, its detachment occurred. Dark blood means that some time has already passed after the detachment and the blood has had time to oxidize.

In the early stages, chorionic detachment is often completely asymptomatic and is accidentally discovered during ultrasound.

Pain happens, but not always. Moreover, if the placenta is on the posterior wall, then there may not be a strong tone of the uterus and a characteristic change in the outline of the uterus.

Diagnosis of premature abruption of a normally located placenta

During a gynecological examination, the doctor notes the presence of bloody discharge directly from the cervix. To confirm the diagnosis, it is enough to do an ultrasound.

The woman feels hypertonicity of the uterus, it becomes painful and asymmetrical. Nausea and vomiting appear. Sweating increases. The pulse quickens. The pressure drops.

If this happens during childbirth, the uterus is constantly under tension, and labor activity is discoordinated.

Treatment and prevention of premature placental abruption

If a woman has already been diagnosed with placenta previa, she needs to be especially careful and careful. Sexual rest, a minimum of physical activity and stress are required. The doctor managing her pregnancy should carefully monitor for other possible pregnancy complications. The placenta begins to exfoliate during the period of rapid growth of the uterus. Usually after 20 weeks of pregnancy. Even a severe cough can cause detachment. You need to take care of yourself.

If detachment has already occurred, then the woman is treated in a hospital setting. They prevent anemia, give hemostatic injections that relax the uterus (remove hypertonicity), monitor the baby’s heartbeat, monitor whether there is premature aging of the placenta and disruption of uteroplacental blood flow. If there is improvement, they are discharged home. But if the abruption continues to progress, delivery is allowed regardless of the gestational age.

Many different complications occur during childbirth, including premature placental abruption. In this case, the doctor acts depending on the situation. With a small detachment of a high-lying placenta and a mature cervix, labor can be performed. True, their stimulation is prohibited. And if the detachment is large, then only an emergency cesarean section.

Thus, it is impossible to somehow influence the placenta, raise it higher in the uterus or stop abruption. But doctors have the power to do everything possible to stabilize the conditions of the mother and child and perform an emergency delivery in the interests of both, if necessary.

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Typically, the placenta is attached to the top of the uterus and remains there until the baby is born. During the last stage of labor, the placenta separates from the uterus and labor contractions push the placenta into the birth canal. This is called "birth of the placenta."

Approximately 1 in 100 pregnant women (1%). This usually occurs in the third trimester of pregnancy, but can occur any time after the 20th week of pregnancy.

Placental abruption can be mild, moderate or severe. If the detachment is mild, that is, not the entire placenta has separated from the wall of the uterus, but only a small part of it, as a rule, does not pose a serious danger. But if the abruption is severe (the distance between the placenta and the uterus is large), then the child may have the following problems:

insufficient height and weight;
premature birth (before the full 37 weeks of pregnancy);
stillbirth (when a baby dies in the womb before birth but after 20 weeks of pregnancy).

Placental abruption is associated with approximately 1 in 10 preterm births (10%). The birth of a child prematurely threatens him with health problems in the neonatal period (the first four weeks of life), the first week is especially dangerous. If a child was born very premature, he may subsequently be diagnosed with a disability, and he may even die.

Symptoms of placental abruption

The main symptom of placental abruption is bleeding from the vagina. A woman may also experience discomfort and pain in the lower abdomen or back pain. Sometimes these symptoms can occur without vaginal bleeding if the separated placenta has blocked the os and blood simply cannot leak out. Therefore, if you suddenly experience abdominal pain, consult a doctor.

If the doctor suspects that a woman’s placenta has separated, she will be admitted to a hospital or maternity hospital. Accurate diagnosis is carried out using a medical examination and ultrasound.

Causes of placental abruption

It is impossible to pinpoint the exact reason why the detachment occurred. But it has been proven that women who:

smoke cigarettes during pregnancy;
use drugs, especially cocaine;
over 35 years old;
suffer from high blood (arterial) pressure;
have an infection in the uterus;
have problems with the uterus or umbilical cord;
have previously encountered abruption in previous pregnancies (if a woman had abruption in a previous pregnancy, then the likelihood that it will happen again is more than 10%);
pregnant with twins, triplets and more children;
(excess amniotic fluid);
whose membranes ruptured before the pregnancy reached a full 37 weeks;
suffered an abdominal injury, for example, during a car accident or as a result of physical violence.

Treatment of placental abruption

Treatment depends on how severe the detachment is and how far into the pregnancy you are. In mild cases, the doctor will simply monitor the condition of the woman and her child. But in more serious cases, the woman is prescribed delivery, regardless of the stage of pregnancy.

If the pregnancy is still very early and the woman urgently needs to give birth, the doctor will prescribe corticosteroids - medications that help speed up the development of the baby's lungs and other organs.

1. Mild placental abruption – if a woman has a mild abruption at 24–34 weeks of pregnancy, she needs careful observation in the hospital. If tests and examinations show that she and her baby are doing well, the doctor will prescribe her treatment aimed at maintaining the pregnancy as long as possible. Often a woman is advised to stay in the hospital until she gives birth. But if the detachment is not accompanied by bleeding, then the woman can be sent home.

