NCM 302: O.B. GYNECOLOGY - PEDIATRICS

Abruptio Placentae

Presented by:ALCANTARA, Eduardo L.

BSN 3rd Year – N1 of St. DominicPresented to:

Ms. Analinda R. Sese, RN, MANClinical Instructor

OBJECTIVES:At the end of 20-minute lecture-discussion, the

students will be able to explain or discuss the ff.:

1. Short review of the Anatomy and Physiology of the Placenta.

2. Definition of Abruptio Placenta and its incidence and types.

3. The nursing assessment.4. Diagnosis.5. Pathophysiology of Abruptio Placenta.6. Nursing diagnosis and interventions.7. The complications.8. The medical and surgical care management.9. The nursing implications.10.Prognosis11.Integrate Christian values such as respect and

love to human life.

Abruptio Placenta

Abruptio Placenta

(a.k.a Accidental Hemorrhage or Ablatio Placenta) - Premature separation of the implanted placenta before the birth of the fetus

Hemorrhage can be either occult (difficult to detect) or apparent (obvious). With an occult hemorrhage, the placenta usually separates centrally, and a large amount of blood is accumulated under the placenta. When the apparent hemorrhage is present, the separation is along the placental margin, and blood flows under the membranes and through the cervix.

If the placenta begins to detach during pregnancy, there is bleeding from these vessels. The larger the area that detaches, the greater the amount of bleeding.

1:700-750*

Abruptio Placenta

1. Incidence: second leading cause of bleeding in the 3rd Trimester; occurs in 1:300* pregnancies.

Abruptio Placenta

Typesa. Type I: concealed, covert, or central type; the

classic type• Placenta separates at the center causing blood to

accumulate behind the placenta.• External bleeding not evident.• Signs of shock not proportional to the signs of

external bleeding.

Abruptio Placenta

Typesb. Type II: Marginal, overt, or external bleeding type.• Placenta separates at the margins.• Bleeding is external, it is usually proportional to

the amount of internal bleeding.• May be incomplete or complete depending on

the degree of detachment.

ASSESSMENT

• Determine the amount and type of bleeding and the presence or

absence of pain.

• Monitor maternal and fetal vital signs, especially maternal BP,

pulse, FHR, and FHR variability or alterations.

• Palpate the abdomen

o Note the presence of contractions and relaxations between

contractions (if contractions are present).

o If contractions are not present assess the abdomen for firmness.

• Measure and record fundal height to evaluate the presence of

concealed bleeding.

• Prepare for possible delivery.

Signs of Shock*

ASSESSMENT:Destruction of the placental tissues

a. Painful vaginal bleeding in the 3rd trimester.b. Rigid, board-like, and painful abdomen.c. Enlarged uterus due to concealed bleeding; signs

of shock not proportional to the degree of external bleeding (classic type).

d. If in labor: tetanic contractions with the absence of alternating contraction and relaxation of the uterus.

Abruptio Placenta

ASSESSMENT:Destruction of the placental tissues

Grade Criteria

0 No symptoms of separation were apparent from maternal or fetal signs; the diagnosis that a slight separation did occur is made after birth, when the placenta is examined and a segment of the placenta shows a adherent clot on maternal surface.

1 Minimal separation, but enough to cause vaginal bleeding and changes in the maternal vital signs; no fetal distress or hemorrhagic shock occurs, however.

2 Moderate separation; there is evidence of fetal distress; the uterus is tense and painful on palpation.

3 Extreme separation; without immediate interventions, maternal shock and fetal death will result.

PREMATURE SEPARATION OF THE PLACENTA:Degrees of Separation

Coagulopathy* and Uterine Tonicity*

ASSESSMENT:

Grade 1 Mild

Separation (10-20%)

Grade 2 Moderate

Separation (20-50%)

Grade 3 Severe

Separation (>50%)

General Findings•Total Amount of Blood Loss

<500 cc 1,000-5,000 cc >1,500 cc

•Color of blood Dark Red Dark Red Dark Red

•Shock Rare: none Mild Common, often sudden

•Coagulopathy Rare: none Occasional DIC Frequent DIC

•Uterine Tonicity Normal Increased Tetanic

•Tenderness (pain)

Usually absent Present Agonizing pain

ASSESSMENT:

Grade 1 Mild Separation

(10-20%)

Grade 2 Moderate

Separation (20-50%)

Grade 3 Severe

Separation (>50%)

