We were trying to do a collectible series on the HIV national guidelines when the health almost went into fits with resident’s doctors and other staff issues. Then came the monkeypox virus going viral in some communities. The Lassa fever was still simmering when the big embarrassment, Aso Rock clinic rocked. But none of them had the compulsion of mention like the deadly Abruptio Placentae, a condition where the placenta separates prematurely while the baby is still in the uterus leading to disastrous bleeding.

On a day that one had written off as being uneventful, clinically speaking, was this rude awakening of a phone call. The proprietress of the health facility who was not even in town called to inform me that her sister in-law was in the hospital with abruption placenta! This was no good music to the ear. Because with abruption you never know how to progress until you’d seen the patient and assess her fully.

I had to dash down on a bike. A colleague’s sister in-law with abruption? It tasted like sour grape. When I got there, a nurse was with a patient listening to the foetal heartbeat with a stethoscope. When I told her that I wanted to see the patient with abruptio, she immediately told me that the patient she was examining was the one. I didn’t bother listening myself to confirm the presence of the foetal heartbeat. I just grabbed the ultrasound scan report and saw it reported a retro placental clot and that was it.

From there on everything took on a frenzy tempo. There was no time to even change into a proper scrub before proceeding for the emergency caesarian section. Luckily, when the baby came out he was alive, although he needed resuscitation. He had made it by whiskers. The retro placenta clot was huge and happily enough oozing of blood was not noticed. Both mother and baby made it. Not a very common phenomenon in our environment.

Basically, there two types of challenges with placenta that can result in ante partum bleeding. Firstly is when the placenta overlies the opening of the womb known as the cervix. The slightest displacement of the placenta would lead to exposure of the attachment to the endometrium and would result in bleeding. This condition is known as Placenta praevia or in common parlance low-lying placenta. There is room for cautious waiting especially if the foetus is not matured. Caesarian section is usually the preferred mode of delivery in this condition. Abruptio is the most deadly ante partum haemorrhage in our environment.

There are two types; revealed and concealed. If there is any preference between these two evils, one would go for the revealed variant.  In this situation, while the bleeding is taking place in the placenta bed, it is also leaking through the vagina. This makes early detection possible good results on prompt intervention. The worse is the concealed bleeding such that by the time the diagnosis is made especially in late presentation the disease has progressed with disastrous consequences. By this time symptoms like abdominal pains, titanic contraction of the uterus with enlargement, distressed or demised foetus would make clinical impression too obvious.

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In this environment, hypertension in pregnancy is the highest ranking risk factor associated with abruptio placenta. Traditional practices, like massaging of the pregnant uterus, especially with short umbilical cord are also contributory factors in abruptio. The tripod of protein in urine, raised blood pressure and swelling of the leg known as Pre-eclampsia is also a known factor. Teenage pregnancies especially those below the age of 20 and on the other hand those above the 35 are all at risk. Having multiple births and multiple pregnancy are all associated with abruptio.

The diagnosis of abruptio placenta is usually based on a very high index of suspicion when a woman with predisposing risk factors complains of sudden localized abdominal pain with or without bleeding. In some developed countries one finds that diagnosis of abruptio is that of exclusion after ruling out other causes of abdominal pain. In such climes early presentation of cases to health facilities is the norm and diagnostic gadgets are commonplace. Here we rely heavily on clinical experience and ultrasonography. The sonological features of retro placenta clot in a lot of cases are the guide. It should be noted that ultrasound may not be useful in making a diagnosis of abruptio, but it is very, very handy in ruling out the existence of placenta praevia.  Magnetic Resonance imaging is very sensitive in making a diagnosis of abruptio. But in this environment it is commonly affordable and could be time wasting in situations that need quick therapeutic intervention.

The management of abruption and its eventual outcome depends on a lot of factors and the environment.  The man challenge in our clime is the all too common massive bleed at the time of presentation with depletion of fibrinogen, a clotting factor in the blood. This situation is often referred to as hypofibrinogenaemia. This phenomenon could lead to a condition known as Disseminated Intravascular Coagulopathy. The hallmark of which is clotting failure and uncontrolled bleeding. With the onset of this, the outcome is commonly fatal. In our environment, the desperation is always on the survival of the mother. In more than 70 per cent of cases, the foetus must have been compromised or demised at the time of presentation.

The hallmark of survival n abruption is blood transfusion to correct shock and quickly replace fibrinogen clotting factor. There should be no hurry to deliver the dead foetus in a full blown case until the blood loss has been reasonably corrected. The catch phrase is transfused and transfuse possibly with fresh blood. If the care giver can lay hands on fresh frozen plasma, it would go a long way. Plasma expanders like haemacel, Iso plasma, 10% Dextran etc. in impending shock would be helpful. Of cause when the shock becomes irreversible, that’s it.

Vaginal delivery should be the preferred option bin terminating the pregnancy. Eventual outcome in abruption depends on early diagnosis and prompt intervention especially with regards to what losses that need correction. Unfortunately in our environment, unnecessary delays and ignorance can be our undoing. This is sometimes compounded by some religious sects that abhor blood transfusion. Here the caregiver hands are tied and you are better of referring to a facility where she could be accommodated.

In spite of all the odds some do get lucky.