Definition- form of antepaturm haemorrhage where the bleeding occurs due to premature separation of normally situated placenta.

Varieties- Revealed ; Concealed; and Mixed

Revealed- following separation; blood insinuates downwards between the membranes and the decidua; ultimately the blood comes out through the cervical canal to be visible externally.

Concealed- blood collects behind the separated placenta or between the membranes and the decidua; its prevented from coming out of the cervix by the presenting part which presses on the lower segment
Mixed

1 in 150 deliveries; its is one of the significant causes of peri-natal and maternal mortality.

Etiology and Risk factors
High birth order
Advancing age of the mother
Poor socio economic state; malnutrition
Smoking
Tendency to recur
Pre-eclampsia, gestational hypertension & essential hypertension
Trauma
Sudden uterine decompression- following delivery of first baby of twins, sudden escape of liqor in hydramnios and PROM
Short cord- relative or absolute.
Supine hypotension syndrome
Poor placentation – “sick placenta”
Folic acid deficiency
Torsion of uterus
Cocain abuse- transient hypertension- abruption
Thrombophilia’s

Pathogenesis
Haemorrhage into decidua basalis

Degeneration & necrosis of D.basalis & adjacent placenta

Rupture of basal plate; thus communicating haematoma with intervillous space

D. Haematoma

small & self limited big haematoma
Retroplacental haematoma

Big haematoma

Complete accumulation blood may dissect blood may gain
behind the placenta directly downwards access to the
in between the amniotic cavity
membranes

Complications
Couvelaire uterus
Blood coagulopathies
Vasospasm is the cause for changes in the liver and the kidney- necrosis and ischemia.

Clinical Classification

Grade 0- C/F absent; diagnosis based on inspection of placenta after delivery.

Grade 1- external bleeding is slight; uterus irritable, may/ may not be tender; shock is absent; fetal heart sound is good.

Grade 2- external bleeding :mild-moderate;tender uterus; chock is absent; fetal distress or even death occurs

Grade 3- bleeding moderate-severe or may be concealed; uterus tender; shock is pronounced; fetal death is the rule; associated coagulation defects or anuria may be present.

Clinical features are given in teh power point presentation below.

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