Regional and central placental abruption. Diagnostics of the Premature detachment of the normally located placenta. Fight against dangerous pathology

Premature detachment of a normally located placenta - detachment of the placenta before the birth of the fetus (during pregnancy, in the first and second stages of labor).

ICD-10 code
O45 Premature placental abruption (abruption placentae).
O45.0 Premature placental abruption with bleeding disorders.
O45.8 Other premature placental abruption.
O45.9 Unspecified premature placental abruption.

EPIDEMIOLOGY

The frequency of PONRP tends to increase and currently occurs in 0.3-0.4% of births.

CLASSIFICATION

Depending on the area, partial and complete placental abruption is isolated. With partial detachment of the placenta of the uterine wall, part of it exfoliates, with complete - the entire placenta. Partial PONRP can be marginal, when the edge of the placenta is exfoliated, or central - respectively, the central part.

Partial placental abruption can be progressive and non-progressive.

ETIOLOGY (CAUSES) OF PREMATURE PLACENTAL Detachment

Finally, the etiology of PONRP has not been determined. Placental abruption is a manifestation of systemic, sometimes latent pathology in pregnant women. Among the causes of pathology, several factors are distinguished: vascular (vasculopathy, angiopathy of the placental bed, superficial invasion of cytotrophoblast into the defective endometrium), hemostatic (thrombophilia), mechanical. Vasculopathy and thrombophilia relatively often occur with gestosis, hypertension, glomerulonephritis.

Changes in hemostasis are the cause and effect of PONRP. APS, genetic defects of hemostasis (Leiden factor mutation, angiotensin-II deficiency, protein C deficiency, etc.), predisposing to thrombosis, are of great importance in the development of PONRP. Thrombophilia, which develops as a result of these disorders, prevents the full-fledged invasion of the trophoblast, contributing to placental defects, PONRP.

Disorders of hemostasis can occur as a result of PONRP, for example, an acute form of DIC, leading to massive bleeding and the development of PON. The situation is typical for central detachment, when pressure rises in the area of ​​blood accumulation, conditions arise for the penetration of placental tissue cells with thromboplastic properties into the maternal bloodstream.

In childbirth, PONRP is possible with a sharp decrease in the volume of the overstretched uterus, frequent and intense contractions.

The placenta, unable to contract, cannot adapt to the changed volume of the uterus, as a result of which it loses its connection with the wall of the uterus.

Thus, the following conditions can be attributed to the predisposing factors of PONRP:

During pregnancy:
- vascular extragenital pathology (hypertension, glomerulonephritis);
- endocrinopathy (DM);
- autoimmune conditions (APS, systemic lupus erythematosus);
- allergic reactions to dextrans, blood transfusion;
- preeclampsia, especially against the background of glomerulonephritis;
- infectious-allergic vasculitis;
- genetic defects of hemostasis, predisposing to thrombosis.

· During childbirth:
- outpouring of OM with polyhydramnios;
- hyperstimulation of the uterus with oxytocin;
- the birth of the first fetus with multiple pregnancies;
- short umbilical cord;
- belated rupture of the fetal bladder.

Possible violent placental abruption as a result of falling and trauma, external obstetric turns, amniocentesis.

PATHOGENESIS

Vascular rupture and bleeding begins in the decidua basalis. The resulting hematoma violates the integrity of all layers of the decidua and exfoliates the placenta from the muscle layer of the uterus, which is adjacent to this area.

With a non-progressive variant of placental abruption, it may not spread further, the hematoma becomes denser, partially resolves, salts are deposited in it. With a progressive variant, the area of ​​detachment can quickly increase. This stretches the uterus. Vessels in the area of ​​detachment are not pinched.

Outflowing blood can continue to exfoliate the placenta, and then the membranes and flow out of the genital tract. If blood does not find a way out during ongoing placental abruption, then it accumulates between the wall of the uterus and the placenta with the formation of a hematoma. In this case, blood penetrates both the placenta and the thickness of the myometrium, which leads to overstretching and saturation of the walls of the uterus, irritation of the receptors of the myometrium. Stretching can be so significant that cracks form in the wall of the uterus, extending to and even to the serous membrane. In this case, the entire wall of the uterus is saturated with blood, and it can penetrate into the peri-uterine tissue, and in a number of cases - through the cracks in the serous membrane and into the abdominal cavity. At the same time, the serous cover of the uterus has a bluish color with petechiae (or with petechial hemorrhages). This pathological condition is called uteroplacental apoplexy; for the first time the pathology was described by A. Couveler in 1911 and was named "Couveler's uterus". The condition disrupts the contractility of the myometrium, which leads to hypotension, progression of disseminated intravascular coagulation syndrome, massive bleeding.

CLINICAL PICTURE (SYMPTOMS) PLACENTAL REMOVAL

The main symptoms of PNRP are:
Bleeding and symptoms of hemorrhagic shock;
· abdominal pain;
· Hypertonicity of the uterus;
· Acute fetal hypoxia.

The severity and nature of the symptoms of PONRP are determined by the size and location of the detachment.

Bleeding with PONRP can be:
· Outdoor;
· Internal;
· Mixed (internal and external).

With marginal placental abruption, external bleeding appears. Blood separates the membranes from the wall of the uterus and quickly leaves the genital tract. The blood is bright in color. If blood flows from a hematoma located high at the bottom of the uterus, then the bleeding is usually dark in color. With external bleeding, the general condition is determined by the amount of blood loss. With internal bleeding, which, as a rule, occurs with central detachment, the blood does not find an outlet and, forming a retroplacental hematoma, permeates the wall of the uterus. The general condition is determined not only by internal blood loss, but also by pain shock.

Abdominal pain is caused by blood imbibition of the uterine wall, stretching and irritation of the peritoneum. Pain syndrome occurs, as a rule, with internal bleeding, when there is a retroplacental hematoma. The pain can be intense. With PONRP located on the back wall of the uterus, pain is localized in the lumbar region. With a large retroplacental hematoma on the anterior surface of the uterus, a sharply painful local "swelling" is determined.

Hypertonicity of the uterus is possible with internal bleeding and is caused by the presence of retroplacental hematoma, imbibition of blood and overstretching of the uterine wall. In response to a constant stimulus, the wall of the uterus contracts and does not relax.

Acute fetal hypoxia occurs due to hypertonicity of the uterus, impaired uteroplacental blood flow and placental abruption. The fetus may die if a third or more of the placenta surface is detached. With complete detachment, immediate fetal death occurs. Sometimes intrapartum fetal death is the only symptom of placental abruption.

According to the clinical course, mild, moderate and severe degrees of severity of the condition of a pregnant woman with placental abruption are distinguished.

Mild form - detachment of a small area of ​​the placenta, minor discharge from the genital tract. The general condition is not disturbed. With ultrasound, it is possible to determine the retroplacental hematoma, but if blood is secreted from the external genital organs, then with ultrasound it is not detected. After childbirth, an organized clot is found on the placenta.

Moderate severity - placental abruption on 1 / 3–1 / 4 of the surface. From the genital tract, there is a separation of blood with clots in significant quantities. With the formation of a retroplacental hematoma, there is pain in the abdomen, hypertonicity of the uterus. If the detachment occurs during labor, the uterus does not relax between contractions. With a large retroplacental hematoma, the uterus can become asymmetric, sharply painful on palpation. Untimely delivery, the fetus dies. At the same time, symptoms of shock (hemorrhagic and painful) develop.

Severe form - detachment of more than 1/2 of the surface area of ​​the placenta. Suddenness there is pain in the abdomen, bleeding (initially internal, and then external). Symptoms of shock appear fairly quickly. On examination and palpation, the uterus is tense, asymmetric; swelling can be found in the area of ​​the retroplacental hematoma. Symptoms of acute hypoxia or fetal death are noted.

The severity of the condition, blood loss is further aggravated by the development of disseminated intravascular coagulation due to the penetration of a large amount of active thromboplastins into the mother's bloodstream, which are formed at the site of placental abruption.

DIAGNOSIS OF PREMATURE PLACENTAL REMOVAL

Diagnosis of PNRP is based on:
· The clinical picture of the disease;
· Ultrasound data;
· Changes in hemostasis.

PHYSICAL STUDY

Clinical symptoms suggestive of PONRP: bleeding and abdominal pain; hypertonicity, soreness of the uterus; lack of relaxation of the uterus in the pauses between contractions during childbirth; acute fetal hypoxia or antenatal death; symptoms of hemorrhagic shock.

