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Abruptio Placentae By: Alison VanderPol, Sara Tabler, Sarah Temple, Michael Swartwood and Meghan Wagner = = flat



= Pathophysiology  =

Abruptio placentae or placental abruption "is deﬁned as the complete or partial premature separation of the placenta before delivery with hemorrhage into the decidua basalis" (Tikkanen, 2010, p. 732).

__Immunological rejection:__
leukocyte antigens (HLA)" (Tikkanen, 2010, p. 733)
 * The immune response is not suppressed which can lead to an exaggerated response of the mother's immune system and rejection of the fetus.
 * -"Trophoblastic cells interact in the decidua with natural killer cells which express receptors that recognize combinations of human
 * The level of HLA is key in preventing placental abruption
 * With placental abruption the HLA levels are extremely low

__Inflammation:__

 * An increase in neutrophils and macrophages in the placenta.
 * "Abruption is associated with a thrombin-enchanced expression of interleukin (IL)-8, a potent neutrophil chemoattractant which leads to a marked inﬁltration of decidual neutrophils" (Tikkanen, 2010, p. 733).
 * The increase in interleukin (IL)-8 causes a significant increase in the neutrophils
 * The response created by the IL-8 and neutrophils is a mechanism by which placental abruption can occur

__Vascular disease:__
=**Risk factors**=
 * Impaired trophoblastic invasion and defective development of the placental blood vessels
 * The uterine artery blood flow faces high resistance which can lead to vascular rupture within the placenta, specifically rupture of a spiral artery.
 * The placenta is then peeled off of the decidua by a growing hematoma causing a "classic abruption".
 * Venous bleeding
 * Can cause placental abruption
 * Comes from "marginal lakes around the edge of the placenta" (Tikkanen, 2010, p. 734).
 * Smoking
 * 90% increase in risk for Abruptio Placentae
 * Increased capillary fragility and vasoconstriction or arteral walls which leads to vasospasms and arterial rupture
 * 15-25% of Abruptio Placentae attributable to smoking
 * Uterine Abnormalities
 * 0.1-2% of female population
 * poor decidualization and placentation in area of implantation
 * Past Cesarean Sections
 * 40% increase in risk for abruptio placentae
 * Uterine low segment scar may impair placental attachment
 * Past Abruptio Placentae
 * Perminant damage to endometrium caused by earlier abruption
 * Alcohol Use
 * Easily crosses the placenta and disturbs the maternal and fetal hormonal balance
 * Vaginal Bleeding after 28 weeks
 * Preeclampsia is associated with a 2.7 fold increase in abruptio placentae
 * Illicit Drug Use, Especially Cocaine
 * Multiparity

= Medical management =

If the abruption of the placenta is severe enough, the goal is to deliver the baby.
 * Administer prescribed Rh o (D) immune globulin if mother is Rh-negative
 * To induce labor infuse oxytocin (Pitocin)
 * Administer tocolytics (magnesium sulfate) in preterm labor
 * Administer corticosteriods (betamethasone) for fetal maturity

__Pharmacology:__ Rh o (D) immune globulin
 * Suppress Rh isoimmunization during pregnancy
 * Within 72 hours of delivery, give 120 mcg of I.M. or I.V.
 * contraindications
 * Rh o (D) positive or D u positive patients and those previously immunized
 * patients with anaphylaxis or severe systemic reaction to human globulin.
 * Use caution when giving drug to patients with immunoglobulin A deficiency.

