Placental abruption

　　After decades of research by scientists, it has been found that early placental abruption is related to factors such as hypertension (including pregnancy-induced hypertension syndrome, primary hypertension, and renal hypertension), trauma, premature rupture of membranes, maternal age, smoking, and cocaine use, and its occurrence may be related to the following main risk factors.

　　1. Hypertension

　　Hypertension includes pregnancy-induced hypertension syndrome (abbreviated as PIH, especially severe PIH), primary hypertension, chronic nephritis complicated with hypertension, which are the primary causes of placental abruption. Some researchers have reported that the incidence of placental abruption in pregnant women with hypertension during pregnancy is five times higher than that of those with normal blood pressure during pregnancy. The pathogenesis is mainly that the spiral arteries of the basal decidua at the placental attachment site spasm, acute atherosclerosis occurs, causing ischemia, necrosis, and rupture of distal capillaries, leading to bleeding, forming a hematoma, gradually expanding, and causing the placenta to abduct from the uterine wall, leading to placental abruption. If pregnant women have pre-existing vascular lesions such as primary hypertension and then develop PIH, making the vascular lesions more severe, the chance of placental abruption increases more.

　　2. Mechanical Factors

　　Direct impact on the abdomen is often a cause of early placental abruption, for example, car collisions, sudden braking collisions when taking buses, falling and the abdominal wall being the first to land, beating, and so on can all lead to early placental abruption. Excessive force during external version correction of the fetal position can also cause early placental abruption. When the placenta is located on the anterior wall of the uterus, amniocentesis may also lead to early placental abruption. Other indirect factors, such as a sudden outflow of amniotic fluid when there is an excessive amount of amniotic fluid and the membrane breaks, or when the first fetus is delivered too quickly in twin pregnancy, all these can cause a sudden drop in intrauterine pressure, leading to early placental abruption. U.S. research data reports that placental abruption caused by pregnant women's trauma accounts for 1% to 2%.

　　3. Smoking

　　Research over the past 10 years has confirmed the correlation between smoking and early placental abruption. Some reports indicate that smoking increases the risk of early placental abruption by 90%, and the risk also increases with the increase in the number of cigarettes smoked each day. Smoking causes degenerative changes in blood vessels, increases the fragility of capillaries, and the effect of nicotine on vasoconstriction, as well as the increased concentration of carboxyhemoglobin in serum, can all lead to vasospasm and ischemia, thereby triggering early placental abruption.

　　4. Premature Rupture of Membranes

　　Many studies from China and abroad have reported the correlation between premature rupture of membranes and early placental abruption. The risk of early placental abruption in pregnant women with premature rupture of membranes is three times higher than that of those without. The mechanism of its occurrence is unclear and may be related to chorioamnionitis after premature rupture of membranes.

　　5, Abuse of cocaine

　　There are reports that among 50 pregnant women who abuse cocaine during pregnancy, 8 cases of stillbirth were caused by placental abruption. Another report of 112 pregnant women who abuse cocaine during pregnancy showed that 13% of them developed placental abruption.

　　6, Age and number of deliveries of pregnant women

　　The age of pregnant women is related to the occurrence of placental abruption, but some scholars report that the number of deliveries is more likely to be related to placental abruption than age. With the increase in the number of deliveries, the risk of placental abruption increases geometrically.

　　7, Other

　　Prolonged supine or semi-supine position in pregnant women can cause the enlarged uterus to compress the inferior vena cava, obstructing venous return, leading to venous congestion or rupture of the decidua layer, causing partial or complete placental abruption. Short umbilical cord or umbilical cord around the neck, body, during the process of fetal descent, umbilical cord length is insufficient and is strongly pulled, which can also lead to early placental abruption.

　　After 20 weeks of pregnancy or during the delivery period, the normally located placenta partially or completely detaches from the uterine wall before the fetus is delivered, which is called placental abruption. Placental abruption is a serious complication in the late stage of pregnancy, with an acute onset and rapid progression. If placental abruption is not treated in time, it can threaten the lives of both the mother and the child; then what are the complications of placental abruption?