With a vaginal examination during pregnancy, the cervix is ​​usually preserved, the external pharynx is closed. In the first stage of labor, with placental abruption, the fetal bladder is usually tense, sometimes a moderate amount of blood discharge with clots from the uterus is observed. When the fetal bladder is opened, the outflowing agents may contain an admixture of blood.

INSTRUMENTAL RESEARCH

An ultrasound scan should be performed as early as possible if there is a suspicion of PONRP. With longitudinal and transverse scanning, it is possible to determine the place and area of ​​placental abruption, the size and structure of the retroplacental hematoma. In a number of cases, with a slight detachment of the placenta along the edge with external bleeding, according to ultrasound data, the detachment cannot be detected.

LABORATORY RESEARCH

Analysis of hemostasis indices indicates the development of disseminated intravascular coagulation.

SCREENING

Detection of latent thrombophilia in patients at risk for the development of PONRP.

DIFFERENTIAL DIAGNOSTICS

Differential diagnosis is carried out with histopathic rupture of the uterus, placenta previa, rupture of umbilical cord vessels.

PONRP has identical symptoms with histopathic uterine rupture: abdominal pain, tense, non-relaxing uterine wall, acute fetal hypoxia. An ultrasound scan reveals an area of ​​exfoliated placenta. If this is absent, then the differential diagnosis is difficult. Irrespective of the diagnosis, emergency delivery is necessary.

Detachment of placenta previa is easily established, since in the presence of blood discharge from the genital tract, the remaining characteristic symptoms are absent. With ultrasound, it is not difficult to determine the location of the placenta.

It is extremely difficult to suspect rupture of umbilical cord vessels. The specified pathology is often observed with the meningeal attachment of the vessels. It is characterized by the discharge of brightly scarlet blood, acute hypoxia and antenatal fetal death. Local soreness and hypertonicity are absent.

TREATMENT OF PREGNANT WOMEN WITH PREMATURE PLACENTAL REMOVAL

Pregnancy management tactics in PONRP depend on the following indicators:

· The amount of blood loss;
· The condition of the pregnant woman and the fetus;
· Gestational age;
· State of hemostasis.

During pregnancy and childbirth, with a pronounced clinical picture (moderate and severe), PONRP is indicated for emergency delivery by KS, regardless of the gestational age and the state of the fetus. During the operation, an examination of the uterus is necessary to detect hemorrhage in the muscle wall and under the serous membrane (Couveler's uterus). When diagnosing Couveler's uterus at the first stage, after delivery, the internal iliac arteries are ligated (a. Iliaca interna). In the absence of bleeding, the scope of the operation is limited by this, and the uterus is preserved. With continued bleeding, the uterus should be extirpated.

For collection and transfusion of the patient's own blood, devices for reinfusion of autoblood erythrocytes are used (for example, "Cell saver", "Haemolit", etc.). With the help of these devices, blood is sucked into a reservoir, where it is purified from free hemoglobin, clotting factors, platelets, and then the red blood cells are returned to the body. At the same time, infusion-transfusion therapy is carried out (see "Hemorrhagic shock").

With a mild course of PONRP, if the condition of the pregnant woman and the fetus does not significantly suffer, there is no pronounced external or internal bleeding (a small non-progressive retroplacental hematoma according to ultrasound), anemia, with a gestational age of up to 34–35 weeks, expectant tactics are possible. The management of a pregnant woman is carried out under the control of ultrasound, with constant monitoring of the condition of the fetus (Doppler, CTG). Therapy involves bed rest of the pregnant woman and consists in the introduction of b-adrenergic agonists, antispasmodics, antiplatelet agents, multivitamins, antianemic drugs. According to indications - transfusion of fresh frozen plasma.

If the condition of the pregnant woman and the fetus is satisfactory, there is no pronounced external or internal bleeding (small non-progressive retroplacental hematoma according to ultrasound), anemia, with gestational age up to 34–36 weeks, expectant tactics are possible. The management of a pregnant woman is performed under the control of an ultrasound scan, with constant monitoring of the condition of the fetus (dopplerometry, CTG). Treatment involves bed rest for the pregnant woman.

MANAGEMENT OF LABOR IN PREMATURE PLACENTAL REMOVAL

With a small detachment, a satisfactory condition of the woman in labor and the fetus, a normal tone of the uterus, childbirth can be carried out through the natural birth canal. An early amniotomy is performed in order to reduce bleeding and the flow of thromboplastin into the maternal bloodstream, accelerate labor (especially with a full-term fetus). Childbirth should be carried out under constant monitoring of the nature of maternal hemodynamics, uterine contractile activity and fetal heartbeat. Catheterization of the central vein is performed, according to indications - infusion therapy. With weakness of labor after amniotomy, uterotonics are administered. Epidural anesthesia is advisable. After the eruption of the head, oxytocin is used to enhance uterine contractions and reduce bleeding.

With the progression of detachment or the appearance of severe symptoms in the second stage of labor, the tactics are determined by the location of the presenting part in the small pelvis. With the head located in the wide part of the pelvic cavity and above, the CS is shown. If the presenting part is located in a narrow part of the pelvic cavity and below, then obstetric forceps are applied with a cephalic presentation, and with a breech presentation, the fetus is extracted at the pelvic end.

In the early postpartum period, after separation of the placenta, a manual examination of the uterus is performed. To prevent bleeding, dinoprost is administered in physiological saline intravenously for 2-3 hours.

In the early postpartum and postoperative periods with PONRP, it is important to correct hemostasis. In the presence of signs of impaired coagulation, transfusion of fresh frozen plasma, platelet mass is carried out, as indicated by blood transfusion (erythrocyte mass). In rare situations with massive blood loss, symptoms of hemorrhagic shock, transfusion of fresh donor blood from the examined donors is possible.

OUTCOME FOR FRUIT

With PONRP, the fetus usually suffers from acute hypoxia. If obstetric care is provided out of time and not quickly enough, antenatal fetal death occurs. With premature delivery in newborns, RDS may develop.

PREVENTION OF PLACENTAL REMOVAL

There is no specific prophylaxis. Prevention of PONRP consists in pregravid preparation, treatment of endometritis and extragenital diseases before pregnancy, correction of identified hemostasis defects.

FORECAST

The prognosis for PONRP is determined not only by the severity of the condition, but also by the timeliness of the provision of qualified assistance.

PATIENT INFORMATION

A pregnant woman should know that when bleeding from the genital tract appears, she should be urgently hospitalized in a hospital.

Placental abruption is a serious complication of pregnancy and childbirth. Detachment of the "baby seat" from the uterine wall can be fatal for the baby and his mother. According to statistics, such a violation occurs in 1.5% of all pregnancies. Why this is happening, if there are any 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 “child's place”, having exhausted its resources and has 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 him with oxygen and all the substances necessary for growth and development.

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Premature detachment is a partial or complete detachment of the placenta from the uterine wall with vascular damage. The mechanism of the detachment development until the end is not 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, pathology occurs in women who decide to become mothers for the first time. In addition, women during preterm birth are 3 times more likely to experience detachment of the "baby's place" than women who give birth on time.

The state and vitality of the baby, its development largely depends on the state 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 and participates in the production of many hormones necessary for the successful bearing of a child. The "baby's place" is usually quite close to the wall of the uterus: the fetus and water are pressed 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.

Detachment of a severe degree, total detachment before the birth of the child leads to acute hypoxia - the baby is deprived of oxygen and nutrients. The hormonal background is disturbed in the body of a pregnant woman. If no emergency medical care is provided, the child will die. If the baby is very premature at the time of the detachment, he will most likely also die.

With marginal, partial detachment, oxygen delivery will not completely stop, but it 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 adversely affects all organs and systems of the child, but to a greater extent - on the nervous system and the work of the brain and spinal cord, as well as the musculoskeletal system.

For a woman, detachment is dangerous due to the occurrence of bleeding. With prolonged bleeding, anemia sets in, the condition of the expectant mother deteriorates significantly. With profuse bleeding, characteristic of a total detachment of a large area, the death of a woman from massive blood loss is possible. Even a small placental abruption that occurs at different times creates huge risks of miscarriage or premature birth.

