abruptio placenta.pptx
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ABRUPTIO PLACENTAE
INTRODUCTION
Placenta Abruption
- is defined as the separation of the placenta from its site of
implantation before delivery.
Complicates 1 out of 20 deliveries .
Placental abruption must be considered whenever bleeding
is encountered in the second half of pregnancy.
Bleeding can be external or concealed. It may be total or
partial.
EPIDEMIOLOGYOccurs in 1% of the of all pregnancies throughout
the world.
More common in African American women.
Resulting factors remains unclear (socio-economic,
genetic)
Higher risk on patients younger than 20 y/o and
those older than 35 y/o
EtiologyThe primary cause of placental abruption is usually
unknown
Risk Factors: Maternal hypertension (approx. 44% of all
cases)
Maternal trauma (falls, MVA)
Smoking
Alcohol consumption
Cocaine use
Short umbilical cord
Sudden depression of the uterus (PROM)
Retroplacental fibromyoma
Retroplacental bleeding from needle puncture
( postamniocentesis)
Previous placental abruption
Chorioamnionitis
Prolonged rupture of membranes (24 h or
longer)
Maternal age 35 years or older and 20 years
below
Low socioeconomic status
Asymptomatic in the
early stages
sudden-onset abdominal
pain
contractions that don't
stop
pain in the uterus
tenderness in the
abdomen
vaginal bleeding
uterus may be
disproportionately
enlarged
pallor
nonreassuring fetal
status, i.e. decreased fetal
movement, worrisome
fetal heart rate
signs and symptoms can
vary
Signs and Symptoms:
Classification of placental
abruption:Classification of placental abruption is based on
extent of separation (partial vs complete) and
location of separation (marginal vs central).
Clinical classification is as follows:
Class 0 – Asymptomatic
Class 1 - Mild (represents approx. 48% of all
cases)
Class 2 - Moderate (represents approx.27% of all
cases)
Class 3 - Severe (represents approx. 24% of all
cases)
Class 0: asymptomatic. Diagnosis is made
retrospectively by finding an organized blood clot or
a depressed area on a delivered placenta.
Class 1 characteristics include the following:o No vaginal bleeding to mild vaginal bleedingo Slightly tender uteruso Normal maternal BP and heart rateo No coagulopathyo No fetal distress
Class 2 characteristics include the following:o No vaginal bleeding to moderate vaginal bleedingo Moderate to severe uterine tenderness with possible
tetanic contractionso Maternal tachycardia with orthostatic changes in BP
and heart rateo Fetal distresso Hypofibrinogenemia (ie, 50-250 mg/dL)
Class 3 characteristics include the following:o No vaginal bleeding to heavy vaginal bleedingo Very painful tetanic uteruso Maternal shocko Hypofibrinogenemia (ie, < 150 mg/dL)o Coagulopathyo Fetal death
ANATOMY AND PHYSIOLOGY
The anatomy of the uterus consists of the following 3
tissue layers
The inner layer, called the endometrium, is the
most active layer and responds to cyclic ovarian
hormone changes; the endometrium is highly
specialized and is essential to menstrual and
reproductive function
The middle layer, or myometrium, makes up most
of the uterine volume and is the muscular layer,
composed primarily of smooth muscle cells
The outer layer of the uterus, the serosa or
perimetrium, is a thin layer of tissue made of
epithelial cells that envelop the uterus
The uterus is a dynamic female reproductive organ
that is responsible for several reproductive
functions, including menses, implantation, gestation,
labor, and delivery. It is responsive to the hormonal
milieu within the body, which allows adaptation to
the different stages of a woman’s reproductive life.
The uterus adjusts to reflect changes in ovarian
steroid production during the menstrual cycle and
displays rapid growth and specialized contractile
activity during pregnancy and childbirth. It can also
remain in a relatively quiescent state during the
prepubertal and postmenopausal years
The uterus is a pear-shaped organ located in the
female pelvis between the urinary bladder anteriorly
and the rectum posteriorly. The average dimensions
are approximately 8 cm long, 5 cm across, and 4 cm
thick, with an average volume between 80 and 200
mL. The uterus is divided into 3 main parts: the
fundus, body, and cervix.
