abruptio placent3

8/6/2019 ABRUPTIO PLACENT3

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ABRUPTIO PLACENTADefinition:

-Premature separation of the placenta from the uterine wall.

-Common cause of bleeding during the second half of pregnancy

-Usually occurs after 20 to 24 weeks of pregnancy but may occur as late as duringfirst or second stage of labor.

Risk factors:

-women with parity of 5 or more

-women over 30 years of age-women with pre-eclampsia - eclampsia and renal or vascular disease.Factors contributing to ABRUPTIO PLACENTA

- multiple gestations

- hydramnios

- cocaine use

-dec. blood flow to the placenta

-trauma to the abdomen

-dec. serum folic acid levels- PIHCause: Unknown

Theories proposed relating its occurrence to dec. blood flow to the placenta

through the sinuses during the last trimester; Excessive intrauter ine pressure caused by

hydramnios or multiple pregnancy may also be contributing factors.Clinical manifestations:Covert (severe)/ Mild separation/ Mild Abruptio Placenta

The placenta separates centrally and the blood is trapped between the placenta and

the uterine wall.

Signs and Symptoms:1.no overt bleeding from vagina2. rigid abdomen3.acute abdominal pain


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4. dec. BP5. inc. pulse

6. uteroplacental insufficiencyOvert (partial)/ Moderate separation/ Moderate Abruptio Placenta

The blood passes between the fetal membranes and the uterine wall and escapes

vaginally. May develop abruptly or progress from mild to extensive separation with

external hemorrhage.

Signs and Symptoms:

1. vaginal bleeding2. rigid abdomen

3.acute abdominal pain

4. dec. BP

5. inc. pulse

6. uteroplacental insufficiencyPlacental Prolapse/ Severe separation/ Severe Abruptio Placenta

Massive vaginal bleeding is seen in the presence of almost total separation with

possible fetal cardiac distress.

Signs and Symptoms:1.massive vaginal bleeding2. rigid abdomen3.acute abdominal pain4. shock5.marked uteroplacental insufficiencyManagement:-monitoring of maternal vital signs, fetal heart rate (FHR), uterine contractions andvaginal bleeding


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-likelihood of vaginal delivery depends on the degree and timing of separation in

labor

-cesarean delivery indicated for moderate to severe placental separation

-evaluation of maternal laboratory values

-F & E replacement therapy; blood transfusion- Emotional supportNursing Interventions:-Assess the patients extent of bleeding and monitor fundal height q 30 mins.

-Draw line at the level of the fundus and check it every 30 mins (if the level of thefundus increases, suspect abruptio placentae)-Count the number of pads that the patient uses, weighing them as necessary todetermine the amount of blood loss-Monitor maternal blood pressure, pulse rate, respirations, central venous pressure,intake and output and amount of vaginal bleeding q 10 15 mins-Begin electronic fetal monitoring to continuously assess FHR

ave equipment for emergency cesarean delivery readily available:

-prepare the patient and family members for the possibility of an

emergency CS delivery, the delivery of a premature neonate and the

changes to expect in the postpartum period

-offer emotional support and an honest assessment of the situation

f vaginal delivery is elected, provide emotional support during labor

-because of the neonates prematurity , the mother may not receive an

analgesic during labor and may experience intense pain

-reassure the patient of her progress through labor and keep her informed

of the fetus condition-tactfully discuss the possibility of neonatal death


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tell the mother that the neonates survival depends primarily on

gestational age, the amount of blood lost, and associated hypertensive

disorders

-assure her that frequent monitoring and promptmanagement greatly

reduce the risk of death.-encourage the patient and her family to verbalize their feelings-help them to develop effective coping strategies, referring them for counseling if

necessary.Goals of Care:1.blood loss is minimized, and lost blood is replaced to prevent ischemic necrosis of

distal organs, including kidneys

2.DIC is prevented or successfully treated.

3.normal reproductive functioning is retained

4.the fetus is safely delivered

5.the woman retains a positive sense of self -esteem and self-worth.