Ultrasonographic Findings

•Location of placenta

Normal, Upper Uterine

segment

Normal, Upper Uterine segment

Normal, Upper Uterine segment

•Station of presenting part

Variable to engaged

Variable to engaged

Variable to engaged

•Fetal position Usual variations

Usual variations Usual variations

Abruptio Placenta

A. Clinical Diagnosis – Signs and symptomsB. Ultrasound – detects the retro placental defects.C. Clotting- reveal DIC, clotting defects.• The thrombosplastia from retroplacental clots

enter maternal circulation and consumes maternal free fibrinogen resulting in:

DIAGNOSIS:

Abruptio Placenta

DIAGNOSIS:

• DIC (disseminated intravascular coagulation): small fibrin clots

• Hypofibronozenia: ↓normal fibronogen results in absence of normal blood coagulation.

Abruptio Placenta

DIAGNOSIS:

Symptoms:• Vaginal bleeding (Light or moderate)• Abdominal pain• Back pain• A uterus that hurts or is sore. It might also feel hard or rigid.

Signs:Physical examination reveals uterine tenderness and/or increased uterine tone. Hemorrhage or heavy bleeding in pregnancy may be visible or concealed.

Abruptio Placenta

DIAGNOSIS:

Tests include:• A CBC, may note decreased hematocrit or

hemoglobin and platelets• Prothrombin time test • Partial thromboplastin time test • Fibrinogen level test • Abdominal ultrasound (may be done)

PATHOPHYSIOLOGY:

Contributing Factors: Smoking/ Cocaine use

DietSocio-economic status 

(Low)

Predisposing Factors:

• Advance Age (> 35y.o)

• Gender (Female) 

• Heredofamilial• High Parity• Previous 

abruptio placenta

• Polydamnios*• Short umbilical 

cord*• CHD

• Trauma (Injury)• Fibrin Defects

• Thrombolphlibitic conditions• PIH  (Pregnancy-

induced HPN)• Renal Disease

• Chorioamnionitis*

• Anemia• Uterine Fibroid

Damage in small arterial vessels

in the basal layer of decidua*

Bleeding Splits decidua, leaving a thin layer attached to

the placenta

Destruction of the placental tissues

OCCULT APPARENT

Hematoma formation

Compression of the basal layer*

Obliteration of the

intervillous space*

Destruction of the placental tissues

Impaired exchange of respiratory

gases and nutrients

Visible Bleeding

Concealed Bleeding

Blood reaches the edge of the

placenta

Blood passes through the membranes of amniotic sac

Blood passes through the membranes of

amniotic sac

Port wine discoloration

of discharges ( PATHOGNOMONIC SIGN) 

NOTE:Small amount of blood goes out to the vagina (not an indication of the

severity of condition)

NSG DXs & NSG INTERVENTIONS

Ineffective tissue perfusion (placental) related to excessive bleeding, hypotension, and decreased

cardiac output, causing fetal compromise

• Evaluate amount of bleeding by weighing all pads. Monitor

CBC results and VS.

• Position in the left lateral position, with the head elevated to

enhance placental perfusion.

• Administer oxygen through a snug face mask at 8-12L per

minute.

• Evaluate fetal status with continuous external fetal

monitoring.

• Prepare for possible CS delivery if maternal or fetal

compromise is evident.

NSG DXs & NSG INTERVENTIONS

• Instruct patient on the cause of pain to decrease anxiety .

• Instruct and encourage the use of relaxation technique to

augment analgesics.

• Administer pain medications as needed and as prescribed.

Acute Pain related to increase uterine activity

NSG DXs & NSG INTERVENTIONS

• Establish and maintain a large-bore IV line, as prescribed and

draw blood for type and screen for blood replacement.

• Evaluate coagulation studies.

• Monitor maternal VS and contractions.

• Monitor vaginal bleeding and evaluate fundal height to

detect an increase in bleeding.

Fluid volume deficit related to excessive bleeding

NSG DXs & NSG INTERVENTIONS

• Use aseptic technique when providing care.

• Evaluate temperature q4h unless elevated; then evaluate

q2h.

• Evaluate WBC and differential count.

• Teach perineal care and hand washing techniques.

• Assess odor of all vaginal bleeding or lochia.

Risk for infection related to excessive blood loss

NSG DXs & NSG INTERVENTIONS

• Inform the woman and her family about the status of herself

and the fetus.

• Explain all procedures in advance when possible or as they

are performed.

• Answer questions in a calm manner, using simple terms

• Encourage the presence of a support person .