Causes

The exact reasons that lead to the departure of the "child's place" from the wall of the uterus are still unknown to science. Doctors tend to believe that in each case, not even one, but a combination of several risk factors at once plays a role.

• Pressure. High blood pressure can cause the placenta to pass. Half of the women who survived the detachment had hypertension. In about 10%, the 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. Long lying on your back leads to a violation of pressure in the inferior vena cava, which can also lead to detachment of the placenta from the uterine wall.
• Repeated pathology. If a woman has already had a detachment before, the probability that it will recur is higher than 70%.
• Multiple pregnancies and many children. Women who carry two or three babies are more prone to pathology than women who carry one child. Often, a detachment is recorded in women who have given birth a lot and often - the walls of the uterus are more flabby and stretched.

• The age of the pregnant woman. In expectant mothers over 30 years old, the risks of premature detachment are several times higher than in women 18-28 years old. If the expectant mother is over 35 years old, then quite often the placenta from her "acquires" an additional lobule, and it is this lobule that breaks off during childbirth, causing the automatic disconnection of the entire "child's place".
• Pregnancy after infertility, IVF. If pregnancy occurs after a long period of infertility, naturally or as a result of assisted reproductive methods, for example, IVF, then the likelihood of placental abruption increases, the risk is estimated at about 25%.
• Gestosis and toxicosis. In the early stages, severe, painful toxicosis is considered a risk factor. Vomiting, nausea, metabolic disorders, pressure drops often lead to exfoliation to one degree or another. In the later stages, gestosis is dangerous.

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

• Features of the uterus and blood vessels. Some anomalies in the structure of the main female reproductive organ, for example, a two-horned or saddle uterus, as well as anomalies in the structure of the vessels of the uterus, can lead to recurrent miscarriage due to constant detachments.
• Placenta previa or low placentation. If, for some reason, the ovum is fixed in the lower segment of the uterus, and subsequently the chorion, and behind it the placenta, did not migrate higher, then detachment becomes the main threat of such a condition. Particularly dangerous is the complete central presentation of the placenta, when the child's place closes the entrance to the cervical canal completely or almost completely.
• Hemostasis disorders... In women with blood clotting disorders, detachment of the "child's seat" during pregnancy and childbirth occurs quite often. Usually, violations of hemostasis are accompanied by other pathologies of pregnancy.

• Labor problems. Often, a dangerous condition arises directly in childbirth - due to a pressure drop, during rapid, rapid childbirth, after the birth of the first child from twins, with an 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 get a blunt trauma to the abdomen, fall on her stomach, get into an accident and hit her stomach. With such an injury, the detachment of the "child's place" occurs in about 60% of cases.
• Bad habits. If the expectant mother cannot part with 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. The immunity of a pregnant woman may begin to produce specific antibodies to her own tissues. This happens with severe allergies, for example, to medications or incorrectly performed blood transfusion, as well as with severe systemic ailments - lupus erythematosus, rheumatism.
• Mom's diseases. From the point of view of the likelihood of detachment, all chronic diseases of a pregnant woman are dangerous, but the greatest risks are caused by diabetes mellitus, pyelonephritis, problems with the thyroid gland, as well as obesity of a woman.

If, when registering, after examining the woman's anamnesis, the doctor decides that this pregnant woman is at risk for the possible development of detachment, he will more closely monitor such a pregnancy. A woman will have to visit a doctor more often, take tests, do 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 "child's place" are reduced to one manifestation - bleeding. The degree and severity of it depends on how extensive the detachment is. Even a small detachment can lead to a large hematoma. It is an accumulation of blood that comes out of damaged vessels and accumulates between the wall of the uterus and the "child's place" itself. If there is no blood outlet, the hematoma grows and increases, contributing to the detachment and death of all new areas of the placenta.

Symptoms may not be only with a mild degree of pathology. Only a very attentive ultrasound doctor, as well as an obstetrician who will take delivery, can notice a small detachment - there will be small depressions on the placenta on the side with which it was adjacent to the uterus, and possibly blood clots.

If a woman feels a slight pulling pain in the abdomen, accompanied by slight brown or pink discharge, this is already a moderate severity of the pathology. When bloody "smears" appear, the state of the placenta is necessarily examined at any time in any woman.

A moderate detachment is much more dangerous than pregnant women themselves are used to thinking. It threatens with hypoxia for the baby, and is often manifested by a violation of the fetal heart rhythm.

A severe form of pathology is always characterized by an acute onset. A pregnant woman has a sharp, sudden, severe pain in the abdomen, a feeling of fullness from the inside, dizziness. Loss of consciousness is not excluded. With this form of detachment, bleeding is strong, intense. Moderate bleeding is also possible. A distinctive feature of the form is the color of blood. With severe detachment, it is scarlet, bright. The woman almost immediately develops shortness of breath, the skin becomes pale, she sweats intensely.

In severe and moderate forms, there is always a tension of the smooth muscles of the uterus, an increased tone, upon examination, the doctor states the asymmetry of the reproductive female organ. By the nature of the bleeding, an experienced doctor can easily determine the type of detachment.

• No or minor bleeding- Central placental abruption is not excluded, in which all blood accumulates between the wall of the uterus and the central part of the "child's place". This is the most dangerous form.
• Moderate vaginal bleeding- marginal or partial detachment is not excluded, in which blood quickly leaves the space between the uterus and the "baby's place". Pathology of this kind has more favorable prognosis, since the discharge of blood increases the likelihood of thrombosis of damaged vessels and healing of the site.
• 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 usually has a dull and aching character, but with acute and severe detachment, it can be sharp, radiating to the lower back, thigh. When the doctor palpates the uterus, the woman will experience severe pain. The baby's heartbeat is disturbed due to oxygen deficiency, which develops against the background of the discharge of the placenta.

The first signs of fetal disruption make themselves felt if the "child's place" has moved away by about a quarter of its total area, with a threatening condition, which is manifested by a violation of the baby's motor activity, they say about detachment of about 30% of the placenta. When the organ leaves 50% of its own area, the child usually dies.

When diagnosing, the doctor will certainly take into account the gestational age, because in different trimesters the symptoms and manifestations of pathology may be different.

Detachment at different times

In the early stages, placenta discharge occurs most often, but you should not be upset, because with timely access to a doctor, there are many ways to preserve the pregnancy and prevent negative consequences for the mother and her baby. Usually, in the first trimester, such a detachment is manifested by a retrochorial hematoma, which is confirmed by ultrasound results. Discharge may or may not appear at all.

In most cases, competent treatment at this stage allows the placenta to fully compensate for the loss of contact of a part of the area with the uterus in the future, and pregnancy will develop quite normally.

If the detachment occurs in the second trimester up to 27 weeks inclusive, then this is a more dangerous condition that threatens the baby with hypoxia. The baby at the initial stage of oxygen starvation 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 areas. Therefore, the forecasts are more favorable if the detachment occurred before 20-21 weeks. After this period, the forecasts are not so rosy.

In the later stages, pathology is the greatest danger. The "child's seat" can no longer grow, and it is physically impossible to compensate for some of the lost functions. Fetal hypoxia will only progress, the child's condition may become critical. If the detachment continues to grow and grow in size, the woman is given a caesarean section to save the baby.

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

Only if the detachment in the third trimester does not progress, there is a chance to maintain a 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 twins or women in labor with diagnosed polyhydramnios. The walls of the uterus, due to profuse blood flow, may lose their contractile ability. At any stage of the birth process in this situation, doctors use stimulation of contractions, if this turns out to be ineffectual, then an emergency caesarean section is performed.

Treatment

If there is very little left before the date of birth, then the treatment of the detachment is inappropriate. Doctors recommend giving birth - to stimulate natural childbirth or to have a cesarean section (depending on the period 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 detachment does not progress. There is no single, ready-made solution - in each specific situation, the doctor and the patient must carefully weigh the risks: to give birth to a premature baby who may not survive, or to risk and possibly face a critical condition of the baby due to detachment and hypoxia.

Detachment is always treated in stationary conditions. Therapy, which will include drugs - hemostatics that stop bleeding, as well as drugs of 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, vaginal bleeding is absent or moderate, and there are no signs of severe fetal hypoxia and the progression of detachment of the "child's place".

To remove the threat, antispasmodics are prescribed, which should maintain the muscles of the uterus in a relaxed state, preventing even a short-term tone. The woman will be injected with drugs that will make up for the baby's nutritional deficiencies and improve blood circulation between the uterus and the placenta. And also sedatives and iron preparations can be recommended to her, which will help get rid of the symptoms of anemia.