Additional lab results:Hgb-

Platelet -

Fibrinogen -

Fibrin degradation products -Other possible nursing diagnosis: Impaired gas exchange: fetal related to insufficient oxygen supply secondary to

premature separation of the placenta. Pain related to bleeding between the uterine wall and the placenta secondary topremature separation of the placenta. Fear related to perceived or actual grave threat to body integrity secondary toexcessive bleeding and threat to fetal survival.


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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

O>

estimated

blood loss

FHR

pattern

BP

compared to

baseline

Pulse

Severeabdominal

pain and

rigidity

Pallor

Changes in

Ineffective Tissue

Perfusion

related to

Excessive blood

loss secondary

to

premature

placental

separation

Rationale:

0ne of the

symptoms of

premature

separation of the

placenta is

uterine

bleeding with a

Goal: Client

will

maintain

adequate

tissue

perfusion by(date/time).

Outcome:

1. Client will

maintain BP

and pulse

(specify: BP

>100/60and

pulse

between 60-

90 beats

per

Assess patients

condition

especially the

SaO2, BP, PR

and RR.

Monitor for

restlessness,

anxiety, air

hunger and

changes in

LOC.

Monitor

accurately input

and output.

Evaluate also

blood loss by

weighing pads.

Continuously

Assessment

provides

baseline

information

about clients

presentcondition.

S/Sx of the

said

condition

provides

information of

developing

indications of

inadequate

cerebral tissue

perfusion.

Monitoring

Patients blood

pressure was

maintained(100/60)

Patients pulse was

at least 60 beats

perminute.


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LOC

Decrease

urine output

small amount to

moderate

amount of

dark-red vaginal

bleeding in 80%

to

85% of cases.

Bleeding may

resultin maternal

hypovolemia

(shock, oliguria,

anuria) and

coaglulopathy.

minute),

warm skin

and dry.

Urine

outputnot

less

than30cc/ho

ur.

3. Client will

remain alert

and

oriented,

FHR pattern

remains

reassuring.

monitor FHR

pattern

compare to

baseline data

from prenatal

record. Inform

other health

care team for

any signs ofnon reassuring

changes.

Assess for

uterine

irritability,

abdominal pain,

rigidity andincrease

abdominal

girth.

Assess

clients

skin color,

temperature,moisture, turgor

and capillary

refill.

Initiate IV

provides data

about renal

perfusion and

function and

the

extent of blood

loss.

The fetus

may

initially respond

reassuring to

decrease

placental

perfusion by

raising the FHR

above thenormal

baseline.

Non reassuring

FHR is an

indication for

delivery. Assessment

gives

information

about the

severity of

placental

abruption.


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access with

gauge 18

catheter and

provide fluids,

blood products,

or blood as

ordered.

Monitor

laboratory

results (Hgb,

Hct, Clotting

studies).

Observe

client

for signs of

spontaneous

bleeding.

Keep client

and

significant

others informed

of the condition

and plan of

care.

Notify

caregivers and

prepare for

Bleeding may

be occult

causing

abdominal

rigidity and

pain. Assessment

provides

informationabout

peripheral

tissue

perfusion.

Hypovolemia

results in

shunting of

blood away

from peripheral

circulation to

the brain and

vital organs. Intervention

provides

venousaccess to

replace

fluids. Laboratory

studies provide

information on


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immediatedelivery and

neonatal

resuscitation

for maternal

and fetal.

extent of blood

loss and signs

of

impeding DIC. Thisprovides

information

about the

depletion ofclotting factors

and

development of

DIC. Informationof

the condition of

the client willpromote

understandingandcooperation. Continuedblood

loss or

development ofDIC may lead

to

maternal or

fetal

injury or death.


