Abruptio Placentae: When the Placenta Separates Prematurely

Definition

• Abruptio placentae (also known as placental abruption) is the premature separation of the placenta that occurs late in the pregnancy.¹

Pathophysiology

• The placenta has implanted in the correct location.
• For some unknown reasons, it suddenly begins to separate, causing bleeding.
• This separation would occur late in pregnancy, and accounts for 10% of perinatal deaths.

Risk Factors

The following are the risk factors that surround abruption placenta and these should be made known to all pregnant mothers to avoid development of this fatal condition.

• 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.

Types

The types of abruption placenta.  are measured according to the degree of placental separation that has occurred.

• Grade 0. No indication of placental separation and diagnosis of slight separation is made after birth.
• Grade 1. There is minimal separation which causes vaginal bleeding, but no changes in fetal vital signs occur.
• Grade 2. Moderate separation occurs and fetal distress is already evident. The uterus is also hard and painful upon palpation.
• Grade 3. Extreme separation; maternal shock and fetal death is imminent if no interventions are done.

Signs and Symptoms

The signs and symptoms of abruption placenta.  must be monitored and detected early before it progresses to a critical stage.

• Sharp, stabbing pain. A woman may experience the pain on the upper uterine fundus as initial separation occurs.
• Heavy bleeding. This usually happens after the separation of the placenta.  External bleeding will only occur if the placenta. separates first from the edges. Internal bleeding will occur if placenta. separates from the center because blood would pool under it.
• Uterus is tense and rigid. Most often called as Couvelaire uterus, it appears as a board-like, hard uterus without any bleeding.

Diagnostic Tests

These diagnostic procedures would be enforced by the physician to finally diagnose the presence of abruption placenta.

• Hemoglobin level and fibrinogen level. These tests are performed to rule out disseminated intravascular coagulation.

Medical Management

To avoid a worsening condition, these medical procedures are implemented for both the mother and the fetus.

• 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.

Surgical Management

Once the condition has reached a stage that mightily endangers the life of both patients, then surgical management is put into action.

• Cesarean delivery.If birth is imminent, it is safest to deliver the baby via caesarean delivery.
• Hysterectomy. The worst outcome would be for the woman to develop DIC, and to prevent exsanguinations, hysterectomy must be performed.

Nursing Management

A vital role is also upheld by the nurses during this situation. Their accurate assessment would be one of the baseline data for all health care providers to plot the care plan for the patient.

Nursing Assessment

• 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.

Nursing Diagnosis

• Deficient fluid volume related to bleeding during premature placental separation.

Nursing Interventions

• 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

Evaluation

• Maternal vital signs are all within the normal range, especially the blood pressure.
• Urine output should be more than 30mL/hr.
• No bleeding or minimal amount of bleeding observed.
• Uterus is not tense and rigid.
• Fetal heart sounds are within the normal range.