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In the early stages of placental abruption, there may be no symptoms. When symptoms develop, they tend to develop suddenly. Common symptoms include sudden-onset abdominal pain, contractions that seem continuous and do not stop, vaginal bleeding, enlarged uterus disproportionate to the gestational age of the fetus, decreased fetal movement, and decreased fetal heart rate.
Vaginal bleeding, if it occurs, may be bright red or dark.
A placental abruption caused by arterial bleeding at the center of the placenta leads to sudden development of severe symptoms and life-threatening conditions including fetal heart rate abnormalities, severe maternal hemorrhage, and disseminated intravascular coagulation (DIC). Those abruptions caused by venous bleeding at the periphery of the placenta develop more slowly and cause small amounts of bleeding, intrauterine growth restriction, and oligohydramnios (low levels of amniotic fluid).
A placental disease is any disease, disorder, or pathology of the placenta. The article also covers placentation abnormalities, which is often used synonymously for placental disease.
Women with placenta previa often present with painless, bright red vaginal bleeding. This commonly occurs around 32 weeks of gestation, but can be as early as late mid-trimester. 51.6% of women with placenta previa have antepartum haemorrhage. This bleeding often starts mildly and may increase as the area of placental separation increases. Previa should be suspected if there is bleeding after 24 weeks of gestation. Bleeding after delivery occurs in about 22% of those affected.
Women may also present as a case of failure of engagement of fetal head.
Trophoblastic neoplasms derive from trophoblastic tissue. Examples include:
- Choriocarcinoma
- Hydatidiform mole
Hyperemesis gravidarum is the presence of severe and persistent vomiting, causing dehydration and weight loss. It is more severe than the more common morning sickness and is estimated to affect 0.5–2.0% of pregnant women.
Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.
The cause of placental abruption is not entirely clear. Risk factors include smoking, preeclampsia, prior abruption, trauma during pregnancy, cocaine use, and previous cesarean section. Diagnosis is based on symptoms and supported by ultrasound. It is classified as a complication of pregnancy.
For small abruption bed rest may be recommended while for more significant abruptions or those that occur near term, delivery may be recommended. If everything is stable vaginal delivery may be tried, otherwise cesarean section is recommended. In those less than 36 weeks pregnant, corticosteroids may be given to speed development of the babies lungs. Treatment may require blood transfusion or emergency hysterectomy.
Placental abruption occurs in about 1 in 200 pregnancies. Along with placenta previa and uterine rupture it is one of the most common cause of vaginal bleeding in the later part of pregnancy. Placental abruption is the reason for about 15% of infant deaths around the time of birth. The condition was described at least as early as 1664.
Circumvallate placenta is a placental morphological abnormalitiy, a subtype of placenta extrachorialis in which the fetal membranes (chorion and amnion) "double back" on the fetal side around the edge of the placenta. After delivery, a circumvallate placenta has a thick ring of membranes on its fetal surface.
The fetal surface is divided into a central depressed zone surrounded by a thickened white ring which is incomplete the ring is situated at varying distance from the margin of the placenta. The ring is composed of a double fold of amnion and chorion with degenerated decidua vera and fibrin in between. Vessels radiate from the cord insertion as far as the ring and then disappear from the view.
Complete circumvallate placenta occurs in approximately 1% of pregnancies. It is diagnosed prenatally by medical ultrasonography, although one 1997 study of prenatal ultrasounds found that "of the normal placentas, 35% were graded as probably or definitely circumvallate by at least one sonologist," and "all sonologists misgraded the case of complete circumvallation as normal." The condition is associated with perinatal complications such as placental abruption, oligohydramnios, abnormal cardiotocography, preterm birth, and miscarriage.
It is diagnosed by a microscopic examination of the placenta.
Commonly used criteria from Altshuler are: "a minimum of 10 villi, each with 10 or more vascular channels, in 10 or more areas of 3 or more random, non-infarcted placental areas when using a ×10 ocular." The Altshuler criteria are not theoretically rigorous, as they do not define the area. Normal villi have up to five vascular channels.
Gestational diabetes is when a woman without diabetes develops high blood sugar levels during pregnancy.
Placenta praevia is when the placenta attaches inside the uterus but near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.
Risk factors include pregnancy at an older age and smoking as well as prior cesarean section, labor induction, or termination of pregnancy. Diagnosis is by ultrasound. It is classified as a complication of pregnancy.
