Premature Separation of Placenta (Ablation of Placenta)
The early separation of the placenta, which occurs one out of 200 in pregnant women and is called “decidua basalis” behind the placenta, is called “ablatio placenta” or “abrubtio placenta” in the medical literature. Bleeding behind the placental tissue that meets the vital need of the fetus between the mother and the fetus will reduce or eliminate communication with the mother and the placenta at the rate of severity of bleeding. This brings high fetal nutritional problems and loss rates.
If there is a bleeding area on the back of the placenta, but if it is trapped behind the placenta and does not cause vaginal bleeding, it is named as “hidden separation” which is the more dangerous form. If the separation from the edge of the placenta has occurred and bleeding comes out of the vaginal route, the sign of the danger will come before and the table to be experienced puts the mother-baby life at less risk by making the diagnosis earlier.
The Risk Factors of Premature Separation of Placenta
1) High parity: Ablatio placenta rates also increase in women with increasing number of births.
2) Advanced maternal age: It is not known whether advanced maternal age is only age or increasing the number of births, but the risk increases.
3) Smoking: It is known that the risk is doubled in women who smoke.
4) The risk increases when using cocaine.
5) The presence of ablatio placenta in previous pregnancy or pregnancies indicates 10-15% in the second pregnancy and 25% in the third pregnancy.
6) The rupture of the amniotic membranes, called early membrane rupture, by tearing of the early waters is also accompanied by the presence of a three-fold increase in ablatio placenta, and the risk increases more clearly if the time of the water exceeds 24 hours.
7) In the case of twin pregnancy or polyhydramnios where amnios fluid is more than normal when the woman’s water comes, the rapid decrease in intrauterine pressure also provokes the contraction of the uterus and increases the risk of ablatio placenta.
8) Increased vascular pressures in pregnancy hypertension and preeclampsia increase the possibility of ablatio placenta.
9) Abdominal trauma is also a risk factor in relation to the severity of the injury, and the risk can range from 1-5% in mild injuries to 50% in severe injuries.
10) Coagulation disorders, called thrombophilia, which negatively affect the gestational history, are also effective in increasing the frequency of ablation placenta.
11) When the causes belonging to the fetus are eliminated at the height of alphafetoprotein, the adhesion anomalies of the placenta and the possibility of early separation should be considered.
Diagnosis of Premature Separation of Placenta
Unlike the placement anomalies of the placenta, the most important criterion in the early separation of the placenta is the clinical signs and symptoms of the pregnant woman. The main complaints of the woman are:
* vaginal bleeding
* uterine contraction
* and abdominal pain.
In mild weathering, the situation may not be understood until the examination of the placenta after delivery. However, clinical findings and complaints of the woman are mild to severe in all cases. Naturally, decomposition may be followed by premature fetus distress and perhaps loss of fetus.
The pain can be sudden, sharp and severe in severe decomposition. In the early separation of the placenta, delivery of labour begins in half of women, and birth pain and separation pain of the placenta may not be distinguished. The difference here is that the pain is continuous in the early separation of the placenta and birth pain comes 2 or 3 times in 10 minutes. There may also be anxiety, weakness, nausea, restlessness and thirst accompanying pain.
In half of the cases in which the placenta dissolves prematurely, dark and clot-free bleeding may be observed before 36 weeks. A combination of bleeding and pain makes the diagnosis easier.
If the severity of the bleeding is high, shock symptoms such as drop in blood pressure, increase in the number of pulses, blurring of consciousness, palpitations may appear. In these cases, the uterus is typically hardened like a stone and the fetus is not palpable. Heartbeat of the fetus may be bradycardic or undetectable.
In case of premature separation of the placenta, 30% of women can have widespread intravascular coagulation disorder, which is one of the most important factors that increase the possibility of maternal loss.
In fact, placental dissociation bleeding is typically clot-free. However, clotting bleeding may also occur during vaginal examination. If the woman’s waters have also come, there will be blood coming.
Although ultrasonography is not very typical for diagnosis, it can give information about whether the early separation is accompanied by placenta previa, bleeding localization and the width of the bleeding area. Meanwhile, the fetus should be rapidly evaluated in terms of vital parameters, gestational week and well-being.
Treatment of Premature Separation of Placenta
The approach in treatment is guided by many variables such as the severity of placental dissociation, the general condition of the woman depending on the amount of bleeding, the condition of the fetus, the gestational week.
If there is no risk for either mother or fetus, it can be waited under intense monitoring to save time for the fetus and reduce the risks associated with pematurity. However, during the follow-up, it is always necessary to consider that the fetus can be lost with severe bleeding and the complications of the mother may increase. Monitoring should be done in a full-fledged hospital and blood products should be available for the mother. In this group with mild dissociation, cesarean is not an absolute indication if a birth decision is made. Although vaginal delivery can be tried, it should always be kept in mind that the separation and bleeding area may expand during uterine contractions and emergency caesarean conditions should be kept in mind.
Placental dissociation will not usually allow for follow-up treatment. In this case, if there is distress and stress in the fetus, emergency cesarean should be planned. However, the woman’s hemodynamic balance, blood products and coagulation factors should also be rapidly evaluated and replaced. 30% of placental dissociations are accompanied by diffuse intravascular coagulation disorder, as well as fighting shock, which can be caused by bleeding. In common intravascular coagulation disorder, cesarean may also increase the risk of surgery-related bleeding. It is very important to act dynamically for the fetus. However, studies show that 15% of fetuses born alive cannot survive, no matter how early they act.
If the fetus is lost, applying cesarean to the woman increases the risk of bleeding for the mother. In addition to evaluating the woman’s hemodynamic status and blood products and clotting factors, the amniotic sac should be opened and vaginal delivery should be performed with prostaglandins and oxytocin. There is no time limit for childbirth in case of death of the fetus. Women’s fluid and blood product support will affect women’s health outcomes regardless of timing.
In the meantime, if preeclampsia or hypertension is considered to be the cause, routine measures should be added for this group. In the long-term early membrane rupture, broad spectrum antibiotics will be planned as the water sac is open for a long time.
It is known that in addition to shock, diffuse intravascular coagulation in mother, hemodynamic balance can disrupt end organ nutrition such as kidney due to shock or pre-shock condition. Therefore, all organ systems are carefully monitored. It should be noted that the probability of postpartum haemorrhage increases due to atony caused by clotting disorders and bleeding leaking between the uterine muscles. By the way, if the couple has blood incompatibility, anti-D should be done in the first 72 hours.