Abruptio Placentae

When the Placenta Separates Prematurely

Only a few weeks to go and the family would have a new member that would light up everyone’s faces with a smile. As the big day is approaching, the family must also be aware of the dangers that might still claw away their little one from having her first glimpse of the world.

Definition

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

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.

Artboard 1Abruptio Placentae

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.

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

Nursing Care Plans

  • Check out our Nursing Care Plans page.

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.

Practice Quiz for Abruptio Placentae


Just how much you’ve learned from our study guide about abruptio placentae? Take our 5-item quiz below and find out!

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Questions

1. A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client’s complaint of vaginal bleeding?

A. Placenta previa
B. Abruptio placentae
C. Ectopic pregnancy
D. Spontaneous abortion

2. A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks’ gestation. She’s at risk for which of the following blood dyscrasias?

A. Thrombocytopenia.
B. Idiopathic thrombocytopenic purpura (ITP).
C. Disseminated intravascular coagulation (DIC).
D. Heparin-associated thrombosis and thrombocytopenia (HATT).

3. A maternity nurse is caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation?

A. Swelling of the calf in one leg
B. Prolonged clotting times
C. Decreased platelet count
D. Petechiae, oozing from injection sites, and hematuria

4. A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?

A. Absence of abdominal pain
B. A soft abdomen
C. Uterine tenderness/pain
D. Painless, bright red vaginal bleeding

5. An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placentae is present. Based on these findings, the nurse would prepare the client for:

A. Complete bed rest for the remainder of the pregnancy
B. Delivery of the fetus
C. Strict monitoring of intake and output
D. The need for weekly monitoring of coagulation studies until the time of delivery

Rationale

1. Answer: B. Abruptio placentae

The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruptio placentae.

2. Answer: C. Disseminated intravascular coagulation (DIC).

Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage.

Option A: Thrombocytopenia results from decreased production of platelets.
Option B: ITP doesn’t have a definitive cause.
Option D: A patient with abruptio placentae wouldn’t get heparin and, as a result, wouldn’t be at risk for HATT.

3. Answer: A. Swelling of the calf in one leg.

DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.

4. Answer: C. Uterine tenderness/pain.

In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by the failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding.

5. Answer: B. Delivery of the fetus.

The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.

The team of health care providers could very well be the key towards the survival and safety of both the mother and the fetus. The role of the support system is also essential for this situation. Finally, the willpower of the mother to survive with both of their lives intact could be the turning point for those who care deeply for the patient and the child.