For those who are less than 36 weeks pregnant with only a small amount of bleeding recommendations may include bed rest and avoiding sexual intercourse. For those after 36 weeks of pregnancy or with a significant amount of bleeding, cesarean section is generally recommended. In those less than 36 weeks pregnant, corticosteroids may be given to speed development of the babies lungs. Cases that occur in early pregnancy may resolve on their own.
It affects approximately 0.5% of pregnancies. After four cesarean section it, however, effects 10% of pregnancies. Rates of disease have increased over the late 20th century and early 21st century. The condition was first described in 1685 by Paul Portal.
Molar pregnancies usually present with painless vaginal bleeding in the fourth to fifth month of pregnancy. The uterus may be larger than expected, or the ovaries may be enlarged. There may also be more vomiting than would be expected (hyperemesis). Sometimes there is an increase in blood pressure along with protein in the urine. Blood tests will show very high levels of human chorionic gonadotropin (hCG).
Couvelaire uterus (also known as uteroplacental apoplexy) is a life-threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity.
Postmaturity symptoms vary. The most common are dry skin, overgrown nails, creases on the baby's palms and soles of their feet, minimal fat, abundant hair on their head, and either a brown, green, or yellow discoloration of their skin. Doctors diagnose post-mature birth based on the baby's physical appearance and the length of the mother's pregnancy. However, some postmature babies may show no or few signs of postmaturity.
It is associated with gestational diabetes, smoking and high altitude.
Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium (the muscular layer of the uterine wall). Three grades of abnormal placental attachment are defined according to the depth of attachment and invasion into the muscular layers of the uterus:
- Accreta – chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis.
- Increta – chorionic villi invade into the myometrium.
- Percreta – chorionic villi invade through the perimetrium (uterine serosa).
Because of abnormal attachment to the myometrium, placenta accreta is associated with an increased risk of heavy bleeding at the time of attempted vaginal delivery. The need for transfusion of blood products is frequent, and hysterectomy is sometimes required to control life-threatening hemorrhage.
An abdominal pregnancy can be regarded as a form of an ectopic pregnancy where the embryo or fetus is growing and developing outside the womb in the abdomen, but not in the Fallopian tube, ovary or broad ligament.
While rare, abdominal pregnancies have a higher chance of maternal mortality, perinatal mortality and morbidity compared to normal and ectopic pregnancies; on occasion, however, a healthy viable infant can be delivered.
Because tubal, ovarian and broad ligament pregnancies are as difficult to diagnose and treat as abdominal pregnancies, their exclusion from the most common definition of abdominal pregnancy has been debated.
Others—in the minority—are of the view that abdominal pregnancy should be defined by a placenta implanted into the peritoneum.
Retained placenta is a condition in which all or part of the placenta or membranes remain in the uterus during the third stage of labour. Retained placenta can be broadly divided into:
- failed separation of the placenta from the uterine lining
- placenta separated from the uterine lining but retained within the uterus
A retained placenta is commonly a cause of postpartum haemorrhage, both primary and secondary.
In ICD-10, early pregnancy bleeding (code O20.9) refers to obstetrical hemorrhage before 20 completed weeks of gestational age.
First trimester bleeding, is obstetrical hemorrhage in the first trimester (0 weeks-12 weeks of gestational age). First trimester bleeding is a common occurrence and estimated to occur in approximately 25% of all (clinically recognized) pregnancies.
Differential diagnosis of first trimester bleeding is as follows, with the mnemonic AGE IS Low (during first trimester):
- Abortion (spontaneous), also referred to as miscarriage. One study came to the result that the risk of miscarriage during the course of the pregnancy with just spotting during the first trimester was 9%, and with light bleeding 12%, compared to 12% in pregnancies without any first trimester bleeding. However, heavy first trimester bleeding was estimated to have a miscarriage risk of 24%.
- Gestational trophoblastic neoplasia
- Ectopic pregnancy, which implies a pregnancy outside the uterus, commonly in the fallopian tube, which may lead to bleeding internally that could be fatal if untreated. In cases where there is heavy bleeding and an obstetric ultrasonography assists in diagnosing a pregnancy of unknown location (no visible intrauterine pregnancy), it has been estimated that approximately 6% have an underlying ectopic pregnancy.