oxytocin (Pitocin)
 * To induce or stimulate labor
 * Initially, 10 units in 1,000 ml of D 5 W injection, lactated Ringer's, or normal saline solution I.V. infused at 0.5 to 2 milliunits/minute. Increase rate by 1-2 milliunits/minute at 30-to 60-minute intervals until normal concentration pattern is established. Decrease rate when labor is firmly established. Rates exceeding 9-10 milliunits/minute are rarely required.
 * To reduce postpartum bleeding after expulsion of placenta
 * 10-40 units in 1,000 ml of D 5 W injection, lactated Ringer's, or normal saline solution I.V. infused at rate needed to control bleeding, which is usually 20-40 milliunits/minute. Also, 10 units may be given I.M. after delivery of placenta.
 * Administration considerations
 * Never give drug simultaneously by more than one route.
 * To induce or stimulate labor, dilute drug by adding 10 units to 1 L of normal saline, lactated Ringer's, or D 5 W solution.
 * To reduce postpartum bleeding dilute by adding 10 units to 500 ml of normal saline, lactated Ringer's, or D 5 W solution.
 * Do not give bolus injection; use an infusion pump. Give drug only by piggyback so that it may be stopped.
 * Contraindications
 * patients hypersensitive to drug
 * vaginal delivery isn't advised
 * fetal distress when delivery isn't imminent, in prematurity, in other obstetric emergencies, and in patients with severe toxemia or hypertonic uterine patterns
 * Use cautiously during first and second stages of labor because cervical laceraiton, uterine rupture, and maternal and fetal death have been reported.
 * Use cautiously in patients with invasive cervical cancer and in those with previous cervical or uterine surgery.
 * S/Sx of overdose
 * uterine hypersensitivity, tumultuous labor, uterine rupture, cervical and vaginal lacerations, postpartum hemorrhage, uteroplacental hypoperfusion, variable deceleration of FHR, fetal hypoxia, hypercapnia, perinatal hepatic necrosis, water intoxication, seizures, death.

magnesium sulfate
 * To inhibit contractions in preterm labor
 * 4-6 g I.V. over 20 minutes, followed by 2-4 g/hour I.V. infusion for 12-24 hours, as tolerated, after contractions have stopped.
 * Administration considerations
 * infuse no faster than 150 mg/minute
 * monitor vital signs every 15 minutes when giving I.V.
 * Contraindications
 * patients with heart block or myocardial damage
 * patients with toxemia of pregnancy during 2 hours preceding delivery
 * Use cautiously in patients with renal impairment.
 * Use cautiously in pregnant women during labor.
 * S/Sx of overdose
 * disappearance of the patellar reflex, sharp drop in blood pressure, respiratory paralysis.
 * KEEP CALCIUM GLUCONATE AVAILABLE TO REVERSE TOXICITY.

betamethasone (Celestone) = Nursing care  =
 * enhance fetal lung maturity and surfactant production
 * Administered IM and requires a 24-hour period to be effective
 * Administration considerations
 * administer deep into the client's gluteal muscle 24-48 hour prior to birth of a preterm neonate
 * Monitor the mother and neonate for pulmonary edema by assessing lung sounds.
 * Monitor for maternal and neonate hyperglycemia
 * Monitor FHR (ATI)

= = =** Family and Patient Education **= Questions that the nurse may be asked along with appropriate responses that facilitate patient/family learning:
 * Obtain a obstetric/gynecologic history, especially:
 * Estimated age of fetus
 * How many children the mother is expecting
 * Occurrence/incidence of trauma
 * Maternal use of drugs
 * Onset of bleeding
 * Continuous maternal and fetal monitoring
 * Fetal and maternal heart rate and vital signs
 * Assess for bleeding, hemorrhage, shock
 * Monitor contractions
 * Insertion of large bore IV(s) for fluid replacement and/or blood transfusion
 * Administration of oxygen
 * Assess the mother's need for an immediate delivery
 * An emergency cesarean section may be needed if the mother is hemorrhaging (Perry et al., 2010)
 * Instruct the mother to maintain bed rest and assist the mother to a side lying position to relieve pressure on the vena cava and increase blood supply to the fetus (London et al., 2007)
 * Provide education to the mother and family
 * Assess the mother and family's psychosocial needs and provide information and support as needed

What is abruptio placentae?

It is also called placental abruption or premature separation of the placenta and it occurs when the placenta detaches partially or completely from the wall of the uterus.

Why is it a problem?

Abruptio placentae is a common cause of death for the fetus and/or the mother. It can cause significant bleeding, shock, clotting problems, and damage to the uterus. It poses problems for the fetus because it cannot get the proper amount of oxygen. Preterm birth and neurological deficiencies are possible for babies who have been a part of placental abruption (Perry, Hockenberry, Lowdermilk, & Wilson, 2010).

What causes it?