If a woman has a mild abruption at term, the doctor may recommend inducing labor or a cesarean section, or waiting for the natural onset of labor.

But a woman will definitely be prescribed an emergency delivery, even with mild abruption, if:

placental abruption worsens;
the woman is bleeding heavily;
there are problems with the condition of the fetus.

2. Moderate (moderate) or severe placental abruption - in such cases, emergency delivery is usually recommended, usually by caesarean section.

If a woman has lost a lot of blood due to abruption, she may need a blood transfusion. In very rare cases, if a woman has heavy bleeding that cannot be stopped, she may need a hysterectomy - surgical removal of the uterus. A hysterectomy can prevent fatal bleeding and other health problems for the mother. Unfortunately, such a woman will never be able to get pregnant again.

In most cases prevent placental abruption during pregnancy impossible. But you can reduce your risk by not smoking or taking drugs, taking medication for hypertension (high blood pressure) if you have it, and always wearing a seat belt in your car.

Placental abruption is a serious complication of pregnancy and childbirth. Detachment of the “baby spot” from the uterine wall can be fatal for the child and his mother. According to statistics, such a disorder occurs in 1.5% of all pregnancies. Why this happens, what are the chances of saving the baby, and what the consequences may be at different times will be discussed in this article.

What it is?

Placental abruption is considered normal only if it occurs after childbirth, after the baby is born. The “children’s place,” having exhausted its resources and become unnecessary, is rejected and born. During pregnancy, first the chorion, and then the placenta, formed on its basis, nourishes and supports the baby, supplies it with oxygen and all the substances necessary for growth and development.

Premature abruption is the partial or complete separation of the placenta from the uterine wall with damage to blood vessels. The mechanism of development of detachment is not completely clear to medicine, but the processes that follow such detachment are obvious - bleeding of varying intensity develops, comparable to the size of the detachment.

Most often, the pathology occurs in women who decide to become mothers for the first time. In addition, women during premature birth are 3 times more likely to experience detachment of the “baby place” than women who give birth on time.

The condition and vitality of the baby and its development largely depend on the condition of the placenta. The placenta not only participates in gas exchange (supplies the baby with oxygen and removes carbon dioxide), it also nourishes it, protects it and participates in the production of many hormones necessary for the successful bearing of a child. The “baby place” usually fits quite tightly to the wall of the uterus: the fetus and water press on it from above, and the walls of the uterus from below. It is this double pressure that prevents the placenta from leaving its place prematurely.

Severe detachment, total detachment before the birth of the child leads to acute hypoxia - the baby is deprived of oxygen and nutrients. Hormonal levels are disrupted in a pregnant woman's body. If emergency medical care is not provided, the child will die. If the baby is very premature at the time of abruption, he will most likely also die.

With marginal, partial detachment, oxygen delivery will not completely stop, but will be insufficient. The consequences for the child will not be long in coming: the baby will not receive enough nutrients, will experience chronic hypoxia, and may slow down in development and growth. The state of chronic hypoxia has a detrimental effect on all organs and systems of the child, but to a greater extent on the nervous system and the functioning of the brain and spinal cord, as well as the musculoskeletal system.

For a woman, detachment is dangerous due to bleeding. With prolonged bleeding, anemia occurs and the condition of the expectant mother worsens significantly. With heavy bleeding, which is typical for a total, large-area detachment, the woman may die from massive blood loss. Even a small placental abruption that occurs at different stages creates a huge risk of miscarriage or premature birth.

Causes

The exact reasons that lead to the separation of the “baby spot” from the wall of the uterus are still unknown to science. Doctors tend to believe that in each specific case, not just one, but a combination of several risk factors plays a role.

Pressure. High blood pressure can trigger the expulsion of the placenta. Half of the women who survived abruption had hypertension. In approximately 10%, detachment occurred against the background of a spontaneous jump in blood pressure up or down. Often, blood pressure begins to “jump” under severe stress, in a threatening and unfavorable psychological situation. Lying on your back for a long time leads to a disturbance in the pressure in the inferior vena cava, which can also lead to the detachment of the placenta from the wall of the uterus.
Repeated pathology. If a woman has previously experienced detachment, the likelihood that it will recur is above 70%.
Multiple pregnancy and having many children. Women who carry two or three babies are more susceptible to pathology than women who carry one child. Often, abruption is recorded in women who have given birth a lot and often - their uterine walls are more flabby and stretched.

Age of the pregnant woman. For expectant mothers over 30 years old, the risk of premature detachment is several times higher than for women 18-28 years old. If the expectant mother is over 35 years old, then quite often her placenta “acquires” an additional lobe, and it is this lobe that comes off during childbirth, causing automatic detachment of the entire “baby place.”
Pregnancy after infertility, IVF. If pregnancy occurs after a long period of infertility, either naturally or as a result of assisted reproductive methods such as IVF, then the likelihood of placental abruption increases, the risk is estimated at approximately 25%.
Gestosis and toxicosis. In the early stages, severe, painful toxicosis is considered a risk factor. Vomiting, nausea, metabolic disorders, pressure changes often lead to detachment to varying degrees. In the later stages, gestosis is dangerous.