　　Stage III placental abruption, especially in patients with intrauterine fetal death, may develop DIC and coagulation dysfunction. Clinical manifestations include bleeding under the skin, mucous membranes, or injection sites, uterine bleeding that does not clot or only has soft clotting lumps, and sometimes hematuria, hemoptysis, and vomiting of blood. Close observation should be made from admission to postpartum in patients with placental abruption, combined with laboratory results, and attention should be paid to the occurrence of DIC and the appearance of coagulation dysfunction, and active prevention and treatment should be provided.

　　Stage II placental abruption can greatly increase the risk of postpartum hemorrhage due to the influence on the uterine muscle layer and coagulation dysfunction caused by DIC. It is necessary to be vigilant.

　　Stage III placental abruption is often accompanied by pregnancy-induced hypertension, and on this basis, factors such as excessive bleeding, prolonged shock, and DIC severely affect the blood flow to the kidneys, causing bilateral renal cortical or renal tubular ischemic necrosis, leading to acute renal failure.

　　Please pay close attention to placental abruption and actively prevent it in daily life. By doing the above points, you can greatly prevent the occurrence of placental abruption. In addition, if you find that you have already been diagnosed with placental abruption, please go to a regular hospital for treatment in a timely manner, so that your body can recover as soon as possible.

　　Foreign countries commonly adopt the Sher (1985) classification method, which divides placental abruption into stages I, II, and III. Stage I is mild, diagnosed postpartum based on the placental posterior hematoma; stage II is intermediate, with changes in fetal heart rate and clinical symptoms; stage III is severe, with fetal death, IIIa without coagulation dysfunction, and IIIb with coagulation dysfunction. Chinese textbooks classify it into mild and severe types, with the mild type equivalent to Sher stage I and the severe type including Sher stages II and III.

　　The most common typical symptom of early placental detachment is painful vaginal bleeding, but the changes in symptoms and signs of early placental detachment are quite large.

　　1. Mild

　　It is mainly characterized by vaginal bleeding and mild abdominal pain, with the placental detachment surface usually not exceeding 1/3 of the placenta. It is more common during labor, with the main symptoms being vaginal bleeding, which is usually more severe, dark red in color, and may be accompanied by mild abdominal pain or no obvious abdominal pain. The signs of anemia are not significant. If it occurs during labor, the progress of labor is usually faster. Abdominal examination shows a soft uterus, intermittent contractions, the size of the uterus is consistent with the gestational age, the fetal position is clear, and the fetal heart rate is usually normal. If the amount of bleeding is large, the fetal heart rate may change, and the tenderness is not obvious or only mild local (at the site of placental abruption) tenderness. After delivery, the placenta can be seen to have blood clots and indentations on the maternal surface. Sometimes, both symptoms and signs are not obvious, and only when the placenta is examined after delivery are blood clots and indentations found on the maternal surface of the placenta, indicating placental abruption.

　　2. Severe

　　It is mainly characterized by intrapartum hemorrhage and mixed hemorrhage, with the placental detachment surface exceeding 1/3 of the placenta. At the same time, there is a large placental posterior hematoma, which is more common in severe pregnancy hypertension syndrome. The main symptoms are sudden onset of persistent abdominal pain and (or) lumbar pain, which varies in severity depending on the size of the detachment surface and the amount of blood accumulated behind the placenta. The more the blood accumulates, the more severe the pain. In severe cases, nausea and vomiting may occur, followed by pale complexion, sweating, weak pulse, and blood pressure drop, which may be accompanied by no vaginal bleeding or only a small amount of vaginal bleeding. The degree of anemia does not correspond to the amount of external bleeding. Abdominal examination by palpation shows the uterus to be hard like a board, with tenderness, especially at the placental attachment site. If the placenta is attached to the posterior wall of the uterus, the tenderness of the uterus is often not obvious, the uterus is larger than the gestational age, and with the continuous increase in the size of the placental posterior hematoma, the fundus height also increases, and the tenderness becomes more obvious. There may be occasional uterine contractions, and the uterus is in a tense state, which cannot relax well during the intermission, so the fetal position cannot be clearly felt. If the placental detachment surface exceeds 1/2 or more of the placenta, the fetus may die due to severe hypoxia, so the fetal heart sounds of severe patients often disappear.

　　Placental abruption can be divided into mild and severe types, which can pose a certain threat to the health of both mother and child. Therefore, it is necessary to pay attention to its preventive work. What are the effective preventive measures for placental abruption?

　　1. Pregnancy hypertension syndrome is easy to occur in the middle and late stages of pregnancy. If pregnant women have symptoms such as hypertension, edema, and proteinuria, they should actively go to the hospital for early treatment.

