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DRG Information ⬇

DRG Category: 806

Mean LOS: 2.7 days

Description: Medical: Vaginal Delivery Without Sterilization or Dilation & Curettage With Complication or Comorbidity

Introduction ⬆ ⬇

Abruptio placentae is the premature separation of a normally implanted placenta before the delivery of the baby. It is characterized by a triad of symptoms: vaginal bleeding, uterine hypertonus, and fetal distress. It can occur during the prenatal or intrapartum period. In a marginal abruption, separation begins at the periphery, and bleeding accumulates between the membranes and the uterus and eventually passes through the cervix, becoming an external hemorrhage. In a central abruption, the separation occurs in the middle, and bleeding is trapped between the detached placenta and the uterus, concealing the hemorrhage. Frank vaginal bleeding also does not occur if the fetal head is tightly engaged. Since bleeding can be concealed, note that the apparent bleeding does not always indicate actual blood loss. If the placenta completely detaches, massive vaginal bleeding is seen. Abruptions are graded according to the percentage of the placental surface that detaches (see Table 1). Visual inspection of an abrupted placenta reveals circumscribed depressions on its parental surface, and it is covered by dark, clotted blood. Destruction and loss of function of the placenta result in fetal distress, neurological deficits such as cerebral palsy, or fetal death. Complications for the pregnant person include shock, disseminated intravascular coagulation, and/or renal failure, and for the baby, premature birth or stillbirth.

Table 1 Classification System for Abruptions

Class 0Less than 10% of the total placental surface has detached; the patient has no symptoms; however, a small retroplacental clot is noted at birthClass IApproximately 10%–20% of the total placental surface has detached; no vaginal bleeding to mild vaginal bleeding and slightly tender uterus are noted; however, the pregnant person and fetus are in no distressClass IIApproximately 20%–50% of the total placental surface has detached; the patient has moderate to severe uterine tenderness and tetanic contractions; bleeding can be concealed or is obvious; signs of fetal distress are noted; the patient is not in hypovolemic shock, but orthostatic changes in blood pressure may occurClass IIIMore than 50% of the placental surface has detached; uterine tetany is severe; bleeding can be concealed or is obvious; the patient is in shock and often experiencing coagulopathy; fetal death occurs

Causes ⬆ ⬇

The cause of abruptio placentae is unknown; however, any condition that causes vascular changes at the placental level may contribute to premature separation of the placenta. Hypertension, preterm premature rupture of membranes, smoking, heavy alcohol consumption, pregnant person trauma, trauma related to intimate partner violence, motor vehicle crashes, and crack/cocaine abuse are the most common risk factors. A short umbilical cord, fibroids (especially those located behind the placental implantation site), severe diabetes or renal disease, advanced age of pregnant person, and vena caval compression are other predisposing factors. Chronic upper respiratory infections and chronic bronchitis also increase the incidence of abruptio placentae.

Genetic Considerations ⬆ ⬇

Multiple studies have shown possible genetic loci linked to placental abruption (PA), including ABCC8, KCNJ11, ZNF28, CTNND2, and ADAM12. Several SNPs in these genes have been mapped to trophoblast-like cell chromatin interactions, suggesting a potential role in pregnancy-specific regulatory activity. Additionally, several genes involved in coagulation have been associated with PA, including the factor V Leiden SNP.

Sex and Life Span Considerations ⬆ ⬇

Increased incidence of abruption is noted in those with multiparity, in pregnant people over age 40 years, and for those with a history of past abruptio placentae. Abruptions occur in 1 of 200 deliveries and are responsible for 10% of third-trimester stillbirths. Severe abruptions are associated with a 25% to 35% perinatal mortality rate.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

While abruptio placentae is more common in Black pregnant people than in White or Latina pregnant people, experts are unsure of the cause of these differences. However, lower gestational age at delivery is the most important risk factor for poor neonatal outcomes in Black pregnant people with abruptio placentae. A nationwide population-based study showed that nurses had a higher risk for abruptio placentae than nonmedical working pregnant people (Huang et al., 2016). White-collar workers had a significantly higher risk of placental abruption than physicians. Sexual and gender minority status has no known effect on the risk for abruptio placentae.