Fear related excessive bleeding procedures and unknown outcome

COMPLICATIONS

• Maternal shock

• Anaphylactoid syndrome of pregnancy*

• Postpartum hemorrhage or Hemorrhagic shock

• Acute respiratory distress syndrome

• Sheehan’s syndrome*

• Renal tubular necrosis*

• Rapid labor and delivery

• Maternal and fetal death

• Prematurity, fetal distress/demise (IUSD)

COMPLICATIONS

• COUVELAIRE UTERUS: the bleeding behind the

placenta may cause some of the blood to enter

the uterine musculature causing the uterine

muscles not to contract well once the placenta is

delivered.

• Disseminated Intravascular Coagulation (DIC)

• Hypofibrogenemia

• Infection

MEDICAL & SURGICAL mngt…

MEDICAL MANAGEMENT

SURGICAL MANAGEMENT

• IV

administration

of fibrinogen or

cryoprecipitate

• Laboratory

examinations

• CS section

Fibrinogen is a protein produced by the liver. This protein helps stop bleeding by helping blood clots to form. A blood test can be done to tell how much fibrinogen you have in the blood.

Blood Component Therapy Cryoprecipitate (CRYO)- Cryoprecipitate is prepared from plasma and contains fibrinogen, von Willebrand factor, factor VIII, factor XIII and fibronectin. Cryoprecipitate is the only adequate fibrinogen concentrate available for intravenous use.

Indications for  CryoprecipitateBleeding or immediately prior to an invasive procedure in patients with significant hypofibrinogenemia (<100 mg/dL)

CSDuring the procedure

An average C-section takes about 45 minutes to one hour.

Preparation. Before the C-section, a member of your health care team cleanses your abdomen. A tube (catheter) may be placed into your bladder to collect urine. IV lines are placed in a vein in your hand or arm to provide fluid and medication. A member of your health care team may also give you an antacid to reduce your risk of an upset stomach during the procedure.

After the procedure • In the hospital. After a C-section, most mothers stay

in the hospital for about three days. To control pain as the anesthesia wears off, you may use a pump that allows you to adjust the dose of IV pain medication.

• While you're in the hospital, your health care team will monitor your incision for signs of infection. They'll also monitor your appetite, how much fluid you're drinking, and bladder and bowel function.

• Before you leave the hospital, talk with your doctor about any preventive care you may need, including vaccinations. It's a good time to make sure your immunizations are up to date to help protect your health and the health of your baby.

NURSING IMPLICATIONS:

a. Maintain bed rest, LLR

b. Careful monitoring:

• Maternal v/s

• FHT

• Labor onset/progress

• I & O, oliguria/anuria

• Uterine pain

• Bleeding (not proportional to degree of

shock)

c. Administer IV fluid, plasma, or blood as ordered.

NURSING IMPLICATIONS:

d. Prepare for diagnostic examinations.

e. Provide psychological support – prepare for all

examinations, explain what is happening and inform

or explain results.

f. Prepare for emergency birth either per vagina or CS.

g. Observe for ASSOCIATED PROBLEMS AFTER DELIVERY.

• Poorly contracting uterus (Couvelaire uterus) →

Post-partal hemorrhage

• Disseminated Intravascular Coagulation (DIC) →

hemorrhage and possibly CVA

PROGNOSIS

• Maternal mortality is uncommon. Maternal death rates in various

parts of the world range from 0.5 to 5%. Early diagnosis of the

condition and adequate intervention should decrease the maternal

death rate to 0.5 to 1%. Fetal death rates range from 20-35 %.

• 15% of cases - Upon hospital admission, no fetal heart tone is

detectable in about.

• Approximately 50% of cases of fetal distress appears early in the

condition .

• 40 to 50% incidence of illness in infants.

• Risk of maternal or fetal death: concealed vaginal bleeding in

pregnancy, excessive loss of blood resulting in shock, absence of

labor, a closed cervix, and delayed diagnosis and treatment are

unfavorable factors .

Website:http://www.renhealthcare.org/adam/ency/article/000901.htmlhttp://www.scribd.com/

Books:Maternal and Child Health Nursing: Caring of the Childbearing Family by Adele Pillitteri (Pages 416-417)Dr. RPS Maternal and Newborn Care (A Comprehensive Review Guide and Source Book for Teaching and Learning) by Rosalinda Parado Salustiano, RN, RM, MAN, PhDMosby’s PDQ for RN 2nd Edition

Sources

Corita Kent: “Love the moment. Flowers grow out of dark moments. Therefore, each moment is vital. It affects the whole. Life is a succession of such moments and to live each, is to succeed.”