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There are three classifications of placenta abruption: External Abruption (Bleeding is evident when blood is seen flowingfrom the vagina), Relatively Concealed Abruption (There may be blood spotting or no bleeding seen), and ConcealedAbruption (Blood backed up behind the placenta and no blood is seen flowing from the vagina). All classifications are

severe and can result in fetal demise and danger to the mother. Full abruption is when the entire placenta has separatedfrom the uterus and fetal demise is almost certain unless an immediate cesarean is performed. A partial abruption is whenan edge of the placenta has separated, such is seen in a placenta previa (the placenta covers the opening of the cervixeither partially or fully) when cervical dilation begins and the placenta is dislodged.

Also known as Premature separation of placenta; Ablatio placentae; Abruptio placentae; Placental abruption.


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FREQUENT SIGNS & SYMPTOMS

Small separation of the placenta:

y Vaginal bleeding.

y Mild pain or discomfort. Abdominal pain. Back pain.


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y Unborn child remains healthy.

Large separation of the placenta:

y Heavy vaginal bleeding.

y Severe pain in the lower abdomen or back.

y Hard, tender abdomen.

y Shock (rapid heartbeat, rapid breathing, and dizziness).

y Fetal distress; heartbeat of the unborn child may be inaudible.

yCoagulopathy (disseminated intravascular coagulopathy [DIC]) - certain elements of the placenta arereleased into the mother's circulation causing blood clotting defects. Symptoms include nos ebleed, blood inthe urine, oozing from puncture sites, bleeding into the skin, round red spots on the skin.


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y Women who smoke cigarettes.

y Women over age 35.

y Women who have had several pregnancies and deliveries.

y A previous pregnancy with placental separation. After one prior episode there is a 10 -17 percent recurrence; after twoprevious episodes the chance of recurrence exceeds 20 percent.

y A direct blow causing trauma to the uterus.

y Chronic disease, such as diabetes mellitus.

y Abuse of alcohol or drugs (particularly cocaine). Drinking more than 14 alcoholic drinks per week during pregnancy.

y Poor nutrition.

y Low lying placenta (placenta previa) that partially or totally covers the cervical opening. The placenta may be partially ortotally dislodged or detached when the cervix begins to dilate in late pregnancy.

The incidence of placenta abruptio, including any amount of placental separation prior to delivery, is about 1 out of 150deliveries. The severe form, which results in fetal death, occurs in about 1 out of 500 to 750 deliveries.


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PREVENTIVE MEASURES

y Get early and continuous prenatal care.

y Early recognition and proper management of conditions in the mother such as diabetes and high blood pressure alsodecrease the risk of placenta abruptio.

y If pregnant, do not engage in activity more vigorous than what you were accustomed to before pregnancy.

y Avoid risk factors (listed above) when possible. Maintain a positive lifestyle free of smoking, alcohol and recreationaldrug use (e.g., cocaine use).

y Proper and adequate nutrition prior to becoming pregnant and during pregnancy will help to prevent or reduce the riskof many negative outcomes of pregnancy.

y Since the cause is unknown, there is no assured way to prevent the problem.

EXPECTED OUTCOME

When the separation is less severe and with immediate medical care, the outlook for mother and fetus is good.

The mother does not usually die from this condition. Maternal death rates in various parts of the world range from 0.5 to 5percent. Early diagnosis of the condition and adequate treatment should decrease the maternal death rate even further.Fetal death rates range from 20 to 35 percent. Upon hospital admission, no fetal heart tone is detectable in about 15percent of cases.


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Fetal distress appears early in the condition in approximately 50 percent of cases. The infants who live have a 40 -50%chance of complications, which range from mild to severe. Concealed vaginal bleeding in pregnancy, excessive loss ofblood resulting in shock, absence of la bor, a closed cervix, and delayed diagnosis and treatment may increase the risk of

maternal or fetal death.

POSSIBLE COMPLICATIONS

y Shock or life-threatening bleeding in the mother.

y Death of unborn child and mother.

y Brain damage to the unborn child.

y Of the site of placental attachment starts to hemorrhage after the delivery and loss of blood cannot be controlled by

other means, a hysterectomy (removal of the uterus) may become necessary.

y 10 to 17 percent of patients have abruptio placentae in a future pregnancy.