PATHOPHYSIOLOGY
Placental abruption is initiated by hemorrhage into
the decidua basalis. The decidua then splits, leaving
a thin layer adherent to the myometrium.
Consequently, the process in its earliest stages
consists of the development of a decidual hematoma
that leads to separation, compression, and the
ultimate destruction of the placenta adjacent to it.
In its early stage, there may be no clinical
symptoms. The condition is discovered only on
examination of the freshly delivered organ, which
has a circumscribed depression measuring a few
centimeters in diameter on its maternal surface, and
is covered by dark, clotted blood. Undoubtedly, it
takes at least several minutes for these anatomical
changes to materialize
Thus, a very recently separated placenta may
appear no different from a normal placenta at
delivery. According to Benirschke and Kaufmann
(2000), and in our experiences, the "age" of the
retroplacental clot cannot be determined exactly.
In some instances, a decidual spiral artery
ruptures to cause a retroplacental hematoma, which
as it expands disrupts more vessels to separate more
placenta. The area of separation rapidly becomes
more extensive and reaches the margin of the
placenta. Because the uterus is still distended by the
products of conception, it is unable to contract
sufficiently to compress the torn vessels that supply
the placental site. The escaping blood may dissect
the membranes from the uterine wall and eventually
appear externally or may be completely retained
within the uterus.
CONCEALED HEMORRHAGE.
Retained or concealed hemorrhage is likely when:o There is an effusion of blood behind the placenta but
its margins still remain adherent.o The placenta is completely separated yet the
membranes retain their attachment to the uterine wall.
o Blood gains access to the amnionic cavity after breaking through the membranes.
o The fetal head is so closely applied to the lower uterine segment that the blood cannot make its way past it.
Most often, however, the membranes are gradually
dissected off the uterine wall, and blood sooner or
later escapes.
PATIENT’S PROFILE
Patient’s Identity
Name :
Mrs.AP
Age : 24 years old
Occupation : Housewife
Education : Elementary
Race : Filipino
Religion : R Catholic
Address :Quezon City
Patient’s Husband’s
Identity
Name : Mr. AP
Age : 27 years old
Occupation : self-employed
Education : High School
Race : Filipino
Religion : R Catholic
Address : Quezon City
History Taking:
Chief Complaint: Vaginal bleeding
Present Illness:
The patient came to the maternity ER with
active vaginal bleeding since 12 p.m. The blood
discharged was bright red. She mentioned that she
had not felt the fetal movement since 7.00 a.m. She
also was having uterine contractions, blurred vision,
nausea and vomit. Her first day of the final
menstruation was on 10th July 2014.
Past Medical History:
•Hypertension (-)
•Diabetes mellitus (-)
•Heart Disease (-)
•Asthma (-)
•Seizures (-)
•Irregular menstrual cycle
(-)
Menstruation:
•Menarche : 14 years
old
•Menstrual cycle :
± 28 days
•Duration : 7 days
• Diaper/day : 2-3
x/days
•Menstrual pain :
(-)
•Contraception : none
•Operation : none
•Antenatal Care :
regular, monthly with
midwife
•Supplement : fe & folic
acid (+)
Physical Examination
•On February 9th 2015, 12.58 pm
•Overall condition : moderately in pain
•Awareness : full consciousness
•Vital Sign: - Blood pressure : 110/80 mmHg
- Pulse: 120/min
- Respiratory rate: 25/min
- Temperature: 36.7oc
Obstetric Abdominal Examination
•Inspection : striae gravidarum(+), scar (-), fetal
movement (-)
•Palpation: Fetal parts were not palpable due to the
presence of the severe abdominal pain
•Auscultation: FHR: absent
External genitalia
•-Inspection: condition of vulva / vagina normal
Bleeding (+)
•- In-speculo: Not done
Working Diagnosis : G1P0A0, GA 31 weeks + placental
abruption
LAB ORATORY AND EXAMINATIONS
No laboratory studies have been shown to
definitively help with the differential diagnosis of
Placental abruption however, multiple laboratory
studies may be helpful in the management of this
problem.
