Placental abruption

Abruption is not common, and is not easy to treat. The longer you leave a patient undelivered, the worse her prognosis. If she has severe abruption, she has at least a 25% chance of DIC (disseminated intravascular coagulation), if you leave her more than 48 hours. So try to deliver her vaginally well within this time. She will usually go into labour spontaneously within 24 hours. Only section her on the uncommon indications given below. If she has severe abruption, DIC will make it dangerous. Her baby is often dead, and is usually growth-retarded and premature, so CPD (cephalopelvic disproportion) is seldom a problem.

The principles of management are: (1) Correct hypovolaemia. (2) Deliver her quickly, preferably vaginally. (3) Prevent the complications[md]postpartum haemorrhage, DIC, and renal failure.

If she has DIC, try to: (1) Empty her uterus. (2) Give her fresh blood. You can manage most cases with 2 or 3 units, but you may occasionally need much more. Stored blood is less useful, but is much better than no blood. You are unlikely to have fresh frozen plasma, or cryoprecipitate. If you have fibrinogen give it, she will need 3 g (19.11a).

There is no practical way of diagnosing mild abruption, so the account below refers to severe abruption only.

SEVERE ABRUPTION Make the diagnosis, as in Section 16.11. This account applies to revealed and concealed abruption (more common), and combinations of the two. If you are going to rupture a patient's membranes, and you will probably have to, do this EARLY, before you do anything else[md]see below.

THE CLOTTING TIME. If you want to know if her blood will clot normally or not, take 5 ml into a dry glass tube. Invert it every 30 seconds, and see when it clots. It should clot in 5 to 8 minutes. If it takes longer than this, she has a clotting defect. If it clots in 2.5 minutes or less, it is hypercoagulable. Then put the tube in your pocket. If the clot lyses in 30 minutes (fibrinolysis), fibrin degradation products are present, and she needs fibrinogen and an antifibrinolytic agent (aprotinin)[md]if you have it!

RESUSCITATION. Start a rapid transfusion of 0.9% saline, or Ringer's lactate, through a wide needle or cannula. Take a sample to determine her blood group. Ask for an emergency (30 minutes) crossmatch of 4 to 6 units of fresh blood. Measure her clotting time. Give her pethidine 25 to 50 mg by slow intravenous injection.

As soon as blood is ready, transfuse her rapidly. Give her calcium gluconate (10 ml of 10% solution) with every third unit. If you don't have blood, give her Ringer's lactate or saline. Try to correct her hypovolaemia and anaemia within 2 hours of admission. You want her to deliver soon, and you don't want to let her go into labour while she is shocked.

Insert an indwelling catheter and measure her hourly urine output: it should be more than 60 ml. If possible, and you are experienced, insert a central venous catheter (A 19.2). Keep her CVP between 8 and 12 cm of water. Ideally, her haemoglobin should be not less than 110 g/l, and her haematocrit above 30.

- If you cannot measure the CVP, here is a guide as to how much blood she needs.

Transfuse her until her systolic blood pressure is at least 100 mm Hg. If it is below this, she needs at least 1000 ml. If it is below 80 mm she needs 1500 to 2000 ml.

If she is dehydrated, correct her dehydration with 0.9% saline or Ringer's lactate.

If the above measures fail, try correcting her acidosis, with 50 to 100 mmol of sodium bicarbonate (A 15.1).

CAUTION ! (1) Heparin is contraindicated. (2) Don't give plasma expanders, such as dextran, because these may precipitate DIC, and cause uncontrollable haemorrhage.

MONITORING. Start a partogram (M 18.2). All through labour check her pulse, her blood pressure, and her central venous pressure half-hourly. Every 2 hours check her urine output, her clotting time and her haemoglobin, and do a vaginal examination. Note the size of her uterus, and repeatedly check it. An increase in height shows that she is continuing to bleed.

THE DELIVERY [s7]OF A PATIENT WITH ABRUPTION If her baby is alive (unusual), and weighs more than 1.5 kg, consider section, as soon as she is resuscitated. If you are going to section her, you MUST do so immediately, before a clotting defect develops. Waiting a few hours and then sectioning her is a recipe for disaster.