In a hospital setting, a woman will have an ultrasound scan with a Doppler almost daily, as well as CTG to find out how the baby is feeling. Doctors will monitor the laboratory tests of the pregnant woman, paying special attention to blood clotting factors. All measures will be aimed at avoiding re-bleeding.

When even the slightest signs of progression of detachment of the "child's place" appear, a decision is made to stop expectant tactics and preserving therapy in favor of emergency delivery.

Prophylaxis

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 inform you about it and give a number of important recommendations that will help protect your baby and your own health.

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

Women with low placentation or placenta previa, as well as with the threat of termination of pregnancy due to malformations of the "child's place" itself, are not recommended sex, excessive physical activity and stress. It is impossible to neglect visiting a doctor, passing mandatory and additional tests while carrying a child.

If a woman suffers from high blood pressure, she definitely needs to control 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 a Rh-positive man require the introduction of anti-Rh immunoglobulin in the second trimester of pregnancy.

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

Forecasts

Forecasts are more favorable if a woman seeks a doctor as early as possible. With the appearance of bloody discharge, with pain in the abdomen, deterioration of general well-being, one cannot look for an 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 an unambiguous sign of problems with the integrity of the "child's place".

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

Premature detachment of a normally located placenta (separatio placentae normaliter inserte spontanea, PONRP) - its detachment before the birth of the fetus, i.e. during pregnancy or childbirth (in the first and second periods). This pathology poses a danger to the health, and sometimes to the life of a woman; it is extremely dangerous for the fetus.

The placenta during pregnancy and childbirth, due to its spongy structure, easily adapts to changes in intrauterine pressure and the pressure of the muscles of the uterine wall, with which it is intimately connected. The pressure of the uterine muscles on the placenta is compensated by intrauterine pressure, which prevents its detachment. When two forces are balanced, acting in the opposite direction to each other, the connection between the placenta and the uterine wall is not broken. In addition, the preservation of the connection between the placenta and the uterus is facilitated by the significant elasticity of the placental tissue and the low intensity of contraction of the uterus during childbirth in the region of the placental site ("progesterone block"). Any violation of the connection between the placenta and the uterine wall during pregnancy and childbirth is accompanied by bleeding.

Premature detachment of the normally located placenta, according to the literature, occurs in 0.4-1.4% of cases. However, usually only those cases of placental abruption that have been clearly diagnosed are considered. In fact, this pathology occurs much more often, especially with spontaneous premature termination of pregnancy in the early and late stages. Often, with artificial termination of pregnancy, you can see dark blood clots as a result of placental abruption. Quite often, cases of placental abruption, which proceed without clinical manifestations, are not taken into account, and only after birth on the maternal surface of the placenta blood clots or impressions from the hematoma are found (Fig.21.4).

Classification. Until now, there is no single classification of premature detachment of a normally located placenta.

Rice. 21.4.

Deep depression in placental tissue after removal of a blood clot.

Depending on the degree (area) of the detachment, partial (progressive and non-progressive) and complete detachment of the normally located placenta are distinguished. Non-progressive placental abruption is called chronic placental abruption by foreign authors.

According to the severity of the clinical picture, PONRP is distinguished between mild, moderate and severe. The severity of the pathology depends on blood loss, the amount of which is due to the area and rate of placental abruption.

Depending on the type of bleeding, there are three forms of it:

External, or visible, bleeding, in which there is a discharge of blood from the vagina (Fig. 21.5, a);

Internal, or latent, bleeding, in which blood is located between the placenta and the wall of the uterus (retroplacental hematoma) (Fig. 21.5, b);

Combined, or mixed, bleeding, in which bleeding is partially visible and partially hidden (Fig. 21.5, c).

Etiology and pathogenesis. The root cause of premature detachment of a normally located placenta is not always possible to establish. More often, placental abruption should be regarded as the final stage of severe, not always clinically identified pathological conditions, in the pathogenesis of which vasculopathy is essential. Vascular disorders in the area of ​​the uteroplacental complex are the main predisposing factors for any other additional effect leading to detachment: mechanical injury, falling on the abdomen, hitting it, car accidents, etc.

During pregnancy, the development of premature detachment of a normally located placenta is facilitated by extragenital pathology (arterial hypertension of various origins, glomerulonephritis, pyelonephritis, endocrinopathy); autoimmune conditions (antiphospholipid and systemic lupus erythematosus syndromes), contributing to an immunological conflict between maternal and fetal tissues with a rejection reaction; allergic reactions (to drugs, plasma, dextrans, protein preparations, blood transfusion); developmental anomalies (two-horned, saddle-shaped) and tumors (fibroids) of the uterus. The likelihood of PONRP increases with the location of the placenta in the area of ​​localization of myomatous nodes.

Of the complications of pregnancy, preeclampsia most often leads to PONRP. In this case, its duration and severity, the presence of intrauterine growth retardation of the fetus are important. A special risk group is pregnant women with long-term gestosis or pregnant women with a rapidly increasing severity of the disease.

During childbirth, premature detachment of a normally located placenta can be observed with polyhydramnios, at the time of poured water or with multiple pregnancy after the birth of the first fetus, when the intrauterine volume decreases sharply and a pronounced contraction of the uterus occurs; with a short umbilical cord and a delayed rupture of the fetal bladder, when the placenta exfoliates during the period of expulsion due to stretching of it with a short umbilical cord when the fetus advances or non-ruptured, despite the full disclosure of the neck, fetal membranes; with hyperstimulation of the uterus due to the introduction of uterotonic agents. Premature detachment of a normally located placenta can be caused by obstetric operations: external obstetric rotation, amniocentesis.

Rice. 21.5.

A - partial placental abruption with external bleeding; b - complete detachment of the placenta (retroplacental hematoma, internal bleeding); c - complete abruption of the placenta with internal and external bleeding.

Placental abruption begins with hemorrhage in the decidua basalis, disrupting the integrity of all layers of the decidua with its detachment from the muscular layer of the uterus. Due to the progressive rupture of blood vessels, a hematoma is formed, which leads to detachment, compression and destruction of the placenta adjacent to this area.

Placental abruption, which began in a small area of ​​it, in the future, for one reason or another, may not spread further; The blood clot gradually thickens and partially dissolves, and at the site of placental abruption, heart attacks and salt deposits form, which are easily detected after childbirth with a close examination of the placenta.

In some pregnant women, the site of placental abruption may enlarge rapidly. As the uterus stretches due to the growth of hematoma, the contractile ability of the myometrium decreases, as a result of which the ruptured vessels of the placental site in the area of ​​placental detachment are not compressed and bleeding from them may continue. The accumulating blood peels off the membranes from the wall of the uterus and flows out of the genital tract. If the blood does not find an outlet, then it can accumulate between the wall of the uterus and the placenta in the form of a hematoma. In this case, blood penetrates both the placenta and the thickness of the myometrium, which leads to overstretching of the walls of the uterus. This stretch can be so significant that cracks form in the wall of the uterus, extending to the serous membrane and even to it. In this case, the entire wall of the uterus is saturated with blood, which can penetrate into the peri-uterine tissue, and in some cases - through the cracks in the serous membrane and into the abdominal cavity. This pathological condition is called uteroplacental apoplexy. It was first described by A. Couvelaire (1911) and received the name "Couvelaire's womb". In Kuveler's uterus, after childbirth, the contractility of the myometrium is often impaired, which leads to hypotension, progression of disseminated intravascular coagulation (disseminated intravascular coagulation), and massive bleeding.

Clinical presentation and diagnosis. The main clinical manifestations of PONRP are bleeding, pain in the abdomen and lumbar region, soreness and hypertonicity of the uterus, acute fetal hypoxia. Bleeding can be internal (retroplacental hematoma) and external. The degree of bleeding depends on the place and area of ​​placental abruption, the hemostatic properties of the blood. Blood flowing from the genital tract is of different colors. If external bleeding appears immediately after the detachment, then the resulting blood is usually bright scarlet; if a certain period of time has passed from the moment of detachment to the appearance of blood, then the blood is dark in color, with clots. If the blood passes a short distance from the lower pole of the exfoliated placenta to the external pharynx, then it has a scarlet color; if the blood flows from the "old" retroplacental hematoma, located high at the bottom of the uterus, then vaginal discharge is often serous-bloody in nature.