CBC Count
A complete blood cell (CBC) count can help
to determine the patient's current hemodynamic
status, but findings are not reliable for estimating
acute blood loss.
In an acute hemorrhage, the fall in
hematocrit value lags several hours behind the
bleeding and may be falsely decreased by the
administration of crystalloid fluids during
resuscitation.
Fibrinogen examination
Pregnancy is associated with
hyperfibrinogenemia; therefore, modestly depressed
fibrinogen levels may represent significant
coagulopathy. A fibrinogen level of less than 200
mg/dL suggests that the patient has a severe
abruption.
The goal should be to keep the fibrinogen
level above 100 mg/dL, which can be accomplished
via transfusion of fresh frozen plasma or
cryoprecipitate, as necessary.
Prothrombin Time/Activated Partial
Thromboplastin Time
Some form of DIC (Disseminated
intravascular coagulation) is present in up to 20%
of patients with severe abruptions. Because many of
these patients require cesarean delivery, knowing a
patient's coagulation status is imperative.
Blood Urea Nitrogen/Creatinine
The hypovolemic condition brought on by a
significant abruption also affects renal function. The
condition usually self-corrects without significant
residual dysfunction, if fluid resuscitation is timely
and adequate.
Ultrasonography
Ultrasonography is a readily available and
important imaging modality for assessing bleeding in
pregnancy.
Ultrasonography can help to exclude other
causes of third-trimester bleeding. Possible findings
consistent with an abruption include (1)
retroplacental clot, (2) concealed hemorrhage, or (3)
expanding hemorrhage.
Nonstress Test
External fetal monitors often reveal fetal
distress, as evidenced by late decelerations, fetal
bradycardia, or decreased beat-to-beat variability.
An increase in the uterine resting tone may
also be noticed, along with frequent contractions
that may progress to uterine hyperstimulation, as
seen in the fetal tracing below.
DRUG STUDY
Drug name Indication Contraindication
Side effects Nursing responsibilities
Generic name:Tranexamic acid
Brand name:Hemostan, Fibrinon, Cyklokapron, Lysteda, Transamin
Classification: Anti-fibrinolytic, antihemorrhagic
• Treating heavy menstrual bleeding
• Obstetrical and gynecological: abortion, post-partum hemorrhage and menometrorrahgia
• drug hyper- sensitivity
• Presence of blood clots (eg, in the leg, lung, eye, brain), have a history of blood clots, or are at risk for blood clots
• dizziness or lightheadedness
• Headache
• Abdominal or stomach pain, discomfort, or tenderness
• Unusual change in bleeding pattern should be immediately reported to the physician.
• Swallow Tranexamic Acid whole with plenty of liquids. Do not break, crush, or chew before swallowing.
Drug name Indication Contraindication
Side effects Nursing responsibilities
Gelofusine
Classification:gelatin agents
Colloidal plasma volume substitute for prophylaxis and treatment of relative or absolute hypovolaemia
• hypersensitivity towards gelatine,
• hypervolaemia,
• hyperhydration,
• Fever• Urticaria• Sudden
flushing of the face and neck
• solution should be warmed to body temperature.
• Unused contents of an opened container must be discarded.
• Store below 25°C.
• stop the infusion immediately, as soon as there are any indications of adverse reactions.
Drug name Indication Contraindication
Side effects Nursing responsibilities
Generic Name: Ceftriaxone
Brand Name: Rocephin
Classification:Anti-infectives
Gynecologic infection
• Drug hyper sensitivity
• Headache• Diarrhea• N/V• mild pain,
swelling, or redness at the injection site
• WOF s/s of anaphylaxis
Drug name Indication Contraindication
Side effects Nursing responsibilities
Generic name:Oxytocin
Brand name:Pitocin, Syntocinon
Classification:OxytocicsUterine-active agents
• control of postpartum bleeding or hemorrhage
• induction of labor in patients with a medical indication for the initiation of labor, when in the best interest of mother and fetus or when membranes are prematurely ruptured and delivery is indicated
Drug hypersensitivity
• Hypotension
• Decrease uterine bld. Flow
• Assess character, freq., duration of uterine contractions.
• Monitor maternal BP and pulse frequently and fetal heart rate continously.
