Her husband died four months earlier when the pregnancy was 12 weeks old. She just couldn’t cope with the loss, with the current economic situation in the country not helping matters. So she spent most of the time crying and thinking about that fate that had befallen her.
This resulted in sleepless nights, and the blood pressure also rose. In no time, we had a full blown pregnancy-induced hypertension in our hands. Then came the dreaded event: Sudden abdominal pains with some rigidity of the uterus and very marked clinical pallor. The packed cell volume (PCV) was 21 per cent when she appeared in the first hospital. She was immediately transfused with two pints of fresh blood. When the medial director noticed that the two pints of blood didn’t make much impact, she was immediately referred.
On arrival at our facility, two features were evident: The patient was very pale and the foetus was dead. This was confirmed with our in-house ultrasound scan. Ironically, she was looking strong clinically. After assessment, it was obvious that an attempt at vaginal expulsion would take time and hazardous. It was explained to the patient that the essence of the surgical intervention was to save her life, as the baby was already dead. She immediately consented without insisting on the vaginal expulsion option. An emergency two pints of blood was arranged, as the patient was still very pale after the initial transfusion from the referring hospital.
Then we went in. And here was it: A massive retro-placental blood clot and a dead foetus with an estimated age of about 28 weeks. Any surgeon that finds himself in such a situation knows too well the amount of adrenaline surge in his blood. The fear of Disseminated Intravascular Coagulopathy, with uncontrolled bleeding due to clotting challenges, can overwhelm him. This is even worse if he is taken unawares, which happens often.
A point must be made here about relying solely on ultrasound scan diagnosis. In a lot of instances, the sonologists is confronted with a uniform echo pattern on the monitor without a liquid interphase to identify the clot in a retro (behind) placental bleed, especially if the lot is solid enough to mimic other structures sonographically. It should always be remembered that rigidity and tenderness of the abdomen is the norm in advanced abruptio placenta. One can easily goof.
For a recap, Abruptio Placenta is when there is a premature separation of the placenta from the inner wall of the uterus, which results in bleeding and clotting of blood behind the placenta bed. Anatomically speaking, there are basically two sources. The central spiral arterial bleed is the most ferocious and lethal, while the peripheral venous type is the less virulent type.
Clinical Abruptio placenta can be of the reveal type of bleeding in which the blood leaks into the vagina and can be detected early. On the other hand, the bleeding can be concealed and reaches massive proportion before any evidence of bleeding is noticed externally. At this stage, the disease is already advanced; the foetus dead and the most dreaded complication of abruptio placenta, disseminated intravascular clotting challenges must have set in.
Disseminated Intravascular Coagulopathy (DIC), which s literally referred to as ‘death is coming,’ is a well known complication of abruptio placenta. This result from the consumption of the clotting factor FIBRINOGEN, which, in normal circumstances when converted to FIBRIN, helps to form a mesh, which PLATELETES plug in to stop bleeding.
The platelet plugs are broken down by PLASMINOGEN after the bleeding has been arrested. In abruption, this haemostatic mechanism continues unabated because of the widening space between the placenta and the deciduas of the endometrium or rather the inner wall of the uterus. This ultimately leads to the consumption of fibrinogen and failure of blood clotting in the body. If this is not immediately redressed, it is invariably fatal.
In recent times, it has become empirical to immediately initiate blood transfusion once a clinical impression of abruptio placenta is made. Emphasis here should be in replacing the clotting factors, especially FIBRINOGEN. And this makes freshly donated blood the best choice for the transfusion. This transfusion is actually the life saver before consideration is given to how the pregnancy should be terminated. I retrospect with regards to our index case, the two pints of blood transfused at the time of presentation at the referring hospital was the life saver.
As a preference, vaginal root is the option of choice for evacuating the uterus in abruptio placenta. In very bad cases it saves the caregiver from unnecessary blame if the worst happens. Even in catastrophic circumstances, without you touching the patient, you will still blamed for either not acting fast enough or non-intervention. Most experienced care givers know that abruptio placenta is a very dicey clinical challenge. It is well advised that pressure should be resisted and life saving transfusion carried out. But perchance that the baby is still alive and above 34 weeks, the needful should be an emergency caesarian section. In most of such cases, clotting challenges wouldn’t have set in.
In our environment, the commonest cause of abruptio is increase in blood pressure during pregnancy. You could have a collection of symptoms, which include protein in urine, swelling of the extremities known as oedema and increase in blood pressure. This condition is often referred to as pre-eclampsia. It becomes full blown eclampsia when there is associated neurological impairment and convulsions. In most cases, an uncontrolled hypertension in pregnancy is the catalyst. Trauma to the abdomen during pregnancy between 24 and 26 weeks of gestation could be a precipitating cause of abruptio placenta.
There is a high incidence of abruptio of expectant mothers who smoke. For now this is not an issue in our environment, but with increasing westernisation of our life style, we might just get there. In quite a number of cases, no factor can be attributed to abruptio placenta.
Having said this much, the catastrophe in abruptio can be reduced and mortality prevented if only one could be proactive to some of its warning telltale signs, like hypertension. Some of our expectant mothers feel that after having one or two babies, they know it all. The truth is that no two pregnancies are exactly the same. Always keep your antenatal appointments. You never know what could crop up. Having an ultrasound scan done every ANC visit is not too much. Ultrasound scan has no adverse effect on the mother and the baby.