TREATMENT

GENERAL MEASURES

y Abruptio placentae is an emergency, but there is usually time to obtain advice by telephone and arrange safetransportation to the hospital. Panic is not helpful. If the placenta separation is slight, you may be able to return home fo r

bed rest and close observation after examination.


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several days if the condition does not get worse. If the fetus is mature, vaginal delivery may be chosen if there is minimal

distress to the mother and child. Otherwise, a cesarean section may be the preferred choice.

TESTS MAY INCLUDE:

y Pelvic examy CBC, may not decreased hematocrit or hemoglobin and platelets .

y Prothrombin time test.

y Partial thromboplastin time test.

y Abdominal ultrasound.


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MEDICATION

y Oxytocin, a drug to induce labor, may be used if immediate delivery is necessary.

y Intravenous (IV) fluids may be necessary for fluid replacement.

y Blood transfusion may be necessary to replace amount of blood loss.

ACTIVITY

y If you are able to remain at home, rest in bed until bleeding and other symptoms cease. Do not resume normal activities

until specific instructions to do so are given to you.

y Avoid sexual relations until otherwise instructed.

TopCauses

The exact cause of a placetal abruption may be difficult to determine.Direct causes are rare, but include:

y Abnormally short umbilical cord

y Injury to the belly area (abdomen) from a fall or automobile accident

y Sudden loss in uterine volume (can occur with rapid loss of amniotic fluid or the delivery of a first twin)


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Risk factors include:

y Advanced maternal age

y Cigarette smoking

y Cocaine use

y Diabetes

y Drinking more than 14 alcoholic drinks per week during pregnancy

y High blood pressure during pregnancy -- About half of placental abruptions that lead to the baby's death are linked to high blood pressure

y History of placenta abruptioy Increased uterine distention (as may occur with multiple pregnancies or abnormally large volume of amniotic fluid)

y Large number of prior deliveries

Placenta abruptio, including any amount of placental separation prior to delivery, occurs in about 1 out of 150 deliveries. The severe form, which results in

fetal death, occurs only in about 1 out of 500 to 750 deliveries.

Back to TopSymptoms

y

Abdominal painy Back pain

y Vaginal bleeding

Back to TopExams and Tests

Tests may include:

y Abdominal ultrasound

y Complete blood county Fibrinogen level

y Partial thromboplastin time

y Pelvic exam

y Prothrombin time


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Treatment

Treatment may fluids through a vein (IV) and blood transfusions. The mother will be carefully monitored for symptoms ofshockand the unborn baby will be

watched for signs of distress, which includes an abnormal heart rate.

An emergency cesarean section may be necessary. If the fetus is very immature and there is only a small placenta rupture, the mother may be kept in the

hospital for close observation and released after several days if the condition does not get worse

If the fetus is developed (matured) enough, vaginal delivery may be chosen if there is minimal distress to the mother and child. Otherwise, a cesarean

section may be the preferred choice.

Outlook (Prognosis)

The mother does not usually die from this condition. However, the following increase the risk for death in both the mother and baby:

y Absence of labor

y Closed cervix

y Delayed diagnosis and treatment of placenta abruption

y Excessive blood loss resulting in shock

y Hidden (concealed) vaginal bleeding in pregnancy

Fetal distress appears early in the condition in about half of all cases. The infants who live have a 40-50% chance of complications, which range from mild to

severe.

Possible Complications

Excessive loss of blood may lead to shock and possible death in the mother or baby. If bleeding occurs after the delivery and blood loss cannot be controlled by

other means, a hysterectomy(removal of the uterus) may become necessary.

When to Contact a Medical Professional

Call your health care provider if you are in an auto accident, even if the accident is relatively minor.

See your health care provider immediately, call your local emergency number (such as 911), or go to the emergency room if you are pregnant and have

symptoms of this condition. Placenta abruptio can rapidly become an emergency condition that threatens the life of both the mother and baby.