　　2. Pay attention to walking during pregnancy, especially when going up and down stairs. Avoid crowded places, do not take the bus, and do not drive to prevent falls or abdominal impact and compression.

　　3. Prenatal examination can detect abnormalities early. If placental abruption occurs, it can be detected early through ultrasound examination and delivery monitoring devices, and appropriate countermeasures can be taken as soon as possible, which is also an effective preventive measure for placental abruption.

　　4. During pregnancy, especially in the late pregnancy, if there is sudden abdominal pain and vaginal bleeding, one should go to the hospital immediately. Once placental abruption is confirmed, pregnancy should be terminated promptly, and efforts should be made to complete delivery within 6 hours after placental abruption.

　　In summary, the effective preventive measures for placental abruption introduced above must be paid attention to, to avoid the harm caused by placental abruption to the fetus and pregnant women. At the same time, it is necessary to understand what examinations should be done for placental abruption, to check and diagnose early, and to treat according to the symptoms.

　　Patients with placental abruption should eat more light foods rich in vitamins, such as fresh vegetables, fruits, and crucian carp. They can eat steamed eggs with crucian carp, ham winter melon soup, sautéed beef shreds with onions, and congee with鲤鱼 and scallions. They can also eat beneficial foods for the body such as walnuts, black sesame, various fresh fruits and vegetables (broccoli, cauliflower, and cabbage are all good), various grains and beans, eat more protein-rich foods, maternal milk powder, and calcium supplementation in the late pregnancy. What should patients with placental abruption avoid eating?

　　First, avoid hard, rough, and acidic foods.

　　Postpartum women have weak bodies and low levels of physical activity. Eating hard or fried foods can easily cause indigestion and may also damage the teeth, leaving postpartum women with teeth that are prone to pain in the future.

　　Second, avoid foods that are too salty.

　　Because salted foods contain more salt, they can cause water and sodium retention in the body of postpartum women, which is prone to edema and may induce hypertension. However, salt should not be avoided, as postpartum women have more urine and sweat, and the excretion of salt also increases, requiring the supplementation of a certain amount of salt.

　　Third, avoid cold and greasy foods.

　　Due to the weak peristalsis of the gastrointestinal tract after childbirth, foods that are too greasy, such as lard, peanuts, and others, should be eaten in moderation to prevent indigestion. If delivery occurs in summer, most postpartum women may want to eat some cold foods, such as ice cream, iced drinks, and cold dishes and rice, which are easy to damage the spleen and stomach and are not conducive to the discharge of lochia.

　　Fourth, avoid spicy and刺激性 foods.

　　Leek, garlic, chili, pepper, and other spices can affect the gastrointestinal function of postpartum women, causing internal heat, sore mouth and tongue, and may lead to constipation or hemorrhoids.

　　Five. Avoid smoking and drinking after childbirth

　　Tobacco and alcohol are highly刺激性 substances. Smoking can reduce milk supply, and various toxic substances in the smoke, such as nicotine, can also enter the breast milk, affecting the baby's growth and development. When new mothers drink alcohol, alcohol can enter the breast milk, causing symptoms such as drowsiness, deep breathing, delayed tactile sensation, and excessive sweating in infants, which can harm their health.

　　Six. Avoid a single or overfull diet

　　Pregnant women should not be picky or have a preference for food. They should aim for a varied diet, with a combination of coarse and fine, meat and vegetables, and eat widely to ensure a balanced diet. Since the gastrointestinal function of pregnant women is weak, overeating not only affects appetite but also hinders digestion. Therefore, pregnant women should eat less and more frequently, increasing the number of meals from the usual three to five or six per day.

　　Seven. Drug contraindications

　　After childbirth, there is a lot of uterine bleeding, and generally some uterine contraction drugs are needed, but women who are breastfeeding should not use ergot preparations, as they inhibit the secretion of pituitary prolactin, causing milk ejection, and they also have a strong antihypertensive effect, so hypertensive women should avoid using them.

　　Eight. Breastfeeders should avoid eating barley and its products

　　Barley, barley milk, malt sugar, and other foods have lactation-inhibiting effects, so they should be avoided during the postpartum lactation period.