With edema, excess weight, leaching of protein from the body with urine and hypertension, blood vessels suffer, which can also lead to the detachment of the placenta from its proper place.

Features of the uterus and blood vessels. Some anomalies in the structure of the main female reproductive organ, for example, a bicornuate or saddle-shaped uterus, as well as anomalies in the structure of the uterine vessels can lead to recurrent miscarriage due to constant detachments.
Placenta previa or low placentation. If for some reason the fertilized egg is fixed in the lower segment of the uterus, and subsequently the chorion, and behind it the placenta, does not migrate higher, then abruption becomes the main threat to this condition. Particularly dangerous is complete central placenta previa, when the baby's place closes the entrance to the cervical canal completely or almost completely.
Hemostasis disorders. In women with bleeding disorders, detachment of the baby's place during pregnancy and childbirth often occurs. Usually, hemostasis disorders are accompanied by other pathologies of pregnancy.

Problems of labor. Often, a dangerous condition occurs directly during childbirth - due to a pressure drop, during fast, rapid labor, after the birth of the first child from twins, with untimely rupture of the amniotic membranes, as well as with a short umbilical cord.
Injury. Unfortunately, this is also a common cause of severe complications. A woman can suffer blunt trauma to the abdomen, fall on her stomach, get into an accident and hit her stomach. With such an injury, detachment of the “child’s place” occurs in approximately 60% of cases.
Bad habits. If the expectant mother cannot give up the habit of smoking or taking alcohol and drugs even while carrying her baby, then the likelihood of spontaneous sudden detachment increases tenfold.

Autoimmune processes. A pregnant woman’s immune system can begin to produce specific antibodies to her own tissues. This happens with severe allergies, for example, to medications or with an incorrect blood transfusion, as well as with severe systemic illnesses - lupus erythematosus, rheumatism.
Mother's illnesses. From the point of view of the likelihood of abruption, all chronic diseases of a pregnant woman are dangerous, but the greatest risks are posed by diabetes, pyelonephritis, problems with the thyroid gland, and obesity of the woman.

If, upon registration, after studying the woman’s medical history, the doctor decides that this pregnant woman is at risk for the possible development of abruption, he will more carefully manage such a pregnancy. A woman will have to visit a doctor more often, undergo tests, have an ultrasound scan, and she may also be recommended a preventive stay in a day hospital several times during pregnancy.

Symptoms and signs

All signs of premature separation of the “baby place” come down to one manifestation - bleeding. The degree and severity of it depends on how extensive the detachment is. Even a small detachment can lead to the appearance of a large hematoma. It is an accumulation of blood that has come out of damaged vessels and accumulates between the wall of the uterus and the “baby spot” itself. If there is no blood outlet, the hematoma grows and enlarges, promoting detachment and death of more and more areas of the placenta.

There may be no symptoms only with a mild degree of pathology. Only a very attentive ultrasound doctor, as well as an obstetrician who will deliver the baby, can notice a small detachment - there will be small depressions on the placenta on the side on which it was adjacent to the uterus, and possibly blood clots.

If a woman feels slight nagging pain in the abdomen, accompanied by small brown or pink discharge, we are talking about a moderate severity of the pathology. When bloody “smears” appear, the condition of the placenta at any stage in any woman must be examined.

Moderate detachment is much more dangerous than pregnant women themselves are used to thinking. It threatens hypoxia for the baby, and is often manifested by a disturbance in the fetal heart rhythm.

A severe form of pathology is always characterized by an acute onset. A pregnant woman experiences sharp, sudden, severe pain in the abdomen, a feeling of fullness from the inside, and dizziness. Loss of consciousness is possible. With this form of detachment, the bleeding is strong and intense. But moderate bleeding is also possible. The distinctive feature of the form is the color of blood. In case of severe detachment, it is scarlet and bright. The woman almost immediately develops shortness of breath, her skin becomes pale, and she sweats intensely.

In severe and moderate forms, tension in the smooth muscles of the uterus and increased tone are always observed; upon examination, the doctor notes the asymmetry of the female reproductive organ. Based on the nature of the bleeding, an experienced doctor can easily determine the type of detachment.

No or little bleeding- central placental abruption cannot be ruled out, in which all the blood accumulates between the wall of the uterus and the central part of the “baby place”. This is the most dangerous form.
Vaginal bleeding is moderate- marginal or partial detachment cannot be ruled out, in which blood quickly leaves the space between the uterus and the “baby place”. Pathology of this kind has a more favorable prognosis, since the drainage of blood increases the likelihood of thrombosis of damaged vessels and healing of the area.
No bleeding against the background of a noticeable deterioration in the condition of the pregnant woman and soreness of the uterus, the bleeding is hidden, and this is a rather dangerous condition that can lead to total detachment.

