Causes of abruptio placentae :

1) Maternal risk factors:

• Multiparity (≥ 5 gravida). 
• Advancing maternal age.
• Poor socioeconomic condition.
• Malnutrition.
• Anaemia.

2) Hypertension in pregnancy:  Pre-eclampsia, eclampsia.

3) Trauma:

•  Attempted external cephalic version especially under anaesthesia using great forces.
• RTA.
• Blow on the abdomen.
• Needle puncture at amniocentesis.

4) Sudden uterine decompression:

• Delivery of the first baby of the twin.
• Sudden escape of liquor amnii in polyhydramnios
• Premature rupture of membranes.

5) Short cord.

6) Supine hypotension syndrome.

7) Poor placentation / sick placenta.

8) Folic acid deficiency

9) Torsion of the uterus

10) Cocaine abuse.

11) Thrombophilias.

Symptoms abruptio placentae :

• Abdominal pain (severe in concealed type).
• Per-vaginal bleeding (in revealed & mixed type).
• Nausea & vomiting. 
• There may be history of pre-eclampsia.
• Pallor, features of shock & general condition of the patient is proportionate to the visible blood loss (in revealed type) and not proportionate (in concealed type).
• Vaginal bleeding in revealed type.
• Height of uterus: More than gestational period in concealed type & normal in revealed type.
• Feeling of uterus: Woody hard & tender in concealed type; normal in revealed type
• Fetal parts: Cannot be demonstrated in concealed type.
• Fetal heart sound: Usually absent in concealed type
• Per-vaginal examination: Dark coloured bleeding in revealed type, and no bleeding in concealed type.

Investigations of abruptio placentae :

1. Ultrasonography.
2. Blood: Hb% (anaemia).
3. Blood grouping & Rh typing.
4. Platelet count.
5. Clotting time
6. Prothrombin time (extrinsic coagulation)
7. Partial thromboplastin time (intrinsic coagulation).
8. Serum fibrinogen level.
9. Fibrin degradation product (FDP) 
10. Urine: For protein.

Treatment of abruptio placentae :

A) General treatment:

1. A wide bore I/V channel is to be started. 
2.  I/V fluid; Ringer’s lactate, Hartman’s solution, haemaccel to correct hypovolaemia.
3.  Blood transfusion: At least 2-4 unit of blood should be transfused.
4. Inj. 10% Calcium gluconate (10 ml) iv very slowly over 10-20 minutes after each 3 units of blood transfusion.
5. Bed side clot observation test (Weiner): To monitor coagulation profile
6. Catheterization: To monitor urine output.
7. Strict monitoring: Malemal P, BP, T, R/R, urine output & FHS (if fetus alive).

B) Specific/obstetric treatment: 

1) In concealed variety: ARM + Oxytocin (if needed) → if there is no response and there is fetal distress & oliguria → caesarean section.

2) In revealed variety:

a) Patient in labour: ARM± oxytocin. 

b) Patient not in labour:

• >37 weeks; ARM ± oxytocin.
• <37 weeks:

               .Continuous PV bleeding: ARM ± oxytocin.

                .Bleeding stops: Expectant treatment → Try to continue the                          pregnancy up to 37 weeks.

Complications of abruptio placentae:

Maternal complications:

1. Haemorrhage → hypovolaemia→ shock.
2. Postpartum haemorrhage.
3. Oliguria & anuria→ ARF.
4. Blood coagulation disorder: DIC.
5. Sheehan’s syndrome.
6. Increased operative interference,
7.  Psychological upset due to increased rate of fetal death.
8. Risk of recurrence.

Fetal complications :  Fetal death (due to placental separation→ prematurity & anoxia).

• In concealed type: 25-30%. 
• In revealed type: 50-100%.