1. Placental abruption (accidental hemorrhage
-Premature separation of a normally situated placenta
- occurring after the 24th week of pregnancy.
- The etiology is not always clear, associated risk is
hypertension
a sudden reduction in uterine size, when the membranes rupture
after the birth of a first twin
trauma

2. (ECV)external cephalic version of a fetus presenting by the breech
a road traffic accident
domestic violence
high parity previous caesarean section
cigarette smoking.

3. Incidence
-30% as concealed and 70% being revealed
- a combination of both (mixed haemorrhage).
- blood loss may be mild, moderate or severe, ranging from a few spots to continually soaking clothes and bed linen.
-I n revealed hemorrhage:
-blood escapes from the placental site
- separates the membranes from the uterine wall
- drains through the vagina.

4. - concealed haemorrhage
- blood is retained behind the placenta
- forced back into the myometrium
- infiltrating the space between the muscle fibres of the uterus (extravasation )
-a completely concealed abruption with no vaginal bleeding.
the woman will have s&s of hypovolaemic shock
-blood loss is moderate or severe she will experience extreme pain.

5. - what is extravasation
-seepage of blood outside the normal vascular channels
- cause marked damage
-at operation, the uterus will appear bruised, edematous and enlarged. ( Couvelaire uterus or uterine apoplexy).

6. Mild separation of the placenta
-a woman self-admits to the maternity unit with slight vaginal bleeding.
- woman and fetus are in a stable condition
- no indication of shock.
- fetus is alive
-normal heart sounds.
- uterus is normal
- no tenderness on palpation

7. The management
ultrasound to determine the site & degree of concealed bleeding
continuous monitoring of the fetal heart rate
cardiotocograph (CTG) should be undertaken once or twice daily
before 37 weeks. She may return home if there is no further bleeding and the placenta has been found to be in the upper uterine segment.
The woman should be encouraged to return to hospital if there is any further bleeding.
after 37th week of pregnancy IOL
heavy bleeding or evidence of fetal compromise indicate C.S
-rest & comfort
-emotional support.
- remember Physical domestic abuse
-consider if the woman is severely anaemic.

8. Moderate separation of the placenta
-1\4 of the placenta will have separated
-concealed haemorrhage must also be considered.
- shocked and pain, with uterine tenderness and abdominal guarding.
-hypoxic, IUFD
Management :
Fluid replacement ,a central venous pressure (CVP) line.
CTG if the fetus is alive,

9. immediate caesarean section
If the fetus is in good condition or has died, vaginal birth may be considered as this enables the uterus to contract and control the bleeding.
amniotomy is usually sufficient to induce labour.
Oxytocics.
The use of drugs to stop labour is usually inappropriate.

10. Severe separation of the placenta
- an acute obstetric emergency
-2\3 of the placenta has detached
ml of blood or more are lost.
- blood may be concealed behind the placenta.
- shock is sever
-BP low , with pre-eclampsia the reading within the normal range
-The fetus mostly dead.
- severe abdominal pain
-tenderness and the uterus would have a board-like consistency.

11. Complications of sever abruptio:
coagulation defects
renal failure
pituitary failure
postpartum haemorrhage.

12. Treatment :
- the same as for moderate haemorrhage:
Whole blood transfused rapidly with the woman's CVP.
Labour may begin spontaneously ,amniotomy
alert for signs of uterine contraction causing periodic intensifying of the abdominal pain.
If bleeding continues or a compromised fetal heart rate is present, caesarean section will be required