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SLU-OB WARD – CASE PRESENTATION
Abruptio Placentae
Presented by:LUMIBAO, Jommel Ryan C.BALTAKEN, Donna Alpha
S.EVANGELISTA, Tiffany
BlancaMOLINA, Mary Isobelle D.Presented to:
Ma’am Julie Ann Marie Dalisay - Uy, RN
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
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.
Concealed
Abruption
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.
External Abruptio
n
*predominantly/relatively concealed, the membrane gradually separate from the uterine wall and blood escapes through the cervix.
Relatively
Concealed
Abruption
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 fundic 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:• 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
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)
CS
During the procedureAn 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.”
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