Abruptio placenta.pptx

ABRUPTIO PLACENTAE

INTRODUCTION

Placenta Abruption

- is defined as the separation of the placenta from its site of

implantation before delivery.

Complicates 1 out of 20 deliveries .

Placental abruption must be considered whenever bleeding

is encountered in the second half of pregnancy.

Bleeding can be external or concealed. It may be total or

partial.

EPIDEMIOLOGYOccurs in 1% of the of all pregnancies throughout

the world.

More common in African American women.

Resulting factors remains unclear (socio-economic,

genetic)

Higher risk on patients younger than 20 y/o and

those older than 35 y/o

EtiologyThe primary cause of placental abruption is usually

unknown

Risk Factors: Maternal hypertension (approx. 44% of all

cases)

Maternal trauma (falls, MVA)

Smoking

Alcohol consumption

Cocaine use

Short umbilical cord

Sudden depression of the uterus (PROM)

Retroplacental fibromyoma

Retroplacental bleeding from needle puncture

( postamniocentesis)

Previous placental abruption

Chorioamnionitis

Prolonged rupture of membranes (24 h or

longer)

Maternal age 35 years or older and 20 years

below

Low socioeconomic status

Asymptomatic in the

early stages

sudden-onset abdominal

pain

contractions that don't

stop

pain in the uterus

tenderness in the

abdomen

vaginal bleeding

uterus may be

disproportionately

enlarged

pallor

nonreassuring fetal

status, i.e. decreased fetal

movement, worrisome

fetal heart rate

signs and symptoms can

vary

Signs and Symptoms:

Classification of placental

abruption:Classification of placental abruption is based on

extent of separation (partial vs complete) and

location of separation (marginal vs central).

Clinical classification is as follows:

Class 0 – Asymptomatic

Class 1 - Mild (represents approx. 48% of all

cases)

Class 2 - Moderate (represents approx.27% of all

cases)

Class 3 - Severe (represents approx. 24% of all

cases)

Class 0: asymptomatic. Diagnosis is made

retrospectively by finding an organized blood clot or

a depressed area on a delivered placenta.

Class 1 characteristics include the following:o No vaginal bleeding to mild vaginal bleedingo Slightly tender uteruso Normal maternal BP and heart rateo No coagulopathyo No fetal distress

Class 2 characteristics include the following:o No vaginal bleeding to moderate vaginal bleedingo Moderate to severe uterine tenderness with possible

tetanic contractionso Maternal tachycardia with orthostatic changes in BP

and heart rateo Fetal distresso Hypofibrinogenemia (ie, 50-250 mg/dL)

Class 3 characteristics include the following:o No vaginal bleeding to heavy vaginal bleedingo Very painful tetanic uteruso Maternal shocko Hypofibrinogenemia (ie, < 150 mg/dL)o Coagulopathyo Fetal death

ANATOMY AND PHYSIOLOGY

The anatomy of the uterus consists of the following 3

tissue layers 

The inner layer, called the endometrium, is the

most active layer and responds to cyclic ovarian

hormone changes; the endometrium is highly

specialized and is essential to menstrual and

reproductive function

The middle layer, or myometrium, makes up most

of the uterine volume and is the muscular layer,

composed primarily of smooth muscle cells

The outer layer of the uterus, the serosa or

perimetrium, is a thin layer of tissue made of

epithelial cells that envelop the uterus

The uterus is a dynamic female reproductive organ

that is responsible for several reproductive

functions, including menses, implantation, gestation,

labor, and delivery. It is responsive to the hormonal

milieu within the body, which allows adaptation to

the different stages of a woman’s reproductive life.

The uterus adjusts to reflect changes in ovarian

steroid production during the menstrual cycle and

displays rapid growth and specialized contractile

activity during pregnancy and childbirth. It can also

remain in a relatively quiescent state during the

prepubertal and postmenopausal years

The uterus is a pear-shaped organ located in the

female pelvis between the urinary bladder anteriorly

and the rectum posteriorly. The average dimensions

are approximately 8 cm long, 5 cm across, and 4 cm

thick, with an average volume between 80 and 200

mL. The uterus is divided into 3 main parts: the

fundus, body, and cervix.