The pain is usually dull and aching, but with acute and severe detachment it can be sharp, radiating to the lower back and thigh. When the doctor palpates the uterus, the woman will experience severe pain. The baby's heartbeat is disturbed due to oxygen deficiency that develops against the background of the placenta expulsion.

The first signs of a disturbance in the condition of the fetus make themselves felt if the “baby place” has moved away by about a quarter of its total area; in a threatening condition, which is manifested by a violation of the baby’s motor activity, they speak of an abruption of approximately 30% of the placenta. When the organ is removed to 50% of its own area, the child usually dies.

When diagnosing, the doctor will definitely take into account the duration of pregnancy, because in different trimesters the symptoms and manifestations of pathology may be different.

Detachment at different times

In the early stages, the passage of the placenta occurs most often, but you should not be upset, because if you consult a doctor in a timely manner, there are many ways to maintain the pregnancy and prevent negative consequences for the mother and her baby. Typically, in the first trimester, such a detachment manifests itself as a retrochorial hematoma, which is confirmed by ultrasound results. Discharge may or may not appear at all.

In most cases, proper treatment at this stage allows the placenta to completely compensate for the loss of contact between part of the area and the uterus, and the pregnancy will develop quite normally.

If detachment occurs in the second trimester up to the 27th week inclusive, then this is a more dangerous condition that threatens the baby with hypoxia. At the initial stage of oxygen starvation, the baby becomes more active, he tries with all his might to get himself additional oxygen.

If hypoxia becomes chronic, the child’s movements, on the contrary, slow down. Until the middle of the second trimester, the placenta can grow, then it loses this ability and can no longer compensate for the lost area. Therefore, the prognosis is more favorable if the detachment occurs before 20-21 weeks. After this period, the forecasts are not so rosy.

In the later stages, pathology poses the greatest danger. The “children's place” can no longer grow; compensation for some of the lost functions is physically impossible. Fetal hypoxia will only progress, and the child’s condition may become critical. If the detachment continues to grow and increase in area, the woman undergoes a cesarean section to save the child.

It is not always possible to save, since children can be very premature, and then death can occur as a result of acute respiratory failure due to the immaturity of the lung tissue or due to the baby’s inability to maintain body temperature.

Only if the abruption does not progress in the third trimester is there a chance to maintain the pregnancy with strict bed rest under round-the-clock supervision in a gynecological hospital. It is impossible for a woman to stay at home.

Placental abruption during childbirth can occur for a variety of reasons; most often this occurs in pregnant women with twins or in women in labor with diagnosed polyhydramnios. The walls of the uterus may lose contractility due to excessive bleeding. At any stage of the birth process in this situation, doctors use stimulation of contractions; if this turns out to be unsuccessful, then they perform an emergency caesarean section.

Treatment

If there is very little time left before the due date, then treatment of abruption is not advisable. Doctors recommend giving birth - stimulating natural labor or performing a caesarean section (depending on the timing and situation). There is no point in waiting and delaying - delay can lead to tragedy.

But if the child is not yet considered viable, then doctors will try to do everything to prolong the pregnancy if the abruption does not progress.

There is no single, ready-made solution - in each specific situation, the doctor and patient must carefully weigh the risks: give birth to a premature baby who may not survive, or take the risk and possibly face a critical condition of the baby due to detachment and hypoxia. Detachment is always treated in a hospital setting.

Therapy, which will include drugs - hemostatics that stop bleeding, as well as drugs from other groups at the discretion of the doctor, is carried out only when the detachment is partial, the gestational age is less than 36 weeks, there is no or moderate vaginal bleeding, and there are no signs of severe fetal hypoxia and progression of “baby spot” detachment.

To relieve the threat, antispasmodics are prescribed, which should maintain the muscles of the uterus in a relaxed state, preventing even short-term tone. The woman will be given medications that will replenish the baby's nutritional deficiencies and improve blood circulation between the uterus and placenta. And she may also be recommended sedatives and iron supplements, which will help get rid of the symptoms of anemia.

If even the slightest signs of progression of the “baby place” detachment appear, a decision is made to stop expectant management and conservation therapy in favor of emergency delivery.

Prevention

Any pregnant woman should do everything possible to prevent such a pathology. If there is at least a minimal chance of detachment, the doctor will definitely report this and give a number of important recommendations that will help protect the baby and his own health.

Thus, no one can offer any preventive treatment to women who have previously encountered this unpleasant complication, since it does not exist in nature. But to prevent a recurrence of the problem, it is recommended that a pregnant woman contact an antenatal clinic as early as possible for registration.

Women with low placentation or placenta previa, as well as with the threat of miscarriage due to malformations of the “baby place” itself, are not recommended to have sex, excessive physical activity and stress. While carrying a child, you should not neglect visiting a doctor and undergoing mandatory and additional tests.

If a woman suffers from high blood pressure, she must monitor its level and, if necessary, take medications as prescribed by a doctor that will effectively reduce blood pressure without harm to the child’s body. Women with a negative Rh factor during pregnancy from an Rh positive man require the introduction of anti-Rhesus immunoglobulin in the second trimester of pregnancy.