Global Health Considerations ⬆ ⬇

Experts estimate that abruptio placentae occurs in 1% of all pregnancies regardless of country or origin.

Assessment ⬆ ⬇

ASSESSMENT

History

Obtain an obstetric history. Determine the date of the last menstrual period to calculate the estimated day of delivery and gestational age of the infant. Inquire about alcohol, tobacco, and drug usage and any trauma or abuse situations during pregnancy. Ask the patient to describe the onset of bleeding (the circumstances, amount, and presence of pain). When obtaining a history from a patient with an abruption, recognize that it is possible for the patient to be disoriented from blood loss and/or cocaine or other drug usage. Generally, patients have one of the risk factors, but sometimes no clear precursor is identifiable.

Physical Examination

The most common symptoms include vaginal bleeding, abdominal or back pain and tenderness, fetal distress, and abnormal uterine contractions. Assess the amount and character of vaginal bleeding; blood is often dark red in color, and the amount may vary depending on the location of abruption. Palpate the uterus; patients complain of uterine tenderness and abdominal and back pain. The fundal height may be increased due to an expanding uterine hematoma. The fundus is extremely firm, with a poor resting tone between contractions. With a mild placental separation, contractions are usually of normal frequency, intensity, and duration. If the abruption is more severe, strong and erratic contractions occur. Assess for signs of concealed hemorrhage: slight or absent vaginal bleeding; an increase in fundal height; a rigid, board-like abdomen; poor resting tone; constant abdominal pain; and late decelerations or decreased variability of the fetal heart rate. A vaginal examination should not be done until an ultrasound is performed to rule out placenta previa.

Using electronic fetal monitoring, determine the baseline fetal heart rate and presence or absence of accelerations, decelerations, and variability. At times, persistent uterine hypertonus is noted with an elevated baseline resting tone of 20 to 25 mm Hg. Ask the patient if they feel the fetal movement. Fetal position and presentation can be assessed by Leopold maneuvers. Assess the contraction status, and view the fetal monitor strip to note the frequency and duration of contractions. Throughout labor, monitor the patient's bleeding, vital signs, color, urine output, level of consciousness, uterine resting tone and contractions, and cervical dilation. If placenta previa has been ruled out, perform sterile vaginal examinations to determine the progress of labor. Assess the patient's abdominal girth hourly by placing a tape measure at the level of the umbilicus. Maintain continuous fetal monitoring.

Psychosocial

Assess the patient's understanding of the situation and the significant other's degree of anxiety, coping ability, and willingness to support the patient. Assess the patient for intimate partner violence or other violence in the home.

Diagnostic Highlights

General Comments: Abruptio placentae is diagnosed based on the clinical symptoms, and the diagnosis is confirmed after delivery by examining the placenta.

TestNormal ResultAbnormality With ConditionExplanation
Pelvic ultrasoundPlacenta is visualized in the fundus of the uterusNone; ultrasound is used to rule out a previaIf the placenta is in the lower uterine segment, a previa (not an abruption) exists; while ultrasonography helps to determine the location of the placenta, it is not always useful in diagnosing abruptio placentae. A normal sonogram does not exclude the condition.

Other Tests: Complete blood count; coagulation studies including fibrinogen, prothrombin time, and activated partial thromboplastin time; type and crossmatch; magnetic resonance imaging; a nonstress test and biophysical profile are done to assess fetal well-being.

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisRisk for bleeding as evidenced by pregnancy complications and/or vaginal bloody discharge

Outcomes

OutcomesBlood loss severity; Fluid balance; Hydration; Fetal status: Antepartum; Fetal status: Intrapartum; Circulation status; Shock severity: Hypovolemic

Interventions

InterventionsBleeding reduction: Antepartum uterus; Labor suppression; IV insertion; Blood products administration; IV therapy; Shock management: Volume

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

If the fetus is immature (< 37 weeks) and the abruption is mild, conservative treatment may be indicated. However, conservative treatment is rare because the benefits of aggressive treatment far outweigh the risk of the rapid deterioration that can result from an abruption. Conservative treatment includes bedrest, tocolytic (inhibition of uterine contractions) therapy, oxygen, and constant patient and fetal surveillance. Generally, an IV line should be started, and a type and crossmatch completed in case of