PATHOPHYSIOLOGY

Placental abruption is initiated by hemorrhage into

the decidua basalis. The decidua then splits, leaving

a thin layer adherent to the myometrium.

Consequently, the process in its earliest stages

consists of the development of a decidual hematoma

that leads to separation, compression, and the

ultimate destruction of the placenta adjacent to it.

In its early stage, there may be no clinical

symptoms. The condition is discovered only on

examination of the freshly delivered organ, which

has a circumscribed depression measuring a few

centimeters in diameter on its maternal surface, and

is covered by dark, clotted blood. Undoubtedly, it

takes at least several minutes for these anatomical

changes to materialize

Thus, a very recently separated placenta may

appear no different from a normal placenta at

delivery. According to Benirschke and Kaufmann

(2000), and in our experiences, the "age" of the

retroplacental clot cannot be determined exactly.

In some instances, a decidual spiral artery

ruptures to cause a retroplacental hematoma, which

as it expands disrupts more vessels to separate more

placenta. The area of separation rapidly becomes

more extensive and reaches the margin of the

placenta. Because the uterus is still distended by the

products of conception, it is unable to contract

sufficiently to compress the torn vessels that supply

the placental site. The escaping blood may dissect

the membranes from the uterine wall and eventually

appear externally or may be completely retained

within the uterus.

CONCEALED HEMORRHAGE.

Retained or concealed hemorrhage is likely when:o There is an effusion of blood behind the placenta but

its margins still remain adherent.o The placenta is completely separated yet the

membranes retain their attachment to the uterine wall.

o Blood gains access to the amnionic cavity after breaking through the membranes.

o The fetal head is so closely applied to the lower uterine segment that the blood cannot make its way past it.

Most often, however, the membranes are gradually

dissected off the uterine wall, and blood sooner or

later escapes.

PATIENT’S PROFILE

Patient’s Identity

Name :

Mrs.AP

Age : 24 years old

Occupation : Housewife

Education : Elementary

Race : Filipino

Religion : R Catholic

Address :Quezon City

Patient’s Husband’s

Identity

Name : Mr. AP

Age : 27 years old

Occupation : self-employed

Education : High School

Race : Filipino

Religion : R Catholic

Address : Quezon City

History Taking:

Chief Complaint: Vaginal bleeding

Present Illness:

The patient came to the maternity ER with

active vaginal bleeding since 12 p.m. The blood

discharged was bright red. She mentioned that she

had not felt the fetal movement since 7.00 a.m. She

also was having uterine contractions, blurred vision,

nausea and vomit. Her first day of the final

menstruation was on 10th July 2014.

Past Medical History:

•Hypertension (-)

•Diabetes mellitus (-)

•Heart Disease (-)

•Asthma (-)

•Seizures (-)

•Irregular menstrual cycle

(-)

Menstruation:

•Menarche : 14 years

old

•Menstrual cycle :

± 28 days

•Duration : 7 days

• Diaper/day : 2-3

x/days

•Menstrual pain :

(-)  

•Contraception : none

•Operation : none  

•Antenatal Care :

regular, monthly with

midwife

•Supplement : fe & folic

acid (+)

Physical Examination

•On February 9th 2015, 12.58 pm

•Overall condition : moderately in pain

•Awareness : full consciousness

•Vital Sign: - Blood pressure : 110/80 mmHg

- Pulse: 120/min

- Respiratory rate: 25/min

- Temperature: 36.7oc

Obstetric Abdominal Examination

•Inspection : striae gravidarum(+), scar (-), fetal

movement (-)

•Palpation: Fetal parts were not palpable due to the

presence of the severe abdominal pain

•Auscultation: FHR: absent

External genitalia

•-Inspection: condition of vulva / vagina normal

Bleeding (+)

•- In-speculo: Not done

Working Diagnosis : G1P0A0, GA 31 weeks + placental

abruption

LAB ORATORY AND EXAMINATIONS

No laboratory studies have been shown to

definitively help with the differential diagnosis of

Placental abruption however, multiple laboratory

studies may be helpful in the management of this

problem.

CBC Count

A complete blood cell (CBC) count can help

to determine the patient's current hemodynamic

status, but findings are not reliable for estimating

acute blood loss.