Abdominal pain is another major symptom of PONRP. It is caused by stretching of the uterine wall, imbibition of its wall with blood, irritation of the peritoneum. Pain syndrome is especially pronounced with internal bleeding. There is not always a direct relationship between the degree of bleeding and the intensity of pain. Sometimes the pain is so severe that it can only be compared with the pain of a ruptured uterus (the feeling that something has "burst" in the abdomen) or a ruptured tube in an ectopic pregnancy. Sometimes pains radiate to the symphysis, thigh, are often prolonged and often paroxysmal. With premature placental abruption, located on the back of the uterus, pain in the lumbar region is noted.

Hypertonicity of the uterus, as a rule, is observed with internal bleeding and is caused by the presence of retroplacental hematoma, blood imbibition and overstretching of the uterine wall. In response to a constant stimulus in the wall of the uterus, it contracts and does not relax.

Acute fetal hypoxia with PONRP can develop in the early stages of the process, especially with internal bleeding. The development of fetal hypoxia is caused both directly by the detachment itself and by hypertonicity of the uterus, which lead to a sharp decrease in uteroplacental blood flow. When more than 1/3 of the maternal surface of the placenta is detached, the fetus dies from hypoxia.In very rare cases, the entire placenta is detached, which leads to rapid death of the fetus.

Forms of PONRP. According to the clinical course, depending on the area of ​​placental abruption, the severity of the condition, there are mild, moderate and severe forms.

In a mild form, when there is a detachment of a small area, there are no pain symptoms, the uterus is in normal tone, the fetal heart rate does not suffer. Visible mucous membranes and skin are usually pink in color, the pulse is sometimes quickened, but good filling remains.

The only symptom of PNRP may be a scanty dark discharge from the genital tract. With ultrasound, it is possible to determine the retroplacental hematoma. If blood is released outside, then it is not possible to establish any changes in the placenta. After childbirth, when examining the placenta on the maternal surface, a crater-shaped depression (see Fig. 23.6), formed by a blood clot, and the clot itself are found.

The type and density of the clot depend on the time elapsed after detachment. The area where placental abruption has occurred is often whitish or yellowish in color, and can be dense and rough to the touch due to calcification. If a slight detachment occurred during childbirth, then the contractions (attempts) intensify or weaken, sometimes become irregular, signs of fetal hypoxia are found, at the end of the opening period or during the expulsion period with a whole fetal bladder, bleeding often appears.

With moderate severity, there is detachment "/ 4 of the surface of the placenta. The initial symptoms can develop gradually or suddenly with the appearance of constant pain in the abdomen and the discharge from the genital tract of dark blood with clots, sometimes scarlet, in significant quantities. The tone of the uterus is increased, complete relaxation of the uterus between contractions Due to the retroplacental hematoma, the uterus may have an asymmetric shape. Palpation of the uterus is painful. Due to the pronounced tone of the uterus, it is difficult to hear the fetal heartbeat. The fetus suffers from hypoxia, its intrauterine death may occur. Severe symptoms of shock may appear: pallor of visible mucous membranes membranes and skin; the skin is cold, moist to the touch. The pulse is fast, weak filling and tension. Blood pressure is low, breathing is rapid. Ultrasound can reveal a site of placental abruption in the form of an echo-negative layer between the wall of the uterus and the placenta.

A severe form (acute placental insufficiency) is observed when more than 2/3 of the placenta is detached. The onset of the disease is usually sudden: abdominal pain appears. Symptoms of hemorrhagic shock develop rapidly: weakness, dizziness, and often fainting. The patient is restless, groans. The skin and mucous membranes are pale, the face is covered with cold sweat. Breathing and pulse of weak filling and tension. Blood pressure is lowered. On examination, the abdomen is sharply swollen, the uterus is tense, with "local swelling", painful, small parts of the lodus and palpitations are not detected. The pattern of internal bleeding can be complemented by external bleeding. The latter always comes secondarily and is less abundant in comparison with the internal one.

The severity of the condition with premature placental abruption is determined not only by the amount and rate of blood loss, the existence of a focus of constant irritation, but also by the penetration into the mother's bloodstream of a large number of active thromboplastins formed at the placental abruption, which often causes the development of acute intravascular coagulation syndrome (DIC) with massive consumption of clotting factors. In severe cases of placental abruption, renal failure develops, which is caused by both massive blood loss, decreased cardiac output, hypovolemia, intrarenal vasospasm, and the development of disseminated intravascular coagulation. Renal failure is manifested by cortical, glomerular necrosis.

Diagnostics. The diagnosis of premature detachment of a normally located placenta is established on the basis of complaints, anamnesis data, clinical presentation and objective research. When studying the anamnesis, great importance is attached to the presence of such extragenital diseases as arterial hypertension, pyelonephritis, glomerulonephritis, trauma, gestosis, etc. The clinical picture of PONRP is determined by the degree and location of placental abruption. A slight detachment of a normally located placenta during pregnancy, if there is slight pain in the uterus and there is no external bleeding, without the use of special research methods, one can only suspect. This diagnosis is made only with the help of ultrasound or when examining the maternal surface of the placenta after its birth. With significant placental abruption, the diagnosis is made taking into account the clinical picture and ultrasound data. If premature placental abruption occurs in the first stage of labor, then it is necessary to pay attention to the fact that the contractions intensify or weaken, become irregular; the uterus does not relax between contractions, there are signs of acute fetal hypoxia.

It is rather difficult to establish a diagnosis of abruption of a normally located placenta in the second stage of labor. In this case, the main signs of detachment are blood discharge with clots and acute fetal hypoxia. Often worried about bursting pain in the uterus.

Certain diagnostic signs can be obtained with a vaginal examination. During pregnancy, the cervix is ​​usually preserved, the external pharynx is closed, the presenting part of the fetus is high. In the first stage of labor, the fetal bladder with placental abruption is usually tense, sometimes a moderate amount of bloody discharge with clots from the uterus appears. When opening the fetal bladder, amniotic fluid mixed with blood is sometimes poured out.

Of the additional research methods, the most objective and important is ultrasound, which should be carried out as early as possible if placental abruption is suspected. The study with longitudinal and transverse scanning allows you to determine the place and area of ​​placental abruption, the size and structure of the retroplacental hematoma. If there is a slight placental abruption along the edge and there is external bleeding, i.e. blood flows out, then with ultrasound, the detachment may not be detected.

In the case of PONRP, characteristic changes occur in the hemostatic system. Even with a slight detachment of the placenta, thromboplastic substances of tissue and cellular origin enter the maternal bloodstream, as a result of which a picture of disseminated intravascular coagulation develops. Its intensity depends on the size of placental abruption and the time of its development.

In pregnant women with severe clinical manifestations of PONRP, characteristic isocoagulation or hypocoagulation is observed, which is associated with the consumption of blood coagulation factors. At the same time, the number of platelets, the concentration of fibrinogen, the level of antithrombin III decrease, and the concentration of fibrin / fibrinogen degradation products increases.

During the examination of pregnant women, it is necessary to differentiate premature detachment of the normally located placenta from its presence, rupture of the marginal sinus of the placenta, rupture of umbilical cord vessels, rupture of the uterus, etc. (Table 21.1).

Treatment. The choice of the method of therapy for PONRP depends on the following factors: the time of the onset of bleeding (during pregnancy, in childbirth); the general condition of the pregnant woman (woman in labor); fetal condition; massiveness and amount of blood loss; type of bleeding (latent, external, mixed); gestational age; conditions of the birth canal (degree of cervical dilatation); state of hemostasis.

Table 21.1.

During pregnancy, with a pronounced clinical picture of placental abruption, when there is pain, uterine hypertonicity, fetal hypoxia, bleeding (there is a suspicion of uteroplacental apoplexy) and deterioration of the general condition, emergency delivery by cesarean section is indicated, regardless of gestational age and fetal condition ...

If the condition of the pregnant woman and the fetus does not significantly suffer, there is no pronounced external or internal bleeding (small non-progressive retroplacental hematoma), anemia with gestational age up to 34-35 weeks, expectant tactics are possible. In this case, treatment is carried out under the control of ultrasound with constant monitoring of the state of the fetus (dopplerometry, cardiotocography) and includes bed rest of the pregnant woman, the introduction of antispasmodics, antiplatelet agents, multivitamins, antianemic drugs, transfusion of fresh frozen plasma and erythrocyte mass according to indications.