The most common causes include the mother having high blood pressure and the mother using cocaine. Cocaine use causes a spasm in blood vessels to occur, decreases oxygen in the placenta and cause the placenta to separate from the uterus because of the disrupted vessels (Perry et al, 2010). “Placental abruption accounts for 2% to 15% of adverse effects of cocaine use during pregnancy” so it is essential to not use cocaine since there are many other negative effects from it during pregnancy (Keegan, Parava, Finnegan, Gerson, & Belden, 2010). Smoking and blunt trauma (from vehicle accidents or abuse) are other possible causes of placental abruption. Also, women who have had abruptio placentae in previous a pregnancy have a 5-17% chance of having it again (Perry et al, 2010). This number goes up if there has been abruptio placentae with two or more pregnancies.

How do you know you have it?

The most common signs and symptoms are “vaginal bleeding, abdominal pain, ‘port wine’ stained amniotic fluid, uterine contractions. . . uterine tenderness, and abnormal [fetal heart rate] patterns” (Perry et al, 2010). The vaginal bleeding and abdominal pain may or may not be present, however, depending on how badly the placenta is separated.

What is done to treat it?

The condition of the mother and fetus are closely monitored. There is often need for blood and fluid replacement. If the condition declines enough, labor is induced so that the mother gives birth before the condition worsens any more. Medications may be given in advance to promote the development of fetal lungs if this outcome is anticipated. Placental abruption should never be managed at home because the placenta can separate at any time, which is cause for immediate medical attention (Perry et al, 2010).

The nurse should also be sure to provide constant emotional support for the mother and the family and answer any subsequent questions. This diagnosis is serious and can be traumatic as mothers are often worried about what will happen to their baby and themselves. It is important to make the mother feel like she is being listened to and cared //about//, rather than just cared for. It is essential to explain all procedures before they occur to decrease stress on the mother and family. Another element to consider is not using a lot of medical jargon, as demonstrated in the above responses to the questions, because the patient and/or family may be apprehensive about asking for clarification, which will only increase their anxiety.

= Nursing Diagnoses =

= =
 * Risk for impaired fetal gas exchange r/t altered blood flow and decreased area of gas exchange at site of detached placenta
 * Risk for deficient fluid volume r/t abruptio placentae
 * Acute pain r/t placental abruption and possible hemorrhage

= References  =

(2010). RN maternal newborn nursing review module (8th ed.). Assessment Technologies Institute, LLC.

Buckley, L., & Schub, T. (2010). Placental Abruption. Retrieved from //EBSCOhost//.

Carpenito-Moyet, L.J. (2010). Handbook of nursing diagnosis. Philadelphia, PA: Lippincott Williams & Wilkins.

Faiz, A. S., Demissie, K., Ananth, C. V., & Rhoads, G. G. (2001). Risk of abruptio placentae by region of birth and residence among African- American women in the USA. //Ethnicity & Health,// //6//(3), 247-253. doi:10.1080/13557850120078152

Keegan, J., Parva, M., Finnegan, M., Gerson, A., Belden, M. (2010). Addiction in pregnancy. //Journal of Addictive Diseases, 29//(2), 175-191. doi: 10.1080/10550881003684723

Lippincott's nursing 2010 drug handbook (30th ed.). (2010). Philadelphia: Lippincott, Williams & Wilkins.

London, M., Ladewig, P., Ball, J., & Bindler, R. (2007). //Maternal & Child Nursing Care// (2nd Edition). Upper Saddle River, NJ: Pearson Education, Inc..

Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). //Maternal & Child Nursing Care// (4th Edition). Philadelphia, PA: Elsevier.

Tikkanen, M., Nuutila, M., Hiilesmaa, V., Paavonen, J., & Ylikorkala, O. (2006). Clinical presentation and risk factors of placental abruption. //Acta Obstetricia Et Gynecologica Scandinavica,// //85//(6), 700-705. doi:10.1080/00016340500449915

Tikkanen, M., Nuutila, M., Hiilesmaa, V., Paavonen, J., & Ylikorkala, O. (2006). Prepregnancy risk factors for placental abruption. //Acta Obstetricia Et Gynecologica Scandinavica,// //85//(1), 40-44. doi:10.1080/00016340500324241 Tikkanen, M. (2010). Etiology, clinical manifestations, and prediction of placental abruption. //Acta Obstetricia et Gynecologica// //Scandinavica, 89// (6), 732-40.