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.

EPIDEMIOLOGY
Occurs 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

Etiology
The primary cause of placental abruption is usually
unknown

Risk
Factors:
Retroplacental
fibromyoma
Retroplacental
Maternal hypertension
44% puncture
of all
bleeding(approx.
from needle
cases)
( postamniocentesis)
Previous
Maternalplacental
trauma (falls,
MVA)
abruption
Chorioamnionitis
Smoking
Prolonged
Alcohol consumption
rupture of membranes (24 h or
longer)
Cocaine use

Short umbilical
Maternal
age 35 cord
years or older and 20 years
Sudden depression of the uterus (PROM)
below
Low socioeconomic status

Signs and Symptoms:

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

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
o
o
o
o

No vaginal bleeding to mild vaginal bleeding

Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress

Class 2 characteristics include the following:

o No vaginal bleeding to moderate vaginal bleeding
o Moderate to severe uterine tenderness with possible
tetanic contractions
o Maternal tachycardia with orthostatic changes in BP
and heart rate
o Fetal distress
o Hypofibrinogenemia (ie, 50-250 mg/dL)

Class 3 characteristics include the following:

o
o
o
o
o
o

No vaginal bleeding to heavy vaginal bleeding

Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, < 150 mg/dL)
Coagulopathy
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 womans 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 theurinary 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.

PATIENTS PROFILE
Patients Identity
Name : Mrs.AP
Age : 24 years old
Occupation
: Housewife
Education : Elementary
Race : Filipino
Religion : R Catholic
Address

:Quezon City

Patients Husbands 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

L A B O R AT O R Y A N D E XA M I N AT I O N S
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

Contraindica
tion

Side effects

Nursing
responsibilit
ies

Generic
name:
Tranexamic
acid

Treating
heavy
menstrual
bleeding

drug
hypersensitivity

dizziness
or
lightheade
dness

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

Obstetrical
and
gynecologi
cal:
abortion,
postpartum
hemorrhag
e and
menometr
orrahgia

Unusual
change in
bleeding
pattern
should be
immediate
ly reported
to the
physician.
Swallow
Tranexami
c Acid
whole with
plenty of
liquids. Do
not break,
crush, or
chew
before
swallowing
.

Classificati
on:Antifibrinolytic,
antihemorrh
agic

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

Headache
Abdominal
or stomach
pain,
discomfort
, or
tenderness

Drug name

Indication

Contraindica
tion

Side effects

Gelofusine

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

hypersensi
tivity
towards
gelatine,
hypervolae
mia,
hyperhydr
ation,

Classificati
on:
gelatin
agents

Fever
Urticaria
Sudden
flushing
of the
face and
neck

Nursing
responsibilit
ies

solution
should be
warmed to
body
temperatu
re.
Unused
contents of
an opened
container
must be
discarded.
Store
below
25C.
stop the
infusion
immediate
ly, as soon
as there
are any
indications
of adverse
reactions.

Drug name

Indication

Contraindica
tion

Side effects

Generic
Name:
Ceftriaxone

Gynecologic
infection

Drug
hyper
sensitivity

Brand
Name:
Rocephin
Classificati
on:
Antiinfectives

Headache
Diarrhea
N/V
mild pain,
swelling,
or redness
at the
injection
site

Nursing
responsibilit
ies

WOF s/s of
anaphylaxi
s

Drug name

Indication

Contraindica
tion

Side effects

Nursing
responsibilit
ies

Generic
name:
Oxytocin

control of
postpartu
m bleeding
or
hemorrhag
e
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
membrane
s are
premature
ly
ruptured
and

Drug
hypersensitiv
ity

Hypotensi
on
Decrease
uterine
bld. Flow

Assess
character,
freq.,
duration of
uterine
contractio
ns.
Monitor
maternal
BP and
pulse
frequently
and fetal
heart rate
continously
.

Brand
name:
Pitocin,
Syntocinon
Classificati
on:
Oxytocics

Uterineactive
agents

Drug name

Indication

Contraindica
tion

Side effects

Nursing
responsibilit
ies

Generic
name:
Misopostrol

For
termination
of pregnancy

Pregnancy
lactation

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.

Brand
name:
Cytotec
Classificati
on:
Anti-ulcer,
Cytoprotecti
ve agents

Drug name

Indication

Contraindica
tion

Side effects

Nursing
responsibilit
ies

Generic
name:
Ketoprofen

Mild to
moderate
pain
fever

Drug
hypersensi
tivity
Active GI
bleeding
pregnancy

Headache
Dizziness
Blurred
vision
Tinnitus
Edema
Constipati
on
Diarrhea
N/V
Discomfort
rashes

Asses pain
Monitor
temperatu
re

Brand
name:
Actron,
Orudis
Classificati
on:
Antipyretics,
Nonopioid
analgesics,
nonsteroidal
antiinflammatory
agents

Drug name

Indication

Contraindica
tion

Side effects

Generic
name:
Cefadroxil

Septicemia

Drug
hypersensitiv
ity

Brand
name:
Duricef
Classificati
on:
Antiinfectives
1st gen
cephalospori
ns

Diarrhea
N/V
Cramps
Rashes
Pruritus
Urticaria

Nursing
responsibilit
ies

Assess for
infection
Observe
pts S/S of
anaphylaxi
s

NURSING CARE PLAN

Assessment
Subjective:

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

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

Planning
Short Term:
After 30-60 minutes
of administering
oxygen supplement
and performing
blood transfusion,
the patients blood
components that
were lost will be
replaced and the
patients circulation
of blood and oxygen
delivery/transport to
the tissues will be
stabilized .
Long term:
After a week
ofcontinuing 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
of110/80mmHG130/90mmHg.

Intervention
Rationale
>Monitor amount of
bleeding by weighing
all pads
>To measure amount of

blood loss
>Monitor accurately
I&O

>To provide information

>Monitor FHT
regarding fetal distress
continuously
and/or worsening

ofcondition

>Assess Uterine
>To determine the
Irritability, abdominal severity of the placental
pain and rigidity
abruption and bleeding

>Elevate extremity
>To promote circulation
above the level of the
heart

>Assess level of

consciousness of the
mother

>To assess respiratory

>Evaluate pulse
efficiency
oxymetry

todetermine

oxygenation.
>To replace the fluid lost
in the body

>Administer IV
fluids.Administerblo

od transfusion as
>The method of choice
indicated
for the birth

>Prepare for

Evaluation
Short Term:
After 30-60 minutes of
administering oxygen
supplement and
performing blood
transfusion, the patients
blood components that
were lost was replaced
and the patients
circulation of blood and
oxygen delivery/transport
to the tissues will be
stabilized .

Long term:
After 1-2 hrs ofcontinuing
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