Abruption Placenta

DEFINITION-

  • Abruptio Placental is the premature separation of the normally implanted placenta from the uterine wall after the 20th week of gestation until the 2nd stage of labor. 
  • A condition Characterized by premature separation of a normally situated placenta.
  • It is one form of antepartum hemorrhage where the bleeding occurs due to premature separation of normally situated placenta

Incidence-

  • It is seen in 1 to 3% Delivery and occurring in the last trimester of pregnancy with the incident increasing as the term approaches.
  • Recurrence rates are about 5 to 17% after the first episode and about 25% after the second.

Note-Bleeding is almost always maternal. But placental tear may cause fetal bleeding

ETIOLOGY-

The exact cause of separation of a normally situated is Unknowns

Risk factors are

  •  High birth order pregnancies with gravida 5 and above three times more common than in first birth
  • Advancing age of the mother
  • Poor socio-economic condition
  • Malnutrition
  • Smoking (vasospasm).
  • Hypertension
  • Prior abruption
  • Trauma
  • Sudden uterine decompression
  • Short cord
  • Supine hypotension syndrome
  • Placental anomaly
  • Sick placenta
  • Folic acid deficiency
  • Cocaine abuse
  • Thrombophilia’s
  • Alcohol use

CLINICAL CLASSIFICATION

Depending upon the degree of placental abruption and its clinical effects, the cases are graded as follows-

  Grade—0 (Class 0) Asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.

Grade—1 (48%)

  1. Vaginal bleeding is slight
  2.  Uterus- Irritable, tenderness may be minimal or absent
  3.  Maternal BP and fibrinogen levels unaffected
  4.  FHS is good.

Grade—2 (27%)

  1. Vaginal bleeding mild to moderate
  2.  Uterine tenderness is always present
  3. Maternal pulse ↑, BP is maintained
  4. Fibrinogen level may be decreased (Hypofibrinogenemia)
  5. Shock is absent
  6.  Fetal distress or even fetal death occurs.

Grade—3 (24%)-

  • Bleeding is moderate to severe or may be concealed
  • Uterine tenderness is marked
  • Shock is pronounced
  • Fetal death is the rule
  • Associated coagulation defect or anuria may complicate
  • Fetal death
SR.No. MILD-GRADE 1 MODERATE-GRADE 2 SEVERE-GRADE 3
DEFINITION Less than one-sixth of placenta separates prematurely.  From one-sixth to one-half of placenta separates prematurely.  More than one-half of placenta separates prematurely
SIGNS AND SYMPTOMS
  • Total blood loss <500 mL Dark vaginal bleeding (mild to moderate) Vague lower abdominal or back discomfort
  • No uterine tenderness
  • No uterine irritability
  • Total blood loss 1,000–1,500 mL 15%–30% of total blood volume
  • Dark vaginal bleeding (mild to severe) Gradual or abrupt onset of abdominal pain
  • Uterine tenderness present
  • Uterine tone increased 
  • Total blood loss >1,500 mL More than 30% of total blood volume
  • Dark vaginal bleeding (moderate to severe)
  • Usually abrupt onset of uterine pain described as tearing, knifelike, and continuous
  • Uterus board like (hard) 
MATERNAL EFFECTS Vital signs normal
 
  • Mild shock
  • Normal maternal blood pressure
  • Maternal tachycardia
  • Narrowed pulse pressure
  • Orthostatic hypotension Tachypnea
  • Moderate-to-profound shock common
  • Decreased maternal blood pressure
  • Maternal tachycardia significant
  • Narrowed pulse pressure
  • Orthostatic hypotension severe
  • Significant tachypnea 
MATERNAL COMPLICATIONS
 		 Normal fibrinogen of 450 mg/dL
 
  • Early signs of DIC common
  • Fibrinogen 150–300 mg/dL
  • DIC usually develops unless condition is treated immediately
  • Fibrinogen <150 mg/dL 
FETAL/NEONATAL COMPLICATIONS Normal FHR pattern
 		 FHR shows non-reassuring signs of possible fetal compromise
 		 FHR shows signs of fetal compromise and death can occur

 

Classification of the Haemorrhage

  1. Revealed or external Haemorrhage

The effused blood escapes under the placental margin and makes its way between the membranes and the uterine wall down to the internal os from where it passes through the cervix into the vagina.

2. Concealed Haemorrhage

 Almost the whole amount of effused blood is retained due to loss of tone or excitability of the uterine musculature. Sometimes bleeding takes place into the amniotic sac. There is usually a little external bleeding in concealed accidental haemorrhage.

3. Mixed type of haemorrhage

In this type the bleeding is partly external and partly concealed.

Symptoms

  • Vaginal bleeding that is dark red and clotted
  • Severe abdominal pain
  • Backache
  • Sweating and dizziness (symptoms of shock especially from the concealed type).