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Prevention

Avoid drinking, smoking, or using recreational drugs during pregnancy. Get early and continuous prenatal care.

Early recognition and proper management of conditions in the mother such as diabetes and high blood pressure also decrease the risk of placenta abruptio.

VIRTUALMEDICALCENTRE.COM

What is Placental Abruption?

Placental abruption is defined as the premature separation of a normally positionedplacenta. This results in bleeding which may be revealed (seen to come out through the

vagina), in approximately two thirds of cases, or concealed (no visible blood loss), in approximately one third of cases. Abruption may be total, involving the whole placenta, or

partial, where only a portion of the placenta is involved.Placental abruption is an emergency so it is important to seek medical attention as soon as possible if you experience any vaginal blood loss or other symptoms. It is particularly important for

you to seek medical attention for signs of vaginal bleeding within 24 hours if you have a rhesus negative blood group as you will need to be administered anti-D to avoid rhesus disease.

Statistics on Placental Abruption

Placental abruption affects approximately 1% of pregnancies. While abruption can occur in women with no risk factors, there are factors, listed below, that increase the risk of a

mother experiencing placental abruption.

Risk Factors for Placental Abruption

The exact cause of placental abruption is unknown, but there are a number ofrisk factors including:

y Disorders of blood pressure

y Highparity


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y Increased maternal age

y Low socioeconomic groups

y Prolonged preterm rupture of the membranes

y Polyhydramnios

y Following delivery of a first twin

y Trauma (e.g. fall; motor vehicle accident)

y Cigarette smoking (the more that is smoked, the more the risk is increased)

y Cocaine and drug use

y Preeclampsia

y

Oligohydramnios

y Chorioamnionitis

Symptoms of Placental Abruption

The clinical presentation of placental abruption varies widely. Some mothers have no symptoms while others present with one o r more of the classic triad of symptoms including abdominal

pain, vaginal bleeding and uterine contractions. However, note that severe abruption can occur in the absence of any of these signs and is only found out following delivery of the placenta.

Other reported symptoms include backache, nausea, restlessness and faintness. Symptom severity depends on several factors including the location of the placenta, whether the bleeding is

revealed (blood loss from the genital tract) or concealed (no evidence of bleeding fro m the genital tract), and the degree of abruption. Note that the volume of vaginal blood loss is a poor

indicator of the degree of abruption.

Placental abruption also has the potential to affect your unborn child. Depending on the severity, your baby may b e unaffected, distressed and be requiring urgent delivery or may be deceased.

This will be determined by monitoring the baby's heart rate.

Clinical Examination of Placental Abruption


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On examination, your doctor will be examining you for signs and symptoms of placental abruption as well as other differential diagnoses depending on

your presenting symptoms. They will be especially concerned with your vital signs, including heart rate andblood pressure to assess whether you are

showing any signs of shock. They will also feel your abdomen to determine the to ne of your uterus, if there is any pain or tenderness and whether or not it

is contracting. A speculum examination may be performed to assess any vaginal los s and whether or not your cervix is open or closed.

Other than your health, they will also be concerned with the health of your unborn child. They will be inte rested in foetal movements, the foetal heart rate

and how far along you are in the pregnancy. If there are any signs of fetal compromise, active bleeding, uterine activity or tenderness

a cardiotocograph (CTG) will be applied for continuous monitoring.

Several blood tests will be ordered and an ultrasound may be necessary.

How is Placental Abruption Diagnosed?A diagnosis of placental abruption is made on clinical grounds. This means a decision is made based on the signs and symptoms reported and findings from

the investigations performed.

Prognosis of Placental Abruption

Cases of placental abruption vary widely in severity and implications. Cases with minor bleeding may have little or no

consequences, however more severe abruption can lead to foetal death and severe maternal morbidity and mortality. The risks

to the mother primarily depend on the severity of the abruption. However, the risk to the foetus depends not only on the

severity of the abruption but also the gestational age at which the abruption occurs.