　　Nine. Avoid eating too much MSG after childbirth

　　Monosodium glutamate in MSG can enter the baby's body through breast milk. Excessive monosodium glutamate can combine specifically with zinc in the baby's blood, forming glutamic acid that cannot be absorbed by the body, while zinc is excreted in urine, leading to zinc deficiency in infants. As a result, infants not only show poor taste and anorexia but also experience adverse consequences such as intellectual decline and delayed growth and development. Therefore, to prevent zinc deficiency in infants, women should avoid excessive MSG intake.

　　Ten. Foods to avoid after childbirth

　　After childbirth, it is not advisable to drink a lot of tea or yellow wine, nor to eat a lot of chocolate or stewed chicken.

　　Untimely treatment of placental abruption can severely endanger the lives of both the mother and the child. It should be diagnosed promptly and treated actively.

　　1. Correct shock

　　For critically ill patients in shock, a venous access should be established, and blood volume should be rapidly replenished to improve blood circulation. The success of shock rescue depends on the volume and speed of fluid resuscitation. It is best to transfuse fresh blood, which can not only replenish blood volume but also replenish coagulation factors, raising the hematocrit to above 0.30 and urine output to >30ml/h.

　　2. Terminate pregnancy in a timely manner

　　Before the fetus is delivered, placental detachment may worsen. Once confirmed as type II or III placental abruption, pregnancy should be terminated promptly. The method of termination of pregnancy should be decided based on the severity of the pregnant woman's condition, the condition of the fetus in utero, the progress of labor, and the fetal presentation.

　　(1) Bleeding other than vaginal delivery is the main issue. Generally, patients with degree I have good conditions, the cervix has expanded, and it is estimated that childbirth can be completed in a short time, so vaginal delivery can be considered. Artificial rupture of membranes allows amniotic fluid to flow out slowly, reducing the uterine cavity volume. Abdominal bandage is used to tightly wrap the abdomen to compress the placenta, preventing further detachment. If necessary, intravenous infusion of oxytocin can be used to shorten the second stage of labor. During labor, the heart rate, blood pressure, fundal height, vaginal bleeding volume, and fetal condition in utero should be closely observed. If signs of worsening condition or fetal distress are found, an immediate cesarean section should be performed to end childbirth.

　　(2) Cesarean section is indicated for II degree placental abruption, especially for primiparas who cannot complete delivery in a short period of time; I degree placental abruption with signs of fetal distress, requiring rescue of the fetus; III degree placental abruption with deterioration of the maternal condition, fetal death, and inability to deliver immediately; no progress in labor after membrane rupture. After the fetus and placenta are removed by cesarean section, uterine contraction agents should be administered immediately and the uterus should be massaged. If uterine placental necrosis is found, the uterus should be massaged and a hot saline pad should be applied to the uterus. Most uterine contractions improve. If massive bleeding that is difficult to control occurs, a subtotal hysterectomy should be performed while fresh blood, fresh frozen plasma, and platelets are transfused.

　　3. Management of Complications

　　(1) Coagulation dysfunction must be corrected on the basis of rapidly terminating pregnancy and blocking the continuation of procoagulant substances into the maternal blood circulation. Supplementing coagulation factors and timely, adequate transfusion of fresh blood and platelets are effective measures to supplement blood volume and coagulation factors. At the same time, the administration of fibrinogen is more desirable. Each liter of fresh frozen plasma contains 3g of fibrinogen, and the administration of 4g can increase the concentration of fibrinogen in the patient's plasma by 1g/L. The application of heparin, in the hypercoagulable phase of DIC, it is advocated to use heparin early, and heparin should be prohibited in the presence of significant bleeding tendency or hyperfibrinolysis. The application of antifibrinolytic drugs should be based on heparinization and the supplementation of coagulation factors, and antifibrinolytic drugs should be used. Common drugs include aminocaproic acid, tranexamic acid, and tranexamic acid, etc.

　　(2) Urine output in renal failure patients

　　(3) Postpartum hemorrhage: After the baby is delivered, uterine contraction drugs such as oxytocin, ergometrine, misoprostol, etc., should be administered immediately. After the baby is delivered, the placenta should be manually removed, and the uterus should be massaged continuously. If there is still uncontrollable uterine bleeding, or the blood does not clot, or the blood clots are soft, fresh blood should be quickly transfused to supplement coagulation factors, and a subtotal hysterectomy should be performed at the same time.