The prognosis for incipient placental abruption is difficult, its further progression and the transition of a mild form of the disease to a severe one are always possible. Even minor repeated bleeding should be especially alert, which indicates the progression of detachment, which threatens the life of the mother and fetus. In such cases, the question of abdominal delivery should be raised even if the pregnant woman is in a satisfactory condition.

With placental abruption in the first stage of labor, when there is no pronounced bleeding, the condition of the woman in labor is satisfactory, the tone of the uterus between contractions is normal, there are no signs of intrauterine fetal suffering, amniotomy is indicated. The rationality of amniotomy is explained by the fact that the leakage of amniotic fluid leads to a decrease in bleeding, reduces the flow of thromboplastin into the maternal bloodstream. Amniotomy speeds up labor, especially with a full-term fetus. Childbirth should be carried out under constant monitoring of the nature of the contractile activity of the uterus and fetal heartbeat. To enhance the contractile activity of the uterus, the use of oxytocin is not recommended, since the activation of the contractile activity of the uterus promotes the entry of thromboplastin into the maternal bloodstream and the activation of consumption coagulopathy. If bleeding increases during childbirth, hypertonicity of the uterus appears, signs of fetal suffering are noted and there are no conditions for rapid delivery through the vaginal birth canal, then in the interests of the mother and fetus, delivery by cesarean section is indicated.

When performing a cesarean section for detachment of a normally located placenta, both during pregnancy and during childbirth, it is necessary to carefully examine not only the anterior, but also the posterior surface of the uterus to detect hemorrhages under the serous membrane (Couveler's uterus). In fact, the diagnosis of Couveler's uterus is made during a cesarean section.

In the presence of Kuveler's uterus ("shock uterus") after cesarean section, as a rule, extirpation of the uterus without appendages is indicated due to the risk of bleeding in the postoperative period due to hypo-coagulation and hypotension of the uterus. It is inappropriate to limit supravaginal amputation of the uterus in this situation because of the frequent bleeding from the cervical stump and the need for relaparotomy to remove it. If bleeding is increased during caesarean section or uterine extirpation, a drainage tube should be placed in the abdomen to control the discharge. Caesarean section or extirpation of the uterus is performed under endotracheal anesthesia. In the early postoperative period after cesarean section, for the prevention of bleeding, the introduction of uterotonic agents and control over the hemostasiogram data are shown. Simultaneously with stopping bleeding in the postpartum period, the mother is given infusion-transfusion therapy, correction of hemostasis.

In the second stage of labor, when a detachment of a normally located placenta is detected and there are conditions for delivery through the vaginal birth canal (complete dilatation of the cervix, the presenting part of the fetus in the pelvic cavity), urgent delivery is carried out by applying obstetric forceps; with breech presentation of the fetus - its extraction; in the absence of conditions for vaginal delivery - cesarean section. In all cases of vaginal delivery after the birth of the fetus, manual removal of the placenta (if its detachment was incomplete) and examination of the uterus are necessary. Manual examination of the uterus also contributes to good contraction

To exclude damage, it is also necessary to examine the cervix and vagina using mirrors. At the same time, uterine-reducing agents (oxytocin, etc.) are prescribed to prevent bleeding in the early postpartum period.

When late postpartum hemorrhage appears to stop it, additional administration of uterotonic agents (oxytocin, prostaglandin) intravenously or into the cervix against the background of hemostasis correction is indicated (see Treatment of disseminated intravascular coagulation syndrome). In the absence of effect, the uterus is extirpated.

The most effective means for stopping coagulopathic bleeding is intravenous administration of fresh frozen plasma, fresh donor blood, and cryoprecipitate. With thrombocytopenia, the introduction of a platelet mass is indicated.

The question of the introduction of heparin is controversial. Heparin can be applied in small doses (1500-2000 U) drip with blood or blood substitute under the control of blood clotting 12 hours after extirpation of the uterus.

The prognosis for the life of the mother and the fetus with PONRP is very difficult. Maternal mortality with PONRP is 1.6-15.6%, according to various authors. The main causes of death are shock and bleeding.

The outcome of the disease depends on the nature of the etiological factor, the severity of the detachment, the state of hemostasis, the timeliness of the diagnosis, the moment of placental abruption (during pregnancy or in childbirth), the nature of bleeding (external, internal), the choice of an adequate method of treatment, the state of the maternal organism.

Perinatal mortality in premature detachment is due to the severity of intrauterine hypoxia, possible "immaturity" of the fetus and depends on the timeliness and quality of the provision of resuscitation neonatological care.

Prevention of PNRP is reduced to the timely diagnosis and treatment of preeclampsia, hypertension of pregnant women, kidney disease, antiphospholipid syndrome, lupus erythematosus syndrome and other diseases that are factors contributing to placental abruption.

An undoubted role in the prevention of PONRP is played by the correct management of childbirth: timely opening of the fetal bladder, dosed administration of uterotonic drugs.

Premature detachment of a normally located placenta is a dangerous problem during pregnancy, which causes a lot of concern for the expectant mother and is a serious threat of premature birth. Most often, this pathology leads to an urgent caesarean section, as it can lead to severe complications for the mother and child.

The placenta is an organ that develops and only exists during pregnancy. Through it, the supply of necessary substances and microelements to the unborn child from the mother's body is ensured. The protective membrane in the form of a disc begins to develop from 15-17 weeks of gestation, comes to full maturation at 34-37 weeks of gestation. This is a normal condition that allows the fetus to develop steadily without any disturbances.

In the normal course of pregnancy, placental abruption occurs after the birth of the fetus. Its location falls on the upper part of the uterus and does not undergo additional stretching, as happens with the lower segment of the genital organ. If, for some reason, placental abruption began during pregnancy or childbirth, then this condition is considered pathological and requires immediate intervention by doctors. In the early stages, this is observation and drug treatment, in a severe degree - surgery, which entails the extraction of the fetus.

Most often, premature placental abruption provokes profuse bleeding, which leads to severe complications in the form of bleeding disorders or a critical state of the body due to large blood loss (hemorrhagic shock).

Types of placental abruption:

It is worth noting that if a woman develops placental abruption quickly, the pathology progresses, and the area of ​​localization is complete or quite extensive, then this condition can be fatal for both the mother and the unborn child.

In the case of non-progressive compensated placental abruption, a woman may not feel any signs of pathology, bring the baby normally and give birth without any particular complications. Signs of pathology can be detected after childbirth during examination.

Factors of pathology

Many reasons can provoke abnormalities in the placenta and its abruption. The normal state of the protective shell can be disturbed during gestation and during childbirth. In both cases, this is a pathological abnormality that poses a threat to the life of the woman in labor and the child.

The causes of pathology associated with general diseases of a woman:

1. High blood pressure (hypertension).
2. Pathology of the heart and kidneys.
3. Diabetes mellitus, thyroid problems, obesity.
4. Vascular disorders can adversely affect blood circulation in the uterus and placenta. This is due to the fact that the walls of blood vessels and capillaries are weakened, and the permeability of the blood becomes more difficult. All this entails premature detachment of the placenta.

Detachment can also be affected by inflammatory processes in the urogenital system of a woman, which are chronic in nature and have managed to cause uterine-planetary insufficiency. This also applies to uterine fibroids when the placenta is located close to myomatous formations.

The provoking causes of placental abruption:

In addition to these reasons, the abuse of alcoholic beverages, tobacco products can affect delamination. At first, the detrimental effect of such products on a woman's body during pregnancy is manifested by anemia, a decrease in hemoglobin levels and a decrease in erythrocytes, and later develops into a serious pathology - placental abruption.

The main causes of detachment in early pregnancy are:

The presence of extragenital pathologies - heart defects; arterial hypertension; pathological abnormalities in the kidneys; liver; negative abnormalities in the blood; diseases of the stomach, intestines; respiratory system; various kinds of infections.

Complications of the normal course of pregnancy, which can be manifested by edema, increased blood pressure, significant loss of protein. Various reactions of the body of an allergic nature. Propensity to disease at the genetic level.