If a woman is at risk for abruption (and even if she is not), she should stop smoking while pregnant, and also avoid even small doses of alcohol. Women should always wear a seat belt when traveling in a car, and the belt should go above or below the level of the abdomen. In winter, when the stomach becomes quite large, you should move very carefully, since your own legs become invisible and the likelihood of falling and getting a blunt injury to the abdomen increases.

A woman should avoid contact with allergenic substances and not take medications without a doctor’s prescription, since many drugs can cause placental abruption and bleeding. In the presence of chronic diseases, a woman’s pregnancy must be managed by two specialists - an obstetrician-gynecologist and a doctor of the specialty whose jurisdiction includes the disease of the expectant mother. Only a joint medical tandem will avoid complications.

If signs of gestosis appear (the appearance of protein in the urine, increased pressure, swelling and pathological weight gain), the expectant mother must follow all the doctor’s prescriptions, and, if necessary, go to the hospital to be under the supervision of doctors and receive the necessary treatment.

Forecasts

The prognosis is more favorable if a woman seeks help from a doctor as early as possible. If you experience bloody discharge, pain in the abdomen, or a deterioration in your overall health, you cannot look for the answer to the question of what is happening on the Internet or from friends and acquaintances. It is important to call an ambulance as soon as possible. Bloody discharge cannot be considered normal during pregnancy, and in most cases it is a clear sign of problems with the integrity of the “baby place”.

Every day, every hour is of great importance in predicting the outcome and consequences of placental abruption. The longer the pregnancy, the more unfavorable the prognosis will be. The size of the detachment and the presence of its progression also affect prognosis.

Mother and baby are connected through the placenta. This is the life support organ of the fetus: responsible for nutrition, respiration and excretion of metabolites. It is formed and begins to fully function by the 16th week of gestation. Placental abruption in early pregnancy can cause death of both the fetus and the woman.

The rudiments of the placenta appear already in the fifth or sixth week of gestation, and from the seventh or eighth week the placental blood flow begins. But it is fully formed only by 14-15 weeks, so in the 1st trimester they do not talk about placental abruption. If a hematoma appears or miscarriage occurs, this organ is called the chorion before the 16th week. By ultrasound, the location and condition of the chorion can be determined already from the eighth to tenth week.

How the process starts

Partial placental abruption develops when it separates from the wall of the uterus in a certain area. If it is completely detached from the myometrium, then this serious condition is called complete placental abruption.

A small partial placental abruption occurs:

marginal - the placenta begins to separate along the edge;
central - a hematoma grows in the area of the placenta, blood does not flow out of it.

Detachment is preceded by vascular rupture and bleeding. The progression of the pathology depends on how quickly a hematoma forms in this place. She will gradually separate the placenta from the muscles of the uterus. If the detachment is non-progressive, then the bleeding will stop, the hematoma will begin to thicken, dissolve a little, and salts will be deposited in the remains.

The hematoma can quickly increase in size, peeling off an increasingly larger area of the placenta. At the same time, the tissues of the uterus are greatly stretched, and the bleeding vessels are not pinched and support bleeding.

The abruption can gradually reach the edge of the placenta, after which the membranes begin to separate and blood flows to the cervix. It comes out naturally through the vagina.

If there is no outflow, then a large hematoma forms. From it, blood permeates the placenta itself and the muscles of the uterus. In this case, the myometrium stretches even more, and cracks form in it. The tone of the uterus decreases, it loses the ability to contract. A condition develops called placental apoplexy or Couveler's uterus.

Further progression of bleeding disrupts the blood coagulation process, and disseminated vascular coagulation syndrome (DIC) develops. The latter, after a short phase of thrombus formation, turns into heavy bleeding. This is often fatal.

Placental abruption in early pregnancy: 6 provocateurs

This gestational complication occurs in less than 1% of all pregnancies. But the causes of the pathology have not been precisely established. Most often it is considered a consequence of hidden, long-term systemic abnormalities in the body. The following six factors can cause sudden placental abruption during pregnancy.

Vascular pathology. These are diseases that existed before pregnancy - glomerulonephritis, arterial hypertension.
Autoimmune diseases. Antiphospholipid syndrome and systemic lupus erythematosus are not a contraindication for pregnancy, but are associated with the risk of miscarriage due to damage to microvessels by immune complexes.
Endocrine diseases. Diabetes mellitus is also combined with damage to the microvasculature.
Preeclampsia. Pathology of pregnant women, which is manifested by generalized vasospasm, increased blood pressure, edema and protein excretion in the urine. The disease manifests itself only after the formation of the placenta.
Allergic conditions. When using dextrans, as well as when blood transfusion is necessary.
Genetic abnormalities. With deep congenital pathologies of the blood coagulation system, there is a high risk of blood clots.

For reliable attachment of the placenta, the cytotrophoblast must grow to the basal layer of the endometrium. If its attachment is superficial, then under the influence of additional factors the detachment mechanism may be triggered.