In an acute hemorrhage, the fall in

hematocrit value lags several hours behind the

bleeding and may be falsely decreased by the

administration of crystalloid fluids during

resuscitation.

Fibrinogen examination

Pregnancy is associated with

hyperfibrinogenemia; therefore, modestly depressed

fibrinogen levels may represent significant

coagulopathy. A fibrinogen level of less than 200

mg/dL suggests that the patient has a severe

abruption.

The goal should be to keep the fibrinogen

level above 100 mg/dL, which can be accomplished

via transfusion of fresh frozen plasma or

cryoprecipitate, as necessary.

Prothrombin Time/Activated Partial

Thromboplastin Time

Some form of DIC (Disseminated

intravascular coagulation) is present in up to 20%

of patients with severe abruptions. Because many of

these patients require cesarean delivery, knowing a

patient's coagulation status is imperative.

Blood Urea Nitrogen/Creatinine

The hypovolemic condition brought on by a

significant abruption also affects renal function. The

condition usually self-corrects without significant

residual dysfunction, if fluid resuscitation is timely

and adequate.

Ultrasonography

Ultrasonography is a readily available and

important imaging modality for assessing bleeding in

pregnancy.

Ultrasonography can help to exclude other

causes of third-trimester bleeding. Possible findings

consistent with an abruption include (1)

retroplacental clot, (2) concealed hemorrhage, or (3)

expanding hemorrhage.

Nonstress Test

External fetal monitors often reveal fetal

distress, as evidenced by late decelerations, fetal

bradycardia, or decreased beat-to-beat variability.

An increase in the uterine resting tone may

also be noticed, along with frequent contractions

that may progress to uterine hyperstimulation, as

seen in the fetal tracing below.

DRUG STUDY

Drug name Indication Contraindication

Side effects Nursing responsibilities

Generic name:Tranexamic acid

Brand name:Hemostan, Fibrinon, Cyklokapron, Lysteda, Transamin

Classification: Anti-fibrinolytic, antihemorrhagic

• Treating heavy menstrual bleeding

• Obstetrical and gynecological: abortion, post-partum hemorrhage and menometrorrahgia

• drug hyper- sensitivity

• Presence of blood clots (eg, in the leg, lung, eye, brain), have a history of blood clots, or are at risk for blood clots

• dizziness or lightheadedness

• Headache

• Abdominal or stomach pain, discomfort, or tenderness

• Unusual change in bleeding pattern should be immediately reported to the physician.

• Swallow Tranexamic Acid whole with plenty of liquids. Do not break, crush, or chew before swallowing.

Drug name Indication Contraindication

Side effects Nursing responsibilities

Gelofusine

Classification:gelatin agents

Colloidal plasma volume substitute for prophylaxis and treatment of relative or absolute hypovolaemia

• hypersensitivity towards gelatine,

• hypervolaemia,

• hyperhydration,

• Fever• Urticaria• Sudden

flushing of the face and neck

• solution should be warmed to body temperature.

• Unused contents of an opened container must be discarded.

• Store below 25°C.

• stop the infusion immediately, as soon as there are any indications of adverse reactions.

Drug name Indication Contraindication

Side effects Nursing responsibilities

Generic Name: Ceftriaxone

Brand Name: Rocephin

Classification:Anti-infectives

Gynecologic infection

• Drug hyper sensitivity

• Headache• Diarrhea• N/V• mild pain,

swelling, or redness at the injection site

• WOF s/s of anaphylaxis

Drug name Indication Contraindication

Side effects Nursing responsibilities

Generic name:Oxytocin

Brand name:Pitocin, Syntocinon

Classification:OxytocicsUterine-active agents

• control of postpartum bleeding or hemorrhage

• induction of labor in patients with a medical indication for the initiation of labor, when in the best interest of mother and fetus or when membranes are prematurely ruptured and delivery is indicated 

Drug hypersensitivity

• Hypotension

• Decrease uterine bld. Flow

• Assess character, freq., duration of uterine contractions.

• Monitor maternal BP and pulse frequently and fetal heart rate continously.