Drug name Indication Contraindication
Side effects Nursing responsibilities
Generic name:Misopostrol
Brand name:Cytotec
Classification:Anti-ulcer, Cytoprotective agents
For termination of pregnancy
Pregnancylactation
• Diarrhea• Stomach
pain• Miscarriag
e
Asses for epigastric pain or abdominal pain and for frank or occult blood in the stool, emesis, or gastric aspirate.
Drug name Indication Contraindication
Side effects Nursing responsibilities
Generic name:Ketoprofen
Brand name:Actron, Orudis
Classification:Antipyretics,Nonopioid analgesics, nonsteroidal anti- inflammatory agents
• Mild to moderate pain
• fever
• Drug hypersensitivity
• Active GI bleeding
• pregnancy
• Headache• Dizziness• Blurred
vision• Tinnitus• Edema• Constipati
on• Diarrhea• N/V• Discomfort• rashes
• Asses pain• Monitor
temperature
Drug name Indication Contraindication
Side effects Nursing responsibilities
Generic name:Cefadroxil
Brand name:Duricef
Classification:Anti-infectives1st gen cephalosporins
Septicemia Drug hypersensitivity
• Diarrhea• N/V• Cramps• Rashes• Pruritus• Urticaria
• Assess for infection
• Observe pt’s S/S of anaphylaxis
NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective: “Bigla na lang sumakit ng matindi ang tiyan ko , ayaw tumigil sa paghilab”As verbalized by the patient Objectives: (+)Vaginal
bleeding abdominal
pain with pain scale 8/10
Pallor Facial
grimace (-) facial
grimace Pallor BP 110/80 PR 120 RR 25 Temp
36.7c
Ineffective Tissue Perfusion related to excessive blood loss secondary to premature separation of the placenta
Short Term: After 30-60 minutes of administering oxygen supplement and performing blood transfusion, the patient’s blood components that were lost will be replaced and the patient’s circulation of blood and oxygen delivery/transport to the tissues will be stabilized .Long term: After a week of continuing oxygen supplementation ,administering blood transfusion, and providing a calm and stimulant free environment such as limiting the visitation hours, the patient will be able show improvements such as moist skin pinkish skin, and maintain normal blood pressure within the range of 110/80mmHG-130/90mmHg.
>Monitor amount of bleeding by weighing all pads >Monitor accurately I & O >Monitor FHT continuously >Assess Uterine Irritability, abdominal pain and rigidity >Elevate extremity above the level of the heart >Assess level of consciousness of the mother >Evaluate pulse oxymetry to determine oxygenation.
>Administer IV fluids. Administer blood transfusion as indicated
>Prepare for caesarean section
>To measure amount of blood loss
>To provide information regarding fetal distress and/or worsening of condition
>To determine the severity of the placental abruption and bleeding
>To promote circulation >To assess respiratory efficiency >To replace the fluid lost in the body >The method of choice for the birth
Short Term: After 30-60 minutes of administering oxygen supplement and performing blood transfusion, the patient’s blood components that were lost was replaced and the patient’s circulation of blood and oxygen delivery/transport to the tissues will be stabilized . Long term: After 1-2 hrs of continuing oxygen supplementation ,administering blood transfusion, the patient was able to show improvements such as moist skin pinkish skin, and normal blood pressure of 110/80
DISCHARGE PLANNING
Medicine:• Taught proper reference on how to take medication
and supplements.
Exercise:• Avoid strenuous activities.• Range of motion exercises as tolerated.
Health Teaching:• Instructed to have adequate rest periods.• Instructed Deep Breathing exercises.• Maintain proper hydration.• Maintain proper hygiene.• Taught proper breastfeeding.• Taught to use betadine feminine wash and water
when washing perineal area.• Clean the umbilicus of the baby three times a day
using 70% alcohol.
Out Patient Follow up:• Instructed patient to have a follow up appointment
with OPD after one week.
Diet:• Instructed patient to eat foods low in salt and low in
fat.
Spiritual and Sexual:• Encouraged patient to continue to follow her
spiritual beliefs.• Instructed patient to refrain from sexual intercourse
until instructed by physician.
VCEH-DR
BSN 4Y1-2A