Blood coagulation disorders are the main cause and consequence of placental abruption. If a woman has congenital thrombophilia, then even at the stage of chorion formation, some vessels become thrombosed, and the placenta does not attach fully. The consequences of impaired hemostasis (a natural mechanism for stopping bleeding) during detachment are the emergency formation of DIC syndrome.

Rarely, severe placental abruption in the early stages is the result of abdominal trauma (fall, strong blow with a blunt object).

How to notice and react

Symptoms of placental abruption in the early stages appear suddenly:

bleeding;
sharp pain in the abdomen;
signs of shock;
hypertonicity of the uterus.

At the moment of detachment, the fetus enters a state of acute hypoxia. His movements and heartbeat may increase for a short time. But this quickly subsides, the child freezes, and a slow heart rate is heard (less than 90 beats per minute when the norm is 120-140).

Degree of detachment

The severity of the condition is determined by the degree of detachment and clinical manifestations. The amount of medical care and the likelihood of the child’s survival will depend on this.

Easy. Partial detachment of the placenta, usually the marginal area, in late pregnancy is compensated by the rest of the placenta. The general condition does not suffer, vaginal discharge is insignificant. If this is a marginal detachment, then the hematoma is not visible on ultrasound. When a small hematoma forms, it becomes noticeable on ultrasound, and after birth it is found in the form of a clot on the placenta.

Average. About a third to a fourth of the placenta peels off. In this case, a significant amount of blood is released, often with clots. The stomach hurts, the uterus comes into a state of increased tone. When palpating the abdomen, the pain intensifies. If delivery is untimely, the fetus dies.
Heavy. More than half of the placenta is exfoliated. The woman’s condition is serious, with symptoms of hemorrhagic shock: tachycardia, sticky sweat, drop in blood pressure and clouding of consciousness. The uterus looks asymmetrical and is sharply painful. The child dies.

Type of bleeding

The type of bleeding can be determined by external signs.

External. Occurs when the edge of the placenta separates. There may be no pain syndrome. The blood flows out bright scarlet.
Internal. In this case, a retroplacental hematoma is formed, which stretches the walls of the uterus and irritates pain receptors. If the placenta is located on the back wall of the uterus, the pain may radiate to the lower back. When attached to the anterior wall of the uterus, a slight swelling may be noticed on the abdomen.
Mixed. Occurs when a hematoma is emptied. The blood released through the genital tract is dark red in color.

With placental abruption, pregnancy can be maintained only if there is a quick response to the first symptoms and the condition is mild or moderate. If acute abdominal pain or bleeding occurs in the 2nd or 3rd trimester, emergency hospitalization is necessary.

Professional diagnostics

To diagnose a detachment, the doctor only needs to analyze the clinical symptoms, the woman’s complaints, ultrasound data and hemostasiogram parameters.

When a woman with bleeding is admitted to the hospital, an ultrasound examination should be performed as early as possible. This will allow you to identify a hematoma at the beginning of its formation. With marginal detachment, when the blood does not accumulate but flows freely, it is much more difficult to determine this sign by ultrasound.

When examined in a chair, the cervix is usually closed, and there may be slight bleeding. Through an obstetric stethoscope in the 2nd trimester, you can notice the absence of fetal heartbeats and diagnose its death. In the third trimester, a CTG machine is used for these purposes.

A general blood test is not informative, but a hemostasiogram allows you to notice the formation of disseminated intravascular coagulation syndrome in time and take appropriate measures.

Treatment tactics

The choice of treatment tactics for placental abruption in the early stages is influenced by certain factors:

condition of the mother and fetus;
gestational age;
state of hemostasis;
volume of blood loss.

With a mild degree of the condition and at a short stage of pregnancy (up to 34-35 weeks) after placental abruption, expectant management is possible. The woman’s condition is constantly monitored using ultrasound and CTG. The following drugs are prescribed for treatment:

antispasmodics - “No-Shpa”, or “Drotaverine”, “Papaverine”;
beta-agonists- “Ginipral”;
disaggregants - “Dipyridamole”;
vitamins - in the form of injections.

To relieve uterine tone, a solution of magnesia can also be used, which is prescribed intravenously. In some cases, Vikasol is prescribed for bleeding, but its effect does not develop immediately.

Duphaston tablets are useless in the treatment of placental abruption in the second and third trimesters. Transfusions of fresh frozen plasma can be of great benefit, which will become a source of blood clotting factors used up during bleeding.

In moderate to severe cases, the only way to help the pregnant woman is an emergency caesarean section, regardless of gestational age. Saving the child fades into the background. During the operation, the uterus must be examined to exclude areas of blood soaking. If Couveler's uterus is diagnosed, then ligation of the internal iliac arteries is performed to stop the bleeding. If after this the bleeding does not stop, then they resort to the last resort - removal of the organ.

The woman's own blood, which has spilled into the abdominal cavity, is collected, purified and transfused back (if appropriate equipment is available).

Folk remedies for this condition are not only useless, but deadly. No herbs can stop the detachment that has begun, and at home it is impossible to assess the scale of the problem on your own. The result can be massive bleeding, which will lead to the death of mother and child.

