ABRUPTIO PLACENTA -premature separation of placenta from the uterine wall

Risk Factors Causing Abrutio placenta

• Maternal age
• Previous history of abruptio placenta
• Multiparity
• Smoking – can cause vasoconstriction
• Maternal hypertension
• Abdominal trauma – example accident
• PIH

Pathophysiology
•Small vessel rapture- due to strong vasocontraction

•Bleeding lifts placenta because uterus is unable to contract and control bleeding.- because there is
leakage, the pulling of blood in endometrium

•Further Hemorrhage dissects off chorio decidual space

•Due to uterine contractions blood flows through membranes and uterine walls separating them.

•Blood escape through vagina - revealed hemorrhage

•Tissue Damage and blood clots thrombo plastin -escape into maternal circulation through open sinuses
-activate coagulation mechanism - fibrinogen converted to fibrin. – formation of clots
Signs and symptoms of abruptio placenta
• Concealed or visible bleeding
• Painful bleeding
• Dark red bleeding – unoxygenated blood
• Board like abdomen – the uterus is contracted
• Fetal distress – more than 160
• Tetanic contraction – no resting phase
HALLMARK SYMPTOMS:
PAINFUL DARK RED VAGINAL BLEEDING

Couvelaire's uterus – may clot sa layers ng uterus

• Also called as Utero-placental apoplexy
• First described by Couvelaire in early 1900
• Extravasation of blood into uterine musculature & beneath uterine serosa
• Demonstrated only at laparotomy
• These myometrial hge interfere with uterine contraction to produce PPH

Placental Grades
A. Grade O - Patient asymptomatic. Small retroperitoneal clot seen after delivery.

B. Grade 1 - Vaginal bleeding, may have abdominal tenderness or slight uterine tetany, mom and baby
not in distress.
C. Grade 2 - Uterine tenderness, tetany with or without evidence of bleeding, baby shows signs of
distress.

D. Grade 3 - Uterine tetany, severe bleeding may not be visible. Baby is dead. Mom often has
coagulopathy.

Complications of abruption placenta

• Hypovolemic shock =more than 3000
• Intrauterine growth restriction
• Placenta accrete: attachment of placenta beyond uterine walls up to the urinary bladder
• Maternal mortality
• Fetal mortality
• Congenital anomalies

Diagnostic test
• CBC
• Blood typing
• APTT/PT
• Bleeding time
• Clotting time
• Serum electrolyte
• Serum creatine
• UA
• USD
• NST

Placental Abruption: complications

• Shock
• Acute renal failure

Cause: ? seriously impaired renal perfusion 2° to decrease CO and intrarenal vasospasm as in

preeclampsia

• DIC
Consumptive coagulopathy 2° to hypofibrinogenemia along with elevated levels of fibrinogen-
Fibrin degradation products

Thromboplastin is the precursor of fibrin then conveted to fibrinogen to form clots

Management of abruptio placenta

• Bed rest
• Tocolytic : duvadilan
• Steroids: dexamethasone
 • Immediate delivery
• Fluid and blood replacement
• Always CS no NSVD

NURSING CARE:
• Assess and Monitor:

Amount of Vaginal

Bleeding Vital Signs

• I and O
• Measure abdominal girth
• Uterine characteristics and activity EFM-Continuously
• For development of coagulation problems
• Review lab values: CBC, Coagulation studies, PT,PTT

Nursing Diagnosis
• Altered tissue perfusion
• Fluid volume deficit
• Risk for infection
• Anxiety
• Acute pain

Characteristic Placenta previa Abruptio placenta

Onset Third trimester commonly @
32-26 weeks
Bleeding Mostly external, small to
profuse in amount, bright re
Pain and uterine tenderness Usually absent; uterus soft
Fetal heart tone Usually normal
Presenting part Usually not engaged
Shock Usually not present unless
bleeding is excessive
Delivery Delivery may be delayed
depending on size of fetus and
amount of bleeding
Third trimester
May be concede, external dark
hemorrhage or bloody
ammonitic fluid
Usually present; irritable uterus,
progresses to board like
consistency
Maybe irregular or absent
May be engaged
Moderate to severe depending
on extent of concealed and
external hemorrhage
Immediate delivery, usually by
CS section
 ABORTION

Abortion - termination of pregnancy before the age of viability

• Spontaneous abortion
- threatened abortion
- imminent abortion
- complete abortion
- incomplete abortion
- missed abortion
- recurrent/ habitual abortion
- septic abortion

Pathophysiology/Etiology
1. Cause frequently unknown, but 50% are due to chromosomal anomalies – sa DNA
and RNA structure
2. Exposure or contact with teratogenic agents – example medication
3. Poor maternal nutritional status-
4. Maternal illness with or specific bacterial microorganisms – example UTI
5. History of diabetes, thyroid disease,
6. Smoking or drug abuse or both
7. Immunologic factor
8. Luteal phase defect – in menstruation
9. Postmature sperm or ova
10. Structural defect in the maternal reproductive system (including an incompetent
cervix)

Causes of recurrent miscarriage/ spontaneous abortion

RIB CAGE
Radiation

Immune reaction

Bugs ( infection)

Cervical incompetence

Anatomical anomaly (uterine septum etc.)

Genetic (aneuploidy , balanced translocation etc)

Endocrine
Chemiotactic activity – inflammatory response

If the WBC especially the neutrophils is attracted to the site of

infection

Cytokines is responsible for inflammatory response and foe defense

mechanism.
Types of sponatneous abortions
1. Thretened abortion – vaginal bleeding occure, no rupture
2. Inevitable abortion- membranes rupture and cervix dialtes
3. Incomplete abortions- some products of conception have been expelled, but some remain

Induced abortion
1. Therapeutic abortion
2. Eugenic abortion

Secondary abortion – napatay si baby sa tyann pero hindi na labas

Types of miscarriage
1. Missed
- no vaginal bleeding
-close cervical os
- no fetal cardiac activity or empty sac

2. Threatened
- vaginal bleeding
- closed cervical os
- fetal cardiac activity
3. Inevitable
- vaginal bleeding
- dilated cervical os
- products of conception may be seen or felt at or above cervical os

4. Incomplete
- vaginal bleeding
- dilated cervical os
- some products of conception expelled and some remain

5. Complete
- vaginal bleeding
- closed cervical os
- products of conception completely expelled
Inevitable Abortion
- Immediate evacuation of pregnancy.

(If duration of pregnancy less than 12 weeks suction evacuation and greater than 12 weeks oxytocin
infusion.)

- Shock-resuscitation with i/v fluids and blood transfusion.

- Prophylactic antibodies and anti-D.

Management of threated abortion

• Bed rest
• Tocolytic medications (Isoxuprine HCL: Duvadilan)
• Treat underlying factors
• No sexual activity
• Fetal monitoring by ultrasound
• Avoid stress

Threatened Abortion
- Conservative with bed rest and reassurance till bleeding stops .

- Sexual intercourse best avoided.

- Follow up with UL TRASOUND-f2rresence of fetal cardiac activity predicts good outcome in 95%of
cases.

- Hormone therapy -400mg natural progesterone in divided doses orally or vaginally on empirical basis.

- Anti D if mother is Rh negative and pregnancy is beyond 12 weeks