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Abruptio-Placenta NOTES LECTURE
Medicine (Med123)
Ateneo de Davao University
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Abruptio Placenta
I. DEFINITION
● Also called as a premature separation of the placenta. ● The placenta appears to have been implanted correctly, Suddenly, it begins to separate and bleeding results
● Degrees of placental separation can be graded
DEGREES OF SEPARATION; Grade Criteria
0 No symptoms of separation are apparent from maternal or fetal signs; the diagnosis is made after birth when the placenta is examined and a segment of the placenta shows an 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 hemorrhage shock occurs.
2 Moderate separations, there is evidence of fetal distress; the uterus is tense and painful on palpation
3 Extreme separation; without immediate interventions, maternal hypovolemic shock and fetal death will result.
II. ANATOMY AND PHYSIOLOGY
In this section, the body system/s involved in the assigned disease is presented. Also, an explanation of the roles of each of the specific organs involved is highlighted, to deepen understanding about the said condition- abruptio placenta.
Placenta ● It develops in the uterus during pregnancy. ● The main function of the placenta is for nutritional support for the fetus (nutrition in the womb). ● It provides the fetus with oxygen and nutrients while simultaneously removing carbon dioxide and waste from the fetus into the mother’s body for elimination. ● When the placenta partly or completely separates from the inner wall of the uterus before delivery, placental abruption happens. ● This then decreases/blocks the baby's supply of oxygen and nutrients and causes heavy bleeding in the mother.
Uterus ● Also known as the womb is a female reproductive organ that is responsible for many functions in the processes of implantation, gestation, menstruation, and labor. ● This is composed of both maternal tissue and tissue derived from the embryo. ● This is the site where the fertilized egg is implanted for gestation. ● This is lined with mucus membrane rich in the blood capillaries to form the placenta which is responsible for the nourishment of the fetus during the pregnancy through the umbilical cord. ● The partial or complete separation of the placenta from the uterine wall is the structural change in abruptio placenta.
Uterine Arteries ● These are the main blood vessels that supply blood to the uterus. ● They serve the purpose of nourishing the placenta. ● For a number or variety of reasons, these uterine arteries can tear, rupture, and the blood inside them will flow out and start to build up between the uterus and the placenta. ● At such a point, the placenta is not attached to the uterus anymore, the placenta isn’t receiving the oxygenated and nutrient-rich blood anymore.
of the placenta leading to necrotic foci, separation at the necrotic foci, and eventually, an abruption. (Kaminsky et al., 2007). IV. SYMPTOMATOLOGY
D.E.T.A.C.H.E.
D ark red bleeding The bleeding that is occurring in abruptio placenta has been concealed somewhat; if ever the blood comes out through the vaginal area, it's been there for a while so it’s going to be dark red. Dark red blood implies deoxygenated or low oxygen-carrying blood.
E xtended Fundal Height In cases of concealed bleeding, it enlarges the uterus increasing the fundal height.
T ender Uterus Due to detachment of the placenta from uterine wall; wound
A bdominal Pain May due to contractions
C oncealed Bleeding Stays or backflows
H ard Abdomen Due to contractions
E xperience DIC (Disseminated Intravascular Coagulation)
A serious disorder in which the proteins that control blood clotting become overactive; after the detachment of the placenta, there is the release of lots of thromboplastins into mother’s circulation causing clots.
D istressed Baby Occurs if the situation goes on for too long, the baby will not get enough oxygen.
V. GENERAL PATHOPHYSIOLOGY
➔ Abruptio placenta is that there is the separation of the uterine wall and decidua basalis
➔ caused by degeneration of uterine arteries that supply blood to the placenta ➔ vessels rupture, causing bleeding and separation of the placenta ◆ if the separation is near the margin; there is vaginal bleeding ◆ if the separation is more central; there might be a pocket of blood that stays concealed within the deciduous
➔ whether blood is evident or not, signs of hypovolemic shock usually follow quickly ➔ the uterus becomes tense and feels rigid to touch ➔ If blood infiltrates the uterine musculature, Couvelaire uterus or uteroplacental apoplexy, forming a hard, boardlike uterus occurs ➔ As bleeding progress, a woman’s reserve of blood fibrinogen becomes diminished ➔ as her body attempts to accomplish effective clot formation, and DIC syndrome can occur.