Give birth naturally or by cesarean

In the late term, with a small detachment and good condition, women give birth through the natural birth canal. In this case, the process is started using amniotomy. Examination during childbirth includes constant monitoring of the mother's blood pressure and fetal CTG.

The location of the fetus determines the doctor’s tactics for progressive abruption during labor:

in the widest part of the pelvis- emergency surgical delivery;
in the narrow part of the pelvis- complete the birth using obstetric forceps or a vacuum extractor.

Immediately after labor is completed, the uterine cavity is manually examined to prevent subsequent bleeding. Dinoprost is prescribed intravenously. If signs of bleeding disorders occur, plasma or platelet transfusions are performed.

How can it all end for mom...

DIC syndrome is one of the consequences for a pregnant woman. The tissues of the uterus contain a large number of enzymes that reduce blood clotting. During detachment, they are massively released. Therefore, the first phase of DIC develops - hypocoagulation (decreased coagulation). But the body reacts to this with a massive release of blood clotting factors. Therefore, hypocoagulation is replaced by hypercoagulation (increased coagulation). Gradually, the compensation mechanisms are exhausted, and hypocoagulation occurs again. It is accompanied by massive bleeding that cannot be stopped by conventional means.

For a woman who survives such bleeding, the consequences may be severe anemia, as well as Sheehan syndrome - a deficiency of pituitary hormones. Sometimes the only way to save the mother's life is to remove the uterus.

In this article:

The placenta is formed from the surface, cortical layer of cells of a fertilized egg, and performs the functions of the lungs, liver and kidneys of the fetus. Oxygen, necessary for the energy of the fetus, is extracted from the mother’s blood and transferred through the placenta into the baby’s blood. Carbon dioxide and other waste products of the fetus are carried through it into the mother's body. Gas exchange between mother and child occurs through the placenta, so placental abruption leads to oxygen deficiency, which can cause the death of the fetus. In the first trimester, active development and growth of the placenta occurs.

The placenta grows with the baby until the end of the second trimester; in subsequent months its size remains unchanged. A spongy structure, sufficient thickness and diameter are signs of the maturity of this organ. After the birth of the fetus, it peels off from the wall of the uterus, and the blood vessels at its location are pinched due to contractions of the uterus, preventing bleeding. A normally developed placenta fully performs its function; after birth, the doctor carefully examines it so as not to miss signs of pathology.

Pathological conditions during placental abruption

Since the placenta performs vital functions for the fetus, the pathology of its development and vital functions leads to various disorders in the development of the baby.

Ultrasound shows the correct formation of this organ already in the early stages of pregnancy, so the doctor can already at the first stage of the disease classify the symptoms, diagnose the defect and take measures to correct it.

Placental abruption occurs both along its perimeter or along one of the edges, and in the center of the disc. The blood vessels at the site of detachment rupture, causing bleeding, the strength of which is directly proportional to the area of the rupture. In the early stages, while the placenta is not yet fully formed, heavy bleeding is rare, the affected area is small and the vessels thrombose quite quickly. The growth of the placenta can subsequently compensate for the loss, eliminate the causes of hypoxia and ultimately lead to the birth of a healthy baby.

In later stages, placental abruption causes greater blood loss in the pregnant woman, especially if the bleeding occurs in the center of the disc. Tight attachment of the baby's place around the perimeter prevents blood from escaping; it accumulates between the wall of the uterus and the placenta, exerting mechanical pressure and provoking even greater detachment. Placental hematoma grows very quickly; in a few hours a woman can lose up to two liters of blood. Due to physiological changes during pregnancy, this does not have a sharply negative effect on the expectant mother, but she requires at least eight or even twelve units of blood transfusion.

The wall of the uterus becomes saturated with blood, changing the contractility of muscle fibers. Sometimes blood can seep between the membranes, causing the amniotic fluid to turn red. Normal labor in this condition is impossible, it threatens the life of the mother, and the fetus with massive detachment most often dies from hypoxia.

Causes of placental abruption

The causes of placental abruption are different, and they are all divided into internal and external. The difference between them is that a woman can eliminate external causes on her own, but internal risk factors can be minimized only in cooperation with doctors.

Internal reasons

Research projects conducted by various scientific gynecological centers have identified a number of patterns in which placental abruption is diagnosed. In the first place is hypertension in pregnant women - it was high blood pressure that led to bleeding in half of the cases. This relationship is understandable, because hypertension, gestosis and associated internal edema create excess pressure on the vessels. In general, any vascular diseases, blood clotting disorders and fragility of blood vessels - all these reasons are a provoking factor for detachment.

Numerous pregnancies - and this reason is quite understandable: frequent childbirth changes the structure of the uterine mucosa, creating favorable conditions for pathological conditions during pregnancy and after childbirth. The altered cellular structure of the uterine mucosa prevents complete attachment of the placenta, and often creates the preconditions for atonic bleeding in the postpartum period.

Placental abruption increases by thirty-five percent after the first birth by cesarean section. The suture on the uterus, on which the placental disc is attached, provokes a pathological condition during the second and third trimester of pregnancy. A second cesarean section is the cause of abruption in sixty-five percent of cases.

