Abruptio placentae

Definition:

Abruptio placentae is defined as the premature separation of the normally implanted

placenta from the uterine wall after the 20th week of gestation until the 2nd stage of labor.
Patients with abruptio placentae, also called placental abruption, typically present with
bleeding, uterine contractions, and fetal distress.

Anatomy and physiology

Pathophysiology

Risk factors

 High parity. A woman who has given birth multiple times predisposes herself to abruptio
placentae.
 Short umbilical cord. A short umbilical cord could cause the separation of the placenta
especially if trauma occurs.
 Advanced maternal age. Women over the age of 35 years old have higher risk of acquiring
abruptio placentae.
 Direct trauma. Any trauma to the abdomen could cause a separation of the placenta.
 Chorioamnionitis. This is an infection of the fetal membranes and fluid that could predispose
the woman to premature placental separation.
Risk factors for placental abruption include disease, trauma, history, anatomy, and exposure to
substances. The risk of placental abruption increases sixfold after severe maternal trauma.
Anatomical risk factors include uncommon uterine anatomy (e.g. bicornuate uterus), uterine
synechiae, and leiomyoma. Substances that increase risk of placental abruption include cocaine and
tobacco when consumed during pregnancy, especially the third trimester. History of placental
abruption or previous Caesarian section increases the risk by a factor of 2.3.

In the vast majority of cases, placental abruption is caused by the maternal vessels tearing
away from the decidua basalis, not the fetal vessels. The underlying cause is often unknown. A
small number of abruptions are caused by trauma that stretches the uterus. Because the placenta is
less elastic than the uterus, it tears away when the uterine tissue stretches suddenly. When
anatomical risk factors are present, the placenta does not attach in a place that provides adequate
support, and it may not develop appropriately or be separated as it grows. Cocaine use during the
third trimester has a 10% chance of causing abruption. Though the exact mechanism is not known,
cocaine and tobacco cause systemic vasoconstriction, which can severely restrict the placental
blood supply (hypoperfusion and ischemia), or otherwise disrupt the vasculature of the placenta,
causing tissue necrosis, bleeding, and therefore abruption.
In most cases, placental disease and abnormalities of the spiral arteries develop throughout the
pregnancy and lead to necrosis, inflammation, vascular problems, and ultimately, abruption.
Because of this, most abruptions are caused by bleeding from the arterial supply, not the venous
supply. Production of thrombin via massive bleeding causes the uterus to contract and leads to DIC.[
The accumulating blood pushes between the layers of the decidua, pushing the uterine wall and
placenta apart. When the placenta is separated, it is unable to exchange waste, nutrients, and
oxygen, a necessary function for the fetus's survival. The fetus dies when it no longer receives
enough oxygen and nutrients to survive.
Management
Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is
less than 36 weeks and neither mother or fetus are in any distress, then they may simply be
monitored in hospital until a change in condition or fetal maturity whichever comes first.

 Intravenous therapy. Once the woman starts to bleed, the physician would order a large
gauge catheter to replace the fluid losses.
 Oxygen inhalation. Delivered via face mask, this would prevent fetal anoxia.
 Fibrinogen determination. This test would be taken several times before birth to detect
DIC.

Nursing Management

 Assess for signs of shock, especially when heavy bleeding occurs.

 Assess if the bleeding is external or internal.
 Monitor contractions if separation occurs during labor.
 Obtain baseline vital signs.
 Assess for the time the bleeding began, the amount and kind of bleeding, and interventions
done when bleeding occurred if it started before admission.
 Assess for the quality of pain.
 Place the woman in a lateral, not supine position to avoid pressure in the vena cava.
 Monitor fetal heart sounds.
 Monitor maternal vital signs to establish baseline data.
 Avoid performing any vaginal or abdominal examinations to prevent further injury to the
placenta.