ABRUPTIO PLACENTA

Prepared by:

Claire Alvarez Ongchua, RN

Abruptio Placenta

Is the premature separation of the normally

implanted placenta after the 20th week of
pregnancy, typically with sever
hemorrhage.

Also known Placental abruption is an

obstetric catastrophe (complication of
pregnancy)
Hemorrhage can be:
a.Occult
An occult hemorrhage, the placenta usually
separates centrally, and a large amount of
blood is accumulated under the placenta.

b. Apparent
With apparent hemorrhage , 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
PATHOPHYSIOLOGY
 PRECIPITATIONG FACTORS
PREDISPOSING FACTORS
Smoking
Age
(cigarette,tobacco,cocaine0
Race
Trauma
Previous Placenta Abruption
Chorioamnionitis
Thrombophilia
PIH

Damage in small arterial vessels in the

basal layer of decidua

Bleeding Splits decidua, leaving a thin

layer attached to the placenta

Occult Apparent
Hematoma formation

Compression of the
basal layer

Obliteration of the
intervillous space
 Destruction of the
placental tissues

Concealed Visible Impaired exchange of

Bleeding Bleeding respiratory gases and
nutrients

Blood passes through

the membranes of Blood reaches the
amniotic sac edge of the placenta
Port wine discoloration
of discharges
( PATHOGNOMONIC
SIGN)
 TYPES
OF
ABRUPTIO PLACENTA
Concealed hemorrhage

The placenta separation

centrally, and a large
amount of blood is
accumulated under the
placenta.
External
Hemorrhage
The separation is along
the placental margin, and
blood flows under the
membranes and through
cervix.
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 recent adherent clot on the
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.
Grade Criteria

2 Minimal separation, but enough to cause

vaginal bleeding and changes in the
maternal vital signs; no fetal distress or
hemorrhagic shock occurs, however.

3 Extreme separation; without immediate

interventions, maternal shock and fetal
death will result.
Laboratory Examinations
Blood Test Workup:

a. CBC
b. Blood Typing
c. Fibrinogen
d. PT and aPTT
e. BUN
f. Creatinine
g. Rh Type
h. Thrombophilia workup
OTHER TEST:

1. Imaging Studies

2. Nonstress test

3. Biophysical Profile

4. Histologic findings
Maternal Assessment
Signs Symptoms
• Increase Abdominal • Confusion
girth • Abdominal/ back
• Board like rigidity pain
• Uterine tetany
• Cold extremities
• Tachypnea, Pallor
• Decreased Urine
output
• Increase discharges
Fetal Assessment

Signs And Symptoms

• Fetal thrashing
• Signs And Symptoms
• Fetal Acidosis
• Increase FHR
Management
I. Patient Stable (Grade I)

A. General

1. Obstetrics Consultation

2. RhoGAM if Maternal blood Rh Negative

B. Criteria

1. Reassuring Fetal Heart Tracing

2. Coagulopathy
3. Normotensive without Preeclampsia
4. Nontender uterus
5. Negative ultrasound with normal AFI
C. Preterm gestation

1. Consider Tocolysis with Magnesium Sulfate

2. Contraindicated in all but mild abruption <34 weeks
3. Controversial and risky
4. Steroids to promote lung maturity
5. Consider Amniocentesis for lung maturity studies
6. External Fetal Monitoring
7. Observe during short term hospitalization
D. Term gestation or mature lung studies

1. Active management labor towards rapid fetal

delivery
2. Early Rupture of Membranes (PROM)

3. Internal Fetal Monitoring (fetal scalp electrode)

4. Tocometry
5. Intrauterine Pressure Catheter
6. Cautious use of Pitocin
E. Risks

1. Preterm birth

2. Intrauterine Growth Retardation

II. Emergent

A. Precautions

1. Rapid management is critical

2. Fetal death occurs in up to 30% within 2 hours

3. Do not delay management for ultrasound confirmation

a. Ultrasound is unreliable for diagnosis

b. Placental abruption is a clinical diagnosis

i. Indications

a. Brisk bleeding
b. Unstable vital signs

c. Fetal Distress

d. Grade II or III placental abruption

ii. Immediate interventions

1. Oxygen

2. Trendelenburg position

3. Obtain immediate Intravenous Access

a. Two large bore IV (16-18 gauge)

b. Initiate Isotonic crystalloid bolus

>Normal saline

>Lactated Ringers
4. Call for immediate Obstetric and neonatal

support

5. Delivery within 20 minutes if Fetal Distress

a. Cesarean Section unless imminent Vaginal

Delivery

6. RhoGAM if Maternal blood Rh Negative

iii. Monitoring

1. Orthostatic Blood Pressure and pulse

2. Monitor Intake and output
a. Keep Urine Output over 30cc per hour
3. Monitor Hemoglobin or Hematocrit q1-2 hours

a. Keep Hemoglobin >10 g/dl or Hematocrit >30%

b. Packed Red Blood Cell transfusion as needed

4. Monitor coagulation studies (see labs above)

a. Fresh Frozen plasma transfusion as needed

b. Platelet transfusion as needed

NURSING MANAGEMENT
1. Continuous evaluate maternal and fetal physiologic
status, particularly:

a. Vital signs

b. Bleeding

c. Electronic fetal and maternal monitoring

tracings.
d. Signs of shock – rapid pulse, cold and moist
skin, decrease in blood pressure

e. Decreasing urine output

f. Never perform a vaginal or rectal

examination or take any action that would
stimulate uterine activity.
2. Asses the need for immediate delivery. If
the client is in active labor and bleeding
cannot be stopped with bed rest,
emergency cesarean delivery may be
indicated.

3. Provide appropriate management

a. On admission, place the woman on bed

rest in a lateral position to prevent
pressure on the vena cava.
b. Insert a large gauge intravenous catheter
into a large vein for fluid replacement.
Obtain a blood sample for fibrinogen
level.

c. Measure maternal vital signs every 5 to 15

by Monitor the FHR externally and mask.

d. Prepare for cesarean section, which is the

method of choice for the birth
4. Provide client and family teaching.

5. Address emotional and psychosocial needs.

Outcome for the mother and fetus depends on
the extent of the separation, amount of fetal
hypoxia and amount of bleeding.
Nursing Diagnosis
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
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

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
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

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

•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.
•Palpate the abdomen
>Note the presence of contractions and relaxations between
contractions (if contractions are present)
>If contractions are not present assess the abdomen for firmness
• Measure and record fundal height to evaluate the presence of
concealed bleeding.
•
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