Multiple pregnancy - this condition often causes placental abruption during vaginal delivery of the second twin, this does not threaten the condition of the children, but can cause greater blood loss in the mother.
Infectious diseases of the kidneys and urinary tract can provoke the onset of a pathological process; pyelonephritis in pregnant women is a dangerous disease that should certainly be treated with antibiotics in a hospital setting. Refusal to hospitalize and fear of harming the child by taking potent medications, in this case, can lead to the development of dangerous complications.

External risk factors

Smoking - no matter how much doctors talk about the dangers of smoking, pregnant women continue to poison their body and the child growing in it with toxic substances. They cause abruption of the baby's place so often that smoking is the root cause of this pathology in physically healthy mothers. Although cocaine use is not widespread, doctors have recognized a direct link between the use of this drug and severe placental abruption.

The causes of detachment can be: blunt trauma to the abdomen, strong physical impact, violence against a woman. Car accidents, even minor ones, most often provoke this condition, and if in the first hours after the injury the detachment may be insignificant, then after eight hours it can already threaten the life of the mother and fetus.

Diagnosis and symptoms of placental abruption

A condition such as placental abruption is diagnosed according to ultrasound examination, which is the most informative in this case. The doctor prescribes a routine examination at twenty weeks, in the first trimester, when the placenta is already quite mature. Unscheduled studies, in the absence of a woman’s complaints, are prescribed for various disturbing conditions of a pregnant woman: uterine hypertonicity, high blood pressure or concomitant diseases.

With a small placental abruption, bleeding may not occur; most often, the woman does not feel any signs, and this condition is detected only by ultrasound. The first degree of the pathological condition does not pose a threat to the health of the mother and baby, but treatment must be adequate to the threat and requires constant monitoring. The prognosis is usually favorable, the child is born without physical abnormalities, on time.

The average or second degree of the disease causes symptoms such as abdominal pain from the detachment side, and scanty, dark bloody discharge from the genital tract may be observed. The uterine wall is tense and painful on palpation. There is a disturbance in the fetal heart rhythm due to the resulting lack of oxygen. This condition is dangerous because at any time it can provoke further deterioration in the condition of the mother and fetus, so the woman needs emergency hospitalization.

Placental abruption during severe third-degree pregnancy causes a sharp deterioration in the woman’s condition: severe abdominal pain, fainting, low blood pressure and pale skin. Dark red, small amounts of bleeding occurs. Palpation reveals a sharply tense uterine wall, convex at the site of detachment. It is impossible to listen to the child’s heartbeat, and most often the fetus dies instantly, even with emergency surgery. A timely operation in most cases saves the mother’s life.

Treatment of placental abruption

In all cases of detection of a condition such as placental abruption, the pregnant woman is urgently hospitalized. Depending on what symptoms are present and the severity of the condition, a decision is made on conservative or surgical treatment in a hospital setting. If the woman’s condition is stable, her condition is constantly monitored until the last day of pregnancy.

In the early stages of pregnancy, with immaturity of the fetus and minor placental abruption, treatment is conservative: the doctor prescribes drugs to help stop bleeding. A clot forms in the affected area, which does not interfere with the further development of pregnancy. Antispasmodic and hemostatic agents in combination with bed rest and constant monitoring of the condition of the uterus make it possible to eliminate threatening symptoms and maintain pregnancy until the time of birth.

The average degree of placental abruption in the second trimester leads to various disorders in the child’s nervous system. In thirty-two percent of children with cerebral palsy and other psychoneurological diseases, their mothers were diagnosed with “moderate placental abruption” during pregnancy. This is due to the death and underdevelopment of brain cells due to impaired gas exchange and fetal hypoxia in this pathology.

At later stages, when the fetus is already sufficiently formed, placental abruption is an indicator of childbirth, and a cesarean section is performed in half of the cases. In case of a pathological condition of moderate severity, the decision on surgical intervention is made on the basis of blood test data. This is due to the fact that with reduced coagulation rates, any tissue incision will lead to extensive, life-threatening blood loss.
If blood clotting is sharply reduced, then a decision is made to stabilize the mother’s condition through blood transfusions and intravenous infusions of drugs. Labor in this case is forced, which allows the woman to preserve her life and ability to give birth. In case of severe placental abruption, the operation most often ends with the removal of the uterus, treatment is useless, the fetus dies in the first few minutes from the onset of the pathological process.

Preventive actions

Excluding factors such as traumatic injury and the presence of concomitant diseases for which preventive measures cannot be taken, placental abruption is preventable. Even if there are reasons provoking this pathology, constant monitoring of the condition of the placenta using ultrasound examinations and regular visits to the doctor will minimize the occurrence of life-threatening conditions for the child.

The results of studies of women at risk showed that even pregnant women with a history of placental abruption in previous pregnancies are able to bear and give birth to a healthy baby. Careful adherence to medical recommendations, timely treatment and artificial induction of labor during fetal maturity almost completely eliminates the occurrence of such a dangerous and formidable complication as placental abruption.