Drug name Indication Contraindication

Side effects Nursing responsibilities

Generic name:Misopostrol

Brand name:Cytotec

Classification:Anti-ulcer, Cytoprotective agents

For termination of pregnancy

Pregnancylactation

• Diarrhea• Stomach

pain• Miscarriag

e

Asses for epigastric pain or abdominal pain and for frank or occult blood in the stool, emesis, or gastric aspirate.

Drug name Indication Contraindication

Side effects Nursing responsibilities

Generic name:Ketoprofen

Brand name:Actron, Orudis

Classification:Antipyretics,Nonopioid analgesics, nonsteroidal anti- inflammatory agents

• Mild to moderate pain

• fever

• Drug hypersensitivity

• Active GI bleeding

• pregnancy

• Headache• Dizziness• Blurred

vision• Tinnitus• Edema• Constipati

on• Diarrhea• N/V• Discomfort• rashes

• Asses pain• Monitor

temperature

Drug name Indication Contraindication

Side effects Nursing responsibilities

Generic name:Cefadroxil

Brand name:Duricef

Classification:Anti-infectives1st gen cephalosporins

Septicemia Drug hypersensitivity

• Diarrhea• N/V• Cramps• Rashes• Pruritus• Urticaria

• Assess for infection

• Observe pt’s S/S of anaphylaxis

NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective: “Bigla na lang sumakit ng matindi ang tiyan ko , ayaw tumigil sa paghilab”As verbalized by the patient  Objectives:  (+)Vaginal

bleeding abdominal

pain with pain scale 8/10

Pallor Facial

grimace (-) facial

grimace Pallor BP 110/80 PR 120 RR 25 Temp

36.7c 

Ineffective Tissue Perfusion related to excessive blood loss secondary to premature separation of the placenta

Short Term: After 30-60 minutes of administering oxygen supplement and performing blood transfusion, the patient’s blood components that were lost will be replaced and the patient’s circulation of blood and oxygen delivery/transport to the tissues will be stabilized .Long term: After a week of continuing oxygen supplementation ,administering blood transfusion, and providing a calm and stimulant free environment such as limiting the visitation hours, the patient will be able show improvements such as moist skin pinkish skin, and maintain normal blood pressure within the range of 110/80mmHG-130/90mmHg.

>Monitor amount of bleeding by weighing all pads >Monitor accurately I & O   >Monitor FHT continuously   >Assess Uterine Irritability, abdominal pain and rigidity  >Elevate extremity above the level of the heart >Assess level of consciousness of the mother >Evaluate pulse oxymetry to determine oxygenation.

 >Administer IV fluids. Administer blood transfusion as indicated 

>Prepare for caesarean section

  >To measure amount of blood loss 

 >To provide information regarding fetal distress and/or worsening of condition 

>To determine the severity of the placental abruption and bleeding 

>To promote circulation      >To assess respiratory efficiency  >To replace the fluid lost in the body   >The method of choice for the birth

Short Term: After 30-60 minutes of administering oxygen supplement and performing blood transfusion, the patient’s blood components that were lost was replaced and the patient’s circulation of blood and oxygen delivery/transport to the tissues will be stabilized . Long term: After 1-2 hrs of continuing oxygen supplementation ,administering blood transfusion, the patient was able to show improvements such as moist skin pinkish skin, and normal blood pressure of 110/80

DISCHARGE PLANNING

Medicine:• Taught proper reference on how to take medication

and supplements.

Exercise:• Avoid strenuous activities.• Range of motion exercises as tolerated.

Health Teaching:• Instructed to have adequate rest periods.• Instructed Deep Breathing exercises.• Maintain proper hydration.• Maintain proper hygiene.• Taught proper breastfeeding.• Taught to use betadine feminine wash and water

when washing perineal area.• Clean the umbilicus of the baby three times a day

using 70% alcohol.

Out Patient Follow up:• Instructed patient to have a follow up appointment

with OPD after one week.

Diet:• Instructed patient to eat foods low in salt and low in

fat.

Spiritual and Sexual:• Encouraged patient to continue to follow her

spiritual beliefs.• Instructed patient to refrain from sexual intercourse

until instructed by physician.

VCEH-DR

BSN 4Y1-2A