Sing of Placental Abruption

  • Cold clammy extremities (Hands and feet become cold)
  • Rapid and thread pulse
  • Pallor (patient becomes pale)
  • Low blood pressure
  • Tender woody and hard uterus on abdominal examination (in the concealed type of Abruptio Placentae)
  • There may be increasing fundal height due to retained clots

Investigations

  • History & physical examinations 
  • Ultrasonography
  • Coagulation
  • Urine for protein
  • Complete blood cell count 

Complication of Placental Abruptions

Maternal complications

  • Infection
  • Anaemia
  • Hypovolaemic shock secondary to haemorrhage
  • Coagulopathy/disseminated intravascular coagulation (DIC)
  • Acute renal failure
  • Couvelaire uterus
  • Postpartum haemorrhage
  • Ischemic necrosis of distal organs (adrenal, pituitary)
  • Feto–maternal haemorrhage
  • Psychological sequelae

Fetal complications

These include-

  • Intrauterine death
  • Hypoxia and its sequelae
  • Anaemia
  • Fetal growth restriction (FGR), if chronic
  • Risks of preterm birth.

MANAGEMENT

 Prevention: The prevention aims at

  • Elimination of the known factors likely to produce placental separation.
  •  Correction of anemia during antenatal period so that the patient can withstand blood loss.
  •  Prompt detection and institution of the therapy to minimize the grave complications namely shock, blood coagulation disorders and renal failure.

Prevention of known factors

  • Early detection and effective therapy of preeclampsia and other hypertensive disorders of pregnancy.
  •  Needle puncture during amniocentesis should be under ultrasound guidance.
  •  Avoidance of trauma— Specially forceful external cephalic version under anesthesia.
  •  To avoid sudden decompression of the uterus— in acute or chronic hydramnios, amniocentesis is preferable to artificial rupture of the membranes.
  •  To avoid supine hypotension the patient is advised to lie in the left lateral position in the later months of pregnancy.
  • Routine administration of folic acid from the early pregnancy

TREATMENT

  • AT HOME -The patient is to be treated as outlined in placenta previa and arrangement should be made to shift the patient to an equipped maternity unit as early as possible.

IN THE HOSPITAL

 Assessment of the case is to be done as regards:

  • Amount of blood loss
  •  Maturity of the fetus
  •  Whether the patient is in labor or not (usually labor starts)
  •  Presence of any complication 
  • Type and grade of placental abruption

Emergency measures-

  •  Blood is sent for hemoglobin and hematocrit estimation, coagulation profile (fibrinogen level, FDP, prothrombin time, activated partial thromboplastin time and platelets), ABO and Rh grouping and urine for detection of protein
  •  Ringer’s solution drip is started with a wide bore cannula and arrangement for blood transfusion is made for resuscitation. Close monitoring of maternal and fetal condition is done.

Definitive treatment (immediate delivery)

  • The patient is in labor- Most patients are in labor following a term pregnancy: The labor is accelerated by low rupture of the membranes. Rupture of the membranes with escape of liquor amnio accelerates labor and it increases the uterine tone also. Oxytocin drip may be started to accelerate labor when needed

Vaginal delivery is favored in cases with:

  •  Limited placental abruption
  •  FHR tracing is reassuring
  • Facilities for continuous (electronic) fetal monitoring is available
  •  Prospect of vaginal delivery is soon
  •  Placental abruption with a dead fetus.

The patient is not in labor

  • Bleeding continues
  •  > Grade I abruption

Delivery either by

  1.  Induction of labor
  2.  Cesarean section.

Induction of labor is done by low rupture of membranes.

 Oxytocin may be added to expedite delivery. Labor usually starts soon in majority of cases and delivery is completed quickly (4–6 hours). Placenta with varying amount of retroplacental clot is expelled most often simultaneously with the delivery of the baby. Inj. oxytocin 10.IU IV (slow) or IM or Inj. methergine 0.2 mg IV is given with the delivery of the baby to minimize postpartum blood loss.

Cesarean section-

 Indications are -

  • Severe abruption with live fetus
  • Amniotomy could not be done (unfavorable cervix)
  •  Prospect of immediate vaginal delivery despite amniotomy is remote
  •  Amniotomy failed to control bleeding Amniotomy failed to arrest the process of abruption (rising fundal height)
  • Appearance of adverse features (fetal distress, falling fibrinogen level, oliguria).

Nursing Diagnosis

  • Impaired gas exchange to fetus related to insufficient oxygen supply secondary to premature separation of placenta
  • Pain related to concealed bleeding secondary to premature separation of placenta.
  • Risk for fluid volume deficit related to bleeding
  • Powerlessness related to disease condition.
  • Fear related to perceived threat to fetal survival.

Nursing Management of Abruptio Placenta

  • Monitor maternal vital signs.
  • Monitor fetal heart rate, uterine contractions and vaginal bleedings.
  • Vaginal delivery depends on degree & timing of separation of placenta in labor.
  • Caesarean delivery indicated for moderate to severe placental separation
  • Evaluate maternal laboratory values.
  • Replace fluid & electrolyte & if required transfuse blood.
  • Provide emotional support.

Nursing Care

  • Assess the patient's condition and determine the extent of bleeding.
  • Check fundal height every 30 minutes, as if the level of the fundal height increases. suspect abruptio placentae
  • Assess fetal heart rate by electronic fetal monitor such as doppler.
  • Count the number of pads that the patient uses, weighing them as necessary to determine the amount of blood loss.
  • Monitor maternal vital signs such as blood pressure, pulse rate, respiration, central venous pressure.
  • Maintain 1/O record.
  • Provide emotional support by reassuring the patient about the progress of labor and
  •  keeping her informed of the fetus condition.
  • Keep all the equipment's ready for caesarean delivery.
  • Encourage the woman to verbalise her feelings.
  • Counsel her and help by developing effective coping strategies.

#