NCM 302: O.B.

GYNECOLOGY - PEDIATRICS

Abruptio Placentae

Presented by:
ALCANTARA, Eduardo
L.
BSN 3rd Year – N1 of St.
Presented
Dominicto:
Ms. Analinda R. Sese, RN,
MAN
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. Prognosis
11. 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.
 Abruptio Placenta

1. Incidence: second leading

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

1:700-750*
 Abruptio Placenta
Types
a. 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
Types
b. 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.
 Destruction of the placental tissues
ASSESSMENT:

Abruptio Placenta

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.

Signs of Shock*
 Destruction of the placental tissues
ASSESSMENT:

PREMATURE SEPARATION OF THE PLACENTA:

Degrees of Separation
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.
ASSESSMENT:

Grade 1 Grade 2 Grade 3

Mild Moderate Severe
Separation Separation Separation
(10-20%) (20-50%) (>50%)
General Findings
•Total Amount of <500 cc 1,000-5,000 cc >1,500 cc
Blood Loss
•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

Coagulopathy* and Uterine Tonicity*

ASSESSMENT:

Grade 1 Mild Grade 2 Grade 3

Separation Moderate Severe
(10-20%) Separation Separation
(20-50%) (>50%)

Ultrasonographic
Findings

•Location of placenta Normal, Upper Normal, Upper Normal, Upper

Uterine Uterine segment Uterine segment
segment

•Station of Variable to Variable to Variable to

presenting part engaged engaged engaged

•Fetal position Usual Usual variations Usual variations

variations
DIAGNOSIS:

Abruptio Placenta

A. Clinical Diagnosis – Signs and symptoms

B. 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

• DIC (disseminated intravascular coagulation): small

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

Abruptio Placenta
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.
DIAGNOSIS:

Abruptio Placenta
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)
 Destruction of the placental tissues
PATHOPHYSIOLOGY:

Predisposing • CHD
Factors: • Trauma (Injury)
• Advance Age • Fibrin Defects
(> 35y.o) • Thrombolphlibitic Contributing Factors:
•Gender (Female) conditions  Smoking/ Cocaine use
• Heredofamilial •PIH (Pregnancy-
• High Parity induced HPN) Diet
•Previous abruptio • Renal Disease Socio-economic status
placenta
• Polydamnios*
•Chorioamnionitis*
• Anemia
Damage in small (Low)
• Short umbilical • Uterine Fibroid arterial vessels in the
cord*
basal layer of
decidua*

Bleeding
Splits decidua, leaving a thin
OCCULT APPARENT layer attached to the placenta
 Obliteration of the
Hematoma formation intervillous space*

Compression of the basal

layer* Destruction of the placental tissues

Impaired exchange
Concealed Visible of respiratory
gases and
Bleeding Bleeding nutrients

Blood passes through the

membranes of amniotic sac Blood reaches the
edge of the placenta
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

Acute Pain related to increase uterine

activity

• 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.

NSG DXs & NSG INTERVENTIONS

Fluid volume deficit related to

excessive bleeding

• 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.
NSG DXs & NSG INTERVENTIONS

Risk for infection related to excessive blood

loss

• 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.

NSG DXs & NSG INTERVENTIONS

Fear related excessive bleeding procedures

and unknown outcome

• 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 .

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 SURGICAL
MANAGEMENT MANAGEMENT

• IV administration

of fibrinogen or
• CS section
cryoprecipitate

• Laboratory

examinations
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  Cryoprecipitate
Bleeding or immediately prior to an invasive
procedure in patients with significant
hypofibrinogenemia (<100 mg/dL)
CS
During 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 .
 Sources
Website:
http://www.renhealthcare.org/adam/ency/article/000901.html
http://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, PhD
Mosby’s PDQ for RN 2nd Edition
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.”