NCM 109: CARE OF MOTHER & CHILD AT RISK / WITH PROBLEMS

CHAPTER 7: ABRUPTIO PLACENTAE

SOURCE: PPT/Summary
TRANSCRIBERS: Mark Anthony Papasin
BSN 2203 SECOND YEAR
SECOND SEM
TOPIC OUTLINE
1 Introduction
2 Epidemiology
3 Anatomy of the Placenta
4 Pathophysiology
5 Types of Placental Abruption
6 Causes
7 Signs and Symptoms
8 Nursing Interventions
9 Degrees of Separation
10 Comparison
11 Conclusion

INTRODUCTION
WHAT IS THE FUNCTION OF THE PLACENTA
• The placenta plays a major role in maintaining pregnancy.
• It delivers oxygen and nutrients from the mother to the fetus
via the umbilical cord.
• It removes waste products and carbon dioxide from the
fetus.
• Protects the fetus.
• The fetus is highly reliant on the placenta to survive.
WHAT IS ABRUPTIO PLACENTAE
• Also called premature separation of the placenta. The
placenta has been correctly implanted but separated too
early causing bleeding.
• It is a condition where the mother experiences a
detachment of the placenta BEFORE the birth of the baby.
• It happens when there is a separation of the uterine wall
and the decidua basalis.
• This detachment can be classified as a PARTIAL or
TOTAL detachment.
• It is associated with a condition called DIC (Disseminated
Intravascular Coagulation)
• It is also associated with a condition called
Hemoperitoneum, which is bleeding within the peritoneal
cavity. It is caused by the backflow of blood through a
uterine tube, due to placental abruption.
• It occurs in the THIRD trimester (can occur after the 20th
week of gestation up to the day of delivery)
• It is the most frequent cause of perinatal death.
EPIDEMIOLOGY
• Placenta abruption contributes to about one-third of all
antepartum hemorrhages, occurs in about 0.5–1% of all
pregnancies, causes fetal death in about 1 of every 420–
830 deliveries, and results in 10% of preterm births.
Although some studies show increases others show
decreases or plateau in incidence and/or prevalence of
abruptio placenta. The highest incidence of placenta
abruption occurs at 24–26 weeks gestation.
ANATOMY OF THE PLACENTA
• The placenta has 2 layers, the maternal layer, and the fetal
layer
• The maternal layer, the decidua basalis, is a bag of blood
with uterine arteries delivering blood in, and uterine veins
pulling blood out.
• The fetal layer of the placenta is called the chorion, which
is a tissue composed of chorionic villi, which connects to
the decidua basalis.
• Gases and nutrients move back and forth between the
decidua basalis and the fetal vein through the chorionic villi.

WHAT IS DIC
• Disseminated Intravascular Coagulation
• It is a condition that can occur in placental abruption, where
the blood clotting process in the body becomes overactive
and leads to the formation of small blood clots throughout
the blood vessels.
• The clots that form are small and can block blood vessels,
preventing proper blood flow to organs and tissues. This
can lead to organ damage and other complications.
• It is caused by the clotting factors released after placental
abruption and entering the mother’s circulatory system via
the artery, causing the formation of small clots throughout
her body.

1
 Complete or Total the placenta
Placental completely
Abruption detaches
from the
uterine wall.

PRESENCE OR ABSENCE OF VAGINAL BLEEDING

Revealed Placental vaginal bleeding
Abruption is visible.

Concealed little to no visible

PATHOPHYSIOLOGY Placental vaginal bleeding.
1 Placental abruption is caused by several risk factors such Abruption
as abdominal trauma, lifestyle choices (e.g. drugs and
smoking), chronic hypertension in pregnancy, older
maternal age, short umbilical cord which causes tugging
of the placenta, and more.
2 Those risk factors can cause the rupturing of the maternal
vessels in the decidua basalis that anchor and connect to
the placenta. Remember that the decidua basalis is a bag
of blood that delivers blood to the placenta. SITE OF BLEEDING
3 This rupture can cause bleeding due to placental Subchorionic bleeding between myometrium and
separation. Abruption placental membranes
4 Placental bleeding will stimulate clotting formation by
Retroplacental bleeding between myometrium and
releasing tissue factors (thromboplastins).
Abruption placenta
5 As this process continues, the levels of clotting factors will
start to drop. Preplacental bleeding between placenta and
6 Since the decidua basalis is ruptured, the thromboplastins Abruption amniotic fluid
escape and are carried out by the uterine veins and enter Intraplacental bleeding within or inside the placenta
the mother’s circulatory system. Abruption
7 These thromboplastins enter the arteries and start to form
small clots, which is a condition called DIC (Disseminated
Intravascular Coagulation. CAUSES
8 These small clots obstruct the flow of red blood cells, • Chronic hypertension throughout the pregnancy
cutting off the oxygen supplies to different organs. • Preeclampsia
9 When this happens, the body senses that and tries to • History of previous abruptio placentae
correct it. Then it enters in a process called fibrinolysis • Trauma to the abdomen
where it tries to take the fiber in those clots and tries to • Cocaine or smoking
dissolve and get rid of them. • Premature rupture of the membrane
10 As the DIC process continues, the clotting factor level • Carrying multiple babies (twins)
drops and becomes critically low. • History of multiple pregnancy
11 If the mother’s clotting factor is low, her body will not be • Short umbilical cord
able to stop the bleeding in the placenta, putting her at risk
of hemorrhage and blood loss. This can also put her at
shock and the fetus in distress. SIGNS AND SYMPTOMS
DETACHED
• Dark red bleeding
TYPES OF PLACENTAL ABRUPTION
• Extended fundal height
There are several types of placental abruption based on:
• Tender uterus
• Degree of separation
• Abdominal pain/contractions
• Presence or absence of vaginal bleeding
• Concealed bleeding
• Site of bleeding
• Hard abdomen
• Experience DIC
DEGREE OF SEPARATION • Distressed baby
Partial Placental the placenta
Abruption does not
completely
detach from
the uterine
wall.