● Disseminated intravascular coagulation (DIC) is a rare but serious condition that causes abnormal blood clotting throughout the body's blood vessels ● Uteroplacental apoplexy is a rare but nonfatal complication of severe forms of placental abruption. It occurs when vascular damage within the placenta causes hemorrhaging that progresses to and infiltrates the wall of the uterus.
VIII. SURGICAL MANAGEMENT
Separation of the placenta is immediately an emergency situation.
● Cesarean birth - If DIC developed; if birth is imminent, it is safest to deliver the baby via cesarean delivery ○ the possibility of hemorrhage ● Hysterectomy - to prevent exsanguination (severe blood loss) ○ for the worst outcome ○ a procedure to remove the uterus ○ Nursing Management; Postoperative Care ■ Assess for signs of hemorrhage ■ Monitor vital signs every 4 hours, auscultate lungs every shift, and measure intake and output. These data are important indications of hemodynamic status and complications. ■ Assess for complications, including infection, ileus, shock or hemorrhage, thrombophlebitis, and pulmonary embolus ■ Assess vaginal discharge, instruct the woman in perineal care ■ Assess incision and bowel sound every shift ■ Encourage turning, coughing, deep breathing, and early ambulation ■ Encourage fluid intake.
IX. NURSING MANAGEMENT
Nursing Diagnosis: 1. Ineffective Tissue Perfusion related to excessive blood loss Interventions: ● Assess the patient's vital signs, O2 saturation, and skin color. R: For baseline data ● Monitor I&O R: To obtain data about renal perfusion and function and the extent of blood loss. ● Monitor FHT continuously R: To obtain data about renal perfusion and function and the extent of blood loss. ● Elevate extremity above the level of the heart R: Helps promote circulation ● Instruct patient and/or SO to report immediately signs and symptoms of thrombosis: (1) pain in leg, groin (2) unilateral leg swelling (3) pale skin R: To immediately provide additional interventions
Risk for shock related to a. Separation of the placenta b. External or internal bleeding ● Monitor for persistent or heavy fluid or blood loss. R: The amount of fluid or blood loss must be noted to determine the extent of shock. ● Assess vital signs and tissue and organ perfusion. R: For changes associated with shock states ● Administer oxygen by an appropriate route. R: To maximize oxygenation of tissues. ● Monitor uterine contractions and fetal heart rate by an external monitor. R: Assesses whether labor is present and fetal status; external system avoids cervical trauma. ● Collaborate in prompt treatment of underlying conditions and prepare for or assist with medical and surgical interventions. R: To maximize systemic circulation and tissue and organ perfusion.
Acute pain related to a separation of the placenta from the uterine wall b. Pain accompanying labor contractions during initial separation Interventions: ● Assess for referred pain as appropriate. R: To help determine the possibility of an underlying condition or organ dysfunction requiring treatment. ● Monitor skin color and temperature and vital signs. R: These are usually altered in acute pain normal response to pain is an increase in heart rate, breathing rate, and blood pressure. ● Provide comfort measures, a quiet environment, and calm activities. R: To promote non-pharmacological pain management. ● Administer analgesics as indicated. R: To maintain an acceptable level of pain. ● Encourage adequate rest periods. R: To prevent fatigue.
Deficient fluid volume related to bleeding during premature placental separation. ● Place the woman in a lateral, not supine position. R: To prevent pressure on the vena cava and additional interference with fetal circulation. ● Monitor fetal heart sounds.
■ mild abruption: possible close-monitored vaginal delivery ■ abruption got worse: emergency C-section if both fetus and mother’s health are in danger ● Blood transfusion, will be performed in cases of severe blood loss.
BAD PROGNOSIS:
● Maternal ○ depends on how promptly treatment can be instituted ○ death can occur from massive hemorrhage, leading to shock and circulatory collapse of renal failure from circulatory collapse. ● Fetal ○ depends primarily on the gestational age at which the abruption occurs, and on the degree of the abruption. ○ result in blood clots, anoxia, organ failure, and even death.
Reference: Kaminsky, L. M., Ananth, C. V., Prasad, V., Nath, C., Vintzileos, A. M., & New Jersey Placental Abruption Study Investigators. (2007). The influence of maternal cigarette smoking on placental pathology in pregnancies complicated by abruption. American journal of obstetrics and gynecology , 197 (3), 275-e1.
Abruptio-Placenta NOTES LECTURE
Course: Medicine (Med123)
University: Ateneo de Davao University
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