As with most obstetric emergencies, we need to consider both the effects on the mother and the effects on the foetus.

Effects on the mother

The acute blood loss seen with placental abruption, depending on the severity, may result in:

y Hypovolaemic shock

y Disseminated intravascular coagulation (DIC)

y Acute renal failure

y Feto-maternal haemorrhage

Image courtesy ofBlausen Medical Communications.

Contact Andrew Walbank.


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Management in subsequent pregnancy

The risk of placental abruption occurring again in a subsequent pr egnancy is increased approximately ten fold. These women are also at

increased risk of other adverse pregnancy outcomes includingpreeclampsia andpreterm birth.

Women in this situation are encouraged to minimise exposure to those predisposing factors that are within our control, partic ularly cocaine

and tobacco use. Prior to the next pregnancy it is also important to have good blood pressure control in those with hypertension.

It would be reasonable in subsequent pregnancies to increase the frequency of ultrasounds in the second half of the pregnancy to monitor

foetal growth. If a mother has a history of two or more prior abruptions, amniocentesis for lung maturity and delivery at 37 weeks gestation

may be carried out.

Placenta abruptio

Placenta abruptio is the separation of the placenta (the organ that nourishes the fetus) from its attachment to the uterus wa ll before the baby is

delivered.

Causes

The exact cause of a placental abruption may be hard to determine.

Direct causes are rare, but include:

y Injury to the belly area (abdomen) from a fall, hit to the abdomen, or automobile accident

y Sudden loss of uterine volume (can occur with rapid loss of amniotic fluid or after a first twin is delivered)


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Risk factors include:

y Blood clotting disorders (thrombophilias)

y Cigarette smoking

y Cocaine use

y Diabetes

y Drinking more than 14 alcoholic drinks per week during pregnancy

y High blood pressure during pregnancy (about half of placental abruptions that lead to the baby's death are linked to high blood

pressure)y History of placenta abruptio

y Increased uterine distention (may occur with multiple pregnancies or very large volume of amniotic fluid)

y Large number of past deliveries

y Older mother

y Premature rupture of membranes (the bag of water breaks befo re 37 weeks into the pregnancy)

y Uterine fibroids

Placental abruption, which includes any amount of placental separation before delivery, occurs in about 1 out of 150 deliveri es. The severe

form, which can cause the baby to die, occurs only in about 1 out of 800 to 1,600 deliveries.

Symptoms

y Abdominal pain

y Back pain

y Frequent uterine contractions

y Uterine contractions with no relaxation in between

y Vaginal bleeding


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Exams and Tests

Tests may include:

y Abdominal ultrasound

y Complete blood count

y Fetal monitoring

y Fibrinogen level

y Partial thromboplastin time

y Pelvic exam

y Prothrombin time

y Vaginal ultrasound

Treatment

Treatment may include flui ds through a vein (IV) and blood transfusions. The mother will be carefully monitored for symptoms of shock. The

unborn baby will be watched for signs of distress, which includes an a bnormal heart rate.

An emergency cesarean section may be needed. If the baby is very premature and there is only a small placental separation, the mother may

be kept in the hospital for close observation. She may be released after several days if the condition does not get worse.

If the fetus is developed enough, vaginal delivery may be done if it is safe for the mother and child. Otherwise, a cesarean section may be

done.

Outlook (Prognosis)

The mother does not usually die from this condition. However, all of the following increase the risk for death in both the mo ther and baby:

y Closed cervix

y Delayed diagnosis and treatment of placental abruption

y Excessive blood loss, leading to shock


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y Hidden (concealed) uterine bleeding in pregnancy

y No labor

Fetal distress occurs early in the condition in about half of all cases. Infants who live have a 40 -50% chance of complications, which range from

mild to severe.

Possible Complications

Excess blood loss may lead to shock and possible death in the mother or baby. If bleeding occurs after the delivery and blood loss cannot be

controlled in other ways, the mother may need a hysterectomy (removal of the uterus).

abruptio placent3

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