If he is dead and she is not in labour, rupture her membranes (M 19.3) and give her an oxytocin drip (M 22.2). Labour is usually fast. Try to deliver her in 6 to 8 hours. Once she is in the active phase, labour should progress rapidly. You may decide to rupture her membranes, regardless of his condition, and ]]give her life precedence over his. Besides inducing labour, rupturing her membranes will reduce her intra-amniotic pressure. This will slow the abruptive process, and may also release retroplacental clot. Her tense, tender, woody-hard uterus will make her contractions difficult to monitor, and the dose of oxytocin difficult to adjust. If she is obese and highly parous, with an unfavourable cervix, she is particularly at risk; so try to feel for uterine contractions as best you can, and assess the progress of her labour by careful vaginal examination.

If active labour has not started after a further 6 to 8 hours and her clotting time is normal, consider section. If it is abnormal, Caesarean section will probably kill her.

LATER STAGES. [f41]The second stage is usually rapid. Her dead baby, the placenta, and clot may all be expelled suddenly, and tear her perineum, cervix, or uterus.

The third stage causes problems, because of the clotting defect, and because she may have an atonic uterus. She runs a serious risk of postpartum haemorrhage, so be sure to manage this actively. As he is delivered, give her an ampoule of intravenous ergometrine with oxytocin (''Syntometrine'). Add 15 units of oxytocin to 500 ml of Ringer's lactate or saline, and run this in fast to keep her uterus well contracted.

CAESAREAN SECTION should rarely be necessary. Either do it immediately, or don't do it at all. Late section (after 24 hours) is dangerous if she has an abnormal clotting time, unless you have plenty of blood and plenty of experience. At section her uterus will look bruised (''Couvelaire' uterus), but will contract normally.

The absolute indications for Caesarean section include: (1) A previously scarred uterus. Avoid a ''trial of a Caesarean scar' (18.14), because you will not know if she is rupturing[md]vaginal bleeding, tachycardia, and pain can all be caused by abruption, or by a uterus which is rupturing. (2) Failure to progress, despite artificial rupture of her membranes and oxytocin. (3) A patient who is bleeding to death before having a chance to deliver. Caesarean section is a desperate step and may save her life. (4) A live baby at term, with signs of fetal distress. (5) The transverse lie of a baby at term for whom vaginal delivery is impossible.

If you have fibrinogen, give it just before you operate. Have hot packs ready when you operate, and empty her uterus quickly. Bleeding usually stops, but if she bleeds severely, deliver her uterus into the wound, surround it with hot packs, grasp it firmly, and give her ergometrine with oxytocin. If this fails to control bleeding, tie her internal iliac arteries (3.5); if this too fails proceed to hysterectomy (20.12).

DIFFICULTIES [s7]WITH PLACENTAL ABRUPTION If her URINE OUTPUT FALLS to below 30 ml an hour in spite of adequate fluid replacement, as observed by her CVP, give her at least a litre of Ringer's lactate, and then give her frusemide 40 mg intravenously as a bolus injection. If she develops renal failure, see Section 53.3.

If her UTERUS DOES NOT CONTRACT after vaginal delivery (atonic uterus), manage her in the usual way by giving her oxytocin, making sure that her bladder is empty and all blood clot expressed from her uterus. Give her an oxytocin drip as above, and a repeat dose of ergometrine with oxytocin, provided this is not contraindicated, either because she is hypertensive, or because you have already given her two 0.5 mg doses. Compress her uterus bimanually (19-3). If her bleeding fails to stop, you may have to open her abdomen and tie her internal iliac arteries, or do a hysterectomy as a last resort. If possible, give her an ampoule of prostaglandin F[,2]alpha, either intravenously, or through her abdominal wall directly into her myometrium.

If she CONTINUES TO BLEED AFTER DELIVERY from multiple small tears, she may have: (1) DIC. (2) An atonic uterus (see above). (3) Multiple lacerations in her cervix. Correct (1) and (2). Examine her vaginally, and you may see many small lacerations and bleeding points. Carefully pack her genital tract as in section 19.11a. Give her an oxytocin drip to make sure her uterus is well contracted. Remove the pack in 24 to 48 hours.

If you diagnose ABRUPTION IN A PATIENT WITH A CAESAREAN SCAR, it is probably a ruptured uterus. Section her immediately.