Placental abruption can occur not only in the early or late stages of pregnancy, but also directly during stages 1 and 2 of labor. In this case, the following factors can affect the development of pathology:

• a large amount of amniotic fluid (polyhydramnios);
• stimulation of the uterus with medication;
• long delay in rupture of the amniotic fluid;
• the umbilical cord is not long enough;
• first pregnancy with multiple fetuses.

A medical error is also a factor that can provoke detachment. Wrong doses of drugs, delay or stimulation of labor - all this can lead to the development of a dangerous pathology.

Symptoms of the onset of the disease and the degree of the disease

Signs of detachment of the placenta are quite bright, they appear both in the state of the woman and in the state of the unborn baby. Containment violations have the following characteristic symptoms:

If negative signs occur, immediate medical attention is required. Bleeding during pregnancy does not occur on its own and does not go away on its own. Self-medication is unacceptable, it can lead to death for both the mother and the child.

Severity of premature detachment:

Insignificant detachment is characterized by small deviations in the condition of the woman and the fetus, does not harm pregnancy and with timely access to a doctor, the pathology can be eliminated until the end of pregnancy.

The degree of secondary placental abruption. At this time, there is a large localization of the development of pathology (up to 30%), the surface of the placenta. With an average degree of detachment, bleeding of the external form is clearly manifested, which leads to fetal hypoxia and can provoke its death.

A severe form of premature placental abruption is characterized by a significant part of the lesion of the membrane or its complete detachment. Symptoms at this time are pronounced - severe pain in the lower abdomen, profuse bleeding (the blood becomes dark in color), the death of the fetus occurs and there is a threat to the mother's life.

Fight against dangerous pathology

If there is no blood in the discharge or it is insignificant, then specialists conduct an ultrasound scan for a more accurate examination of the uterus and placenta, as well as to detect the localization of pathology. Also, much attention is paid to the condition of the fetus and the pregnant woman, the period of bearing the child and the state of hemostasis (liquid state of blood) are determined.

With an average and severe course of detachment, doctors decide on an immediate caesarean section, which gives a chance to save the life of the woman in labor and the child.

A woman's treatment after surgery comes from whether the bleeding has been stopped. If blood loss is stopped, further treatment is carried out through drug therapy. If, however, the blood does not stop and its loss exceeds all norms, experts carry out the removal of the uterus.

During treatment, a woman is also given a blood transfusion, and intravenous drugs are prescribed, which make it possible to improve blood clotting and eliminate negative plasma disturbances. This method is called infusion - transfusion therapy, with its help you can adjust the volume and content of blood, as well as the fluid that is contained within and between cells.

With regard to premature placental abruption in early pregnancy in a mild form, here doctors choose the observational direction. At this time, the treatment of a woman is based on bed rest, an ultrasound scan is prescribed to monitor the state of the uterus, as well as drug therapy (antispasmodics, adrenomimetics, antiplatelet agents, antianemic agents).

Preventive measures for dangerous pathology

Prevention of placental abruption is primarily based on eliminating the causes that can cause such a negative condition. Therefore, a pregnant woman needs to take her lifestyle seriously, remove bad habits, and establish a correct diet.

As for the risk factors for the disease, they must be identified already in the early stages of pregnancy. It is important for a woman in the first trimester to undergo a thorough examination, to be tested. This will make it possible to identify diseases that can lead to negative abnormalities in the placenta and eliminate them even in the early stages of gestation.

Women who are prone to placental abruption should be constantly monitored by a doctor. In late pregnancy, hospitalization is necessary for constant monitoring of the condition before childbirth. As for the caesarean section, it is applied on a case-by-case basis and may not be performed if the placental abruption is mild and does not harm the baby and mother.

Premature detachment of the placenta is a dangerous and serious pathology for a pregnant woman and an unborn child. The disease has characteristic features and cannot be overlooked during its development. A woman needs to immediately consult a doctor at the first symptoms, otherwise pathology can lead to the death of not only the unborn child, but also the woman in labor. In the later stages and with insignificant localization, there are high chances to save the child. It is worth remembering that profuse bleeding and significant disturbances in the condition of the fetus (weak heartbeat, lack of mobility) indicate a severe form of detachment, which threatens with termination of pregnancy or death for both the mother and the child. Therefore, do not delay and self-medicate, otherwise the consequences may be irreparable.

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Pregnancy, proceeding without complications and ending safely with the birth of a live and healthy baby, is very rare, especially at the present time. One of the formidable complications of gestation is rightfully considered premature placental abruption, which does not always end successfully, without consequences for the mother and fetus.

This complication, fortunately, is quite rare and occurs in 0.3 - 1.5% of cases. The highest frequency of this obstetric pathology occurs in the 1st trimester, but the prognosis in such cases is also more favorable.

The placenta as an organ and its functions

The placenta is a provisional or temporary organ that forms during pregnancy. Another name for the placenta is a child's place, and after the end of the persistent period, the separation of the placenta (afterbirth) begins, therefore the third stage of labor is called successive (see).

The placenta (translated from Latin as a tortilla) is necessary for the connection between the mother and the fetus. The formation of this organ begins 10-13 days after the fertilization of the egg. The final completion of the development of the child's place occurs by 16-18 weeks, when the transition from histotrophic nutrition of the embryo to hematotrophic nutrition occurs. As a result of this transition, a hematoplacental barrier is formed, due to which the placenta performs its functions. The "duties" of a child's place include:

Gas exchange

Oxygen from the mother's blood enters the blood of the fetus, and the carbon dioxide formed during the breathing of the unborn child enters the woman's bloodstream. Thus, the placenta carries out respiration of the fetus (respiratory function).

Nutritious

The mother's blood containing nutrients, vitamins and minerals enters the intervillous space located between the wall of the uterus and the villi of the placenta, from where the listed components enter the placental vessels and are delivered to the fetus.

Excretory

In the process of life of the unborn child, metabolites (urea, creatinine, creatine) of metabolism are formed, which are removed by the placenta.

Hormonal

The child's seat also plays the role of the endocrine gland. The placenta synthesizes a number of hormones that are necessary for the normal course of the gestational period. These include chorionic gonadotropin, which supports the function of the placenta and promotes the synthesis of progesterone by the corpus luteum. Placental lactogen is involved in the development of the mammary glands during gestation; in addition, this hormone prepares the mammary glands for milk production. , which is responsible for the synthesis of milk, and, stimulating the growth of the mucous membrane of the uterus and preventing new ovulations, serotonin, relaxin and other hormones.

Protective

The baby's place allows maternal antibodies to the fetus, thereby providing immunity to the still unformed child. In most cases, the placenta prevents the development of an immune conflict between the maternal and fetal organisms. Also, a child's place is involved in the formation and regulation of immunity in a woman and a fetus. However, it should be remembered that the placenta is unable to protect the child from the penetration of a number of drugs, drugs, ethyl alcohol, nicotine and viruses into his body.

The normal localization of the placenta is the area of ​​the bottom of the uterus with the transition to the back (more often) or front wall.

What is placental abruption?

Detachment of a normally located placenta is a dangerous complication of pregnancy, when this organ is separated from the uterine walls even before the birth of the fetus, which can occur both during pregnancy and during childbirth.

The baby's place is under constant pressure from the muscular layer of the uterus "outside" and the ovum and amniotic fluid "from the inside", that is, on the other side. But both opposing forces are balanced, in addition, due to the spongy structure of the placental tissue, the placenta has significant elasticity, which allows it to stretch during the growth of the uterus without the risk of detachment. Also, the part of the uterine wall where the placenta is attached is able to contract less, which also reduces the risk of developing the described complication.

Why is this happening?

Why placental abruption occurs, medicine could not be explained for sure. It is impossible to name one specific reason for this complication, since such a violation is a manifestation of a systemic pathology in a woman, and in some cases it is hidden. As a rule, there is a combination of several factors:

• vascular pathology (vasculopathy)
• bleeding disorder
• mechanical factor.

The following factors predispose to the development of complications:

In the process of childbirth, the development of the described pathology is due to: abnormalities of labor forces (discoordination, dystocia of the cervix), a rapid drop in intrauterine pressure (during amniotomy and outpouring of water), the birth of the first child with multiple pregnancies, which "pulls" the placenta towards itself, fast and impetuous childbirth. A short umbilical cord or delayed opening of the fetal bladder also leads to this complication. There is a high risk of premature rejection of the child's place and during oxytocin stimulation.