- Implantation bleeding
- Chorionic hematoma
- Spotting
- Lower GU tract causes
- Vaginal bleed
- Cervical bleed
Other causes of early pregnancy bleeding may include:
- Postcoital bleeding, which is vaginal bleeding after sexual intercourse that can be normal with pregnancy
- Iatrogenic causes, or bleeding due to medical treatment or intervention, such as sex steroids, anticoagulants, or intrauterine contraceptive devices
- Infection
Symptoms may include abdominal pain or vaginal bleeding during pregnancy. As this is nonspecific in areas where ultrasound is not available the diagnosis was often only discovered during surgery to investigate the abnormal symptoms. They are typically diagnosed later in the developing world than the developed. In about half of cases from a center in the developing world the diagnosis was initially missed.
It is a dangerous condition as there can be bleeding into the abdomen that results in low blood pressure and can be fatal. Other causes of death in people with an abdominal pregnancy include anemia, pulmonary embolus, coagulopathy, and infection.
Swelling (especially in the hands and face) was originally considered an important sign for a diagnosis of pre-eclampsia. However, because swelling is a common occurrence in pregnancy, its utility as a distinguishing factor in pre-eclampsia is not high. Pitting edema (unusual swelling, particularly of the hands, feet, or face, notable by leaving an indentation when pressed on) can be significant, and should be reported to a health care provider.
In general, none of the signs of pre-eclampsia are specific, and even convulsions in pregnancy are more likely to have causes other than eclampsia in modern practice. Further, a symptom such as epigastric pain may be misinterpreted as heartburn. Diagnosis, therefore, depends on finding a coincidence of several pre-eclamptic features, the final proof being their regression after delivery.
Pregnant patients may have bleeding from the reproductive tract due to trauma, including sexual trauma, neoplasm, most commonly cervical cancer, and hematologic disorders. Molar pregnancy (also called hydatiform mole) is a type of pregnancy where the sperm and the egg have joined within the uterus, but the result is a cyst resembling a grape-like cluster rather than an embryo. Bleeding can be an early sign of this tumor developing.
The exact incidence of maternal mortality related to placenta accreta and its complications is unknown, but has been reported to be as high as 6-7% in case series and surveys.
HELLP syndrome is defined as hemolysis (microangiopathic), elevated liver enzymes (liver dysfunction), and low platelets (thrombocytopenia). This condition may occur in 10–20% of patients with severe pre-eclampsia and eclampsia and is associated with increased maternal and fetal morbidity and mortality. In 50% of instances, HELLP syndrome develops preterm, while 20% of cases develop in late gestation and 30% during the post-partum period.
Molar pregnancy is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to term.
A molar pregnancy is a gestational trophoblastic disease which grows into a mass in the uterus that has swollen chorionic villi. These villi grow in clusters that resemble grapes. A molar pregnancy can develop when a fertilized egg does not contain an original maternal nucleus. The products of conception may or may not contain fetal tissue. It is characterized by the presence of a hydatidiform mole (or hydatid mole, mola hydatidosa). Molar pregnancies are categorized as partial moles or complete moles, with the word "mole" being used to denote simply a clump of growing tissue, or a "growth".
A complete mole is caused by a single sperm (incidence is about 90%) or two (incidence is about 10%) sperms combining with an egg which has lost its DNA (in the first case the sperm then reduplicates forming a "complete" 46 chromosome set). The genotype is typically 46,XX (diploid) due to subsequent mitosis of the fertilizing sperm, but can also be 46,XY (diploid). 46,YY (diploid) is not observed. In contrast, a partial mole occurs when a haploid egg is fertilized by two sperm or by one sperm which reduplicates itself yielding the genotypes of 69,XXY (triploid) or 92,XXXY (tetraploid). Complete hydatidiform moles have 2 - 4% risk of developing into choriocarcinoma in Western countries and 10 - 15% in Eastern countries and overall, also a 15% chance of becoming an invasive mole. Incomplete moles can become invasive (<5% risk) but are not associated with choriocarcinoma. Complete hydatidiform moles account for 50% of all cases of choriocarcinoma.
Vasa praevia, also spelled vasa previa, is a condition in which babies' blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.
Risk factors include in vitro fertilization.
Vasa praevia occurs in about 0.6 per 1000 pregnancies. The term "vasa previa" is derived from the Latin; "vasa" means vessels and "previa" comes from "pre" meaning "before" and "via" meaning "way". In other words, vessels lie before the baby in the birth canal and in the way.