NURSING INTERVENTIONS

2
• Monitor their laboratory results. • vaginal bleeding
o Check if there’s a decrease in platelets, fibrinogen, • sudden onset lower abdominal or back pain
and prothrombin levels. • uterus is “woody hard” and tender
• Signs of gum bleeding due to hemoperitoneum
• Oozing of blood around IV sites due to hemoperitoneum COMPARISON (ABRUPTIO PLACENTAE)
• Check for petechiae (broken blood vessels) or ecchymosis Description • Detachment issue
(bruising)
Causes • Chronic hypertension throughout the
• Micro-emboli (get clotting everywhere). Check for:
o Urinary output, chest pain, shortness of breath, pregnancy
changes in mental status • Preeclampsia
• Monitor their bleeding – it can be concealed or visible. • History of previous abruptio placentae
• Monitor vital signs and fundal height. • Trauma to the abdomen
• NO abdominal or vaginal exams until ultrasound (until • Cocaine or smoking
previa is ruled out) • Premature rupture of the membrane
• Left side-lying, NO supine to prevent pressure on the vena • Carrying multiple babies (twins)
cava and additional interference with fetal circulation. • History of multiple pregnancy
• Monitory CBC, clotting levels, RH factors Signs and DETACHED
• External monitoring of the baby (heart rate) Symptoms • Dark red bleeding
• Prep for delivery depending on how far the mother is in • Extended fundal height
pregnancy. • Tender uterus
• Baby can be delivered vaginally but if there are • Abdominal pain/contractions
complications, then the baby is delivered through C- • Concealed bleeding
Section • Hard abdomen
DIAGNOSIS – LAB TESTS • Experience DIC
• CBC – may reveal anemia and thrombocytopenia. • Distressed baby
• Fibrinogen – may reveal hyperfibrinogenemia. COMPARISON (PLACENTA PREVIA)
• Urea and Creatinine – hypovolemia and organ ischemia Description • Attachment issue
may lead to renal dysfunction. Causes • Older than 35
• Keilhauer-Betke (KB) Test – detects fetal red blood cells in • Scarring of the uterus due to surgery
maternal circulation. like removal of fibroids or C-Section
• Blood type – blood transfusion may be required. • Multiple babies
MANAGEMENT – DELIVERY OF THE BABY • Already had a baby in the past.
Vaginal Delivery • Cocaine or smoke
• Preferable for a fetus that has demised secondary Signs and PREVIA
placental abruption. Symptoms • Painless bright red bleeding (vaginal)
• Dependent on the patient’s hemodynamic or • Relaxed soft non-tender uterus.
contraindications to vaginal birth • Episodes of bleeding
o Previous C-Section, major malpresentation, • Visible bleeding
extremely unfavorable cervix, etc. • Intercourse post bleeding
Cesarean Delivery • Abnormal fetal position
• May be required to save both the mother and child.
• Rapid access to the uterus and its vasculature
• May be complicated by underlying coagulopathy.
• Cesarean hysterectomy may be required for uncontrollable
hemorrhage.

DEGREES OF SEPARATION
Grade 0 • asymptomatic
• no signs and symptoms
• the diagnosis is made after birth
• when the placenta is examined and a
segment of the placenta shows a recent
adherent clot on the maternal surface.
Grade 1 • no signs of maternal or fetal distress or
hemorrhagic shock
• minimal separation but enough to cause
vaginal bleeding and changes in the
maternal vital signs
• minimal to no vaginal bleeding
• slight uterine tenderness
Grade 2 • moderate separation
• moderate to no vaginal bleeding.
• there is evidence of fetal distress but no
signs of maternal shock
• the uterus is tense, painful on palpation, and
increased uterine activity
Grade 3 • severe separation
• without immediate interventions, maternal
hypovolemic shock and fetal death will
result

3
 CONCLUSION
• Placental abruption, or abruptio placentae, is a significant
obstetric complication.
• The placenta separates from the uterine wall before the
baby's birth, leading to vaginal bleeding and maternal
hemorrhage.
• DIC (Disseminated Intravascular Coagulation) often
accompanies placental abruption, forming small clots
throughout the mother’s circulatory system, further
complicating the condition.
• Risk factors for placental abruption include abdominal
trauma, lifestyle choices, chronic hypertension, older
maternal age, and certain medical conditions.
• Prompt recognition and appropriate nursing interventions
are essential for managing placental abruption.
• Monitoring maternal vital signs, bleeding, laboratory
results, and fetal well-being is crucial in providing adequate
care.
• The mode of delivery depends on the type and severity of
placental abruption, with vaginal delivery and emergency
cesarean section being possible options.
• Cesarean hysterectomy may be necessary in severe cases
to control uncontrollable hemorrhage.
• Healthcare professionals should be vigilant in identifying
risk factors and providing timely interventions to minimize
maternal and fetal morbidity and mortality.

ADDITIONAL INFORMATION
Drug of choice:
• Betamethasone
• Dexamethasone
o Both are used to treat pain, redness, and inflammation
in the placenta
• Hypovolemic shock – severe blood or other fluid loss that
makes the heart unable to pump enough blood to the body.