The risk of complications will also increase in the case of the use of obstetric manipulations during childbirth (external rotation on the leg, extraction of the fetus at the pelvic end).

Classification

Depending on the period when the child's place was rejected:

• early placental abruption;
• detachment during childbirth (persistent period and period of contractions);
• detachment of the placenta in the later stages (see);

Depending on the area of ​​the detachment:

• complete (the entire placenta exfoliates, the child instantly dies);
• partial (only part of the child's place is separated from the wall of the uterus);

Depending on the location of the exfoliated placenta:

• marginal or peripheral detachment - detachment of placental tissue occurs along the periphery, from the edge (in this case, external bleeding occurs);
• central detachment (lag of the placenta from the wall of the uterus occurs in its center, while external bleeding may not be present);

Along the pathological process:

• progressive detachment (the growing retrochorial hematoma aggravates the process of exfoliation of the placenta and makes the condition of the mother and fetus heavier);
• non-progressive (uterine vessels are thrombosed, internal bleeding stops, subsequently calcifications are deposited in the hematoma and, in general, the pregnancy proceeds normally).

Clinical picture

Placental abruption has very characteristic symptoms, on the basis of which a diagnosis can be made even without additional examination.

In the first trimester

As noted, this pathology can occur at any gestational age, but in the first trimester it has a favorable prognosis. Placental abruption in the early stages is a consequence of the threat of interruption and is manifested by:

• aching pains or stretching in the lower abdomen and lower back
• slight or moderate bleeding
• decrease in basal temperature.

With timely and adequate treatment, in many cases it is possible to stop the onset of the detachment of the ovum and prolong the pregnancy. The consequences for pregnancy as it progresses are practically reduced to zero, since the growing placenta over time compensates for the area of ​​lost contact with the uterine wall.

This complication in a short time on ultrasound is determined in the form of a retrochorial hematoma, which does not increase and is in a stable state. Although it is not always possible to visualize retrochorial hematoma using ultrasound and the diagnosis is made already post factum, when in the successive period a dark red blood clot of a small color and / or an impression (fossa) of a gray-burgundy color is found on the placenta.

Signs of placental abruption in the second and third trimesters

Uterine bleeding

Bleeding is caused by ruptures of the vessels connecting the wall of the uterus and the placenta, as a result, the released blood begins to accumulate in the uteroplacental space, which contributes to the continuation of exfoliation, the formation of a hematoma, which presses on the child's seat and disrupts its functioning.

The intensity of the discharge during detachment can vary from insignificant to very abundant. Their severity depends on:

• places where detachment occurred
• the size of the detachment site and the state of the blood coagulation system.

In addition, bleeding can be of three types:

• external or visible
• internal
• mixed.

External bleeding- in four out of five cases of the development of this complication, external bleeding occurs (which does not exclude the presence of internal bleeding). External hemorrhage is characteristic of the marginal detachment of the child's place, when blood exits the uteroplacental space and pours out into the vagina.

Internal - if the retroplacental hematoma is located in the bottom of the uterus, then the color of the discharge will be dark, the lower the placenta is located and the fresher its exfoliation, the brighter and bloody discharge. In the case of accumulation of blood in the uteroplacental space and there is no possibility for its outpouring, they speak of internal bleeding, which is characteristic of the central detachment of the child's place.

At the same time, along the edge of the placenta, it is still connected to the walls of the uterus, and there is a hematoma in the zither, which over time (it counts for hours, and sometimes even for minutes) grows, since the accumulating blood more and more separates the placenta from the uterus.

At the same time, not only the child's place itself is soaked in blood, which, accordingly, disrupts its work, but also the wall of the uterus, which leads to a violation of its contractile activity. Imbibition (soaking) of the uterus with blood is called the Couveler's uterus. As the detachment continues, and, accordingly, bleeding, the condition of the pregnant woman worsens, hemorrhagic shock and blood clotting disorder (DIC) develop.

Pain syndrome

Another characteristic sign of a detachment in a child's place is pain. The pain is constant, dull and / or bursting. The location of the pain differs depending on the location of the placenta. If the baby's place is attached mostly along the posterior uterine wall, then the pain is localized in the lumbar region. When the placenta is attached to the anterior wall, the pain is expressed in front, in some cases, a tense and severely painful swelling is felt. Also, pain is accompanied by hypertonicity of the uterus, since the retroplacental hematoma irritates the uterus, in response it begins to contract, but is able to relax.

The pain is caused by the pressure of the retroplacental hematoma on the uterine walls, their stretching, soaking with blood and irritation of the peritoneum.

Intrauterine fetal hypoxia

Violation of the child's cardiac activity is another mandatory symptom of this complication. Due to the disruption of the functioning of the placenta due to rupture of blood vessels and its saturation with blood, the fetus receives less oxygen, which is manifested by intrauterine hypoxia (brady and tachycardia). Moreover, the more massive the detachment site, the worse the prognosis for the child.

With the flow of detachment of the child's place has 3 degrees of severity

Mild degree

It is diagnosed either after childbirth or by ultrasound signs, while the condition of the woman and the fetus does not suffer, there is no characteristic clinic.

Moderate degree

The peeling of a child's seat occurs on a quarter to a third of the total area. There are minor or moderate bleeding from the genital tract, there is hypertonicity of the uterus, abdominal pain, fetal suffering (bradycardia), signs of hemorrhagic shock are increasing.

Severe degree

The pain in the abdomen is very strong, bursting, arose suddenly, the woman notes dizziness, severe weakness, up to loss of consciousness. Bloody discharge is insignificant or moderate, the uterus is dense, sharply painful, has an asymmetric shape. The volume of the detachment area of ​​the child's seat is half or more. The fetus suffers and, in the absence of immediate assistance, dies in utero. Signs of disseminated intravascular coagulation (DIC) are rapidly growing, the woman's condition deteriorates sharply and threatens with death.

Treatment

What to do with the development of such a complication depends on the situation in which the following indicators are assessed:

• the intensity of bleeding and the amount of blood loss;
• the condition of the mother and fetus;
• gestational age;
• when a detachment occurred (during childbirth or pregnancy);
• indicators of hemostasis.

In the early stages

When the placenta is peeled off in the early stages, the woman must be hospitalized with preservation therapy and hemostatic drugs:

• To relax the uterus, antispasmodics are used (, magne-B6)
• progesterone-containing agents (utrozhestan, dyufaston)
• physical (bed rest) and emotional rest
• from hemostatics used dicinone, vicasol, vitamin C
• at the same time, antianemic therapy with iron preparations is carried out (sorbifer-durules, tardiferon, fenuls).

At a later date

At a later date (less than 36 weeks), conservative treatment is possible if the situation meets the following conditions:

• the general condition of both the woman and the child is satisfactory (there are no signs of intrauterine hypoxia);
• detachment of the child's place is partial and does not have a tendency to progression;
• bleeding is insignificant;
• the total volume of blood loss is small (there are no signs of impaired hemostasis and hemorrhagic shock).

In this case, the woman is under continuous supervision in the hospital, the fetal condition is monitored:

• using regular ultrasound, cardiotocography and dopplerometry
• the woman is assigned to bed rest
• tocolytics (partusisten, intravenous ginipral)
• antispasmodics (magnesia, no-shpa and others)
• antiplatelet agents to improve blood rheology and uteroplacental circulation (trental, courantil)
• iron preparations
• sedatives
• if indicated, fresh frozen plasma is poured.

Severe to moderate

With a moderate and severe degree of placental abruption, the pregnant woman is subject to immediate delivery, regardless of the gestational age. The satisfactory condition of the fetus or its intrauterine death in the matter of delivery does not matter, the cesarean section is carried out according to the vital indications on the part of the mother.

During the surgical intervention, the uterus is carefully examined, if Couveler's uterus is diagnosed, then the expansion of the operation is shown to extirpate the organ. At the same time, the fight against disseminated intravascular coagulation syndrome, restoration of blood loss (blood transfusion of plasma, platelet and erythrocyte mass) is carried out.

• In case of detachment during childbirth and the satisfactory condition of the fetus and the woman in labor, minor bleeding, childbirth continues in a natural way, monitoring the fetus. Early amniotomy allows in some cases to stop bleeding and the progression of detachment.
• If placental abruption occurs during a persistent period, then labor either ends with a cesarean section (the location of the head in the wide part of the small pelvis) or the imposition of obstetric forceps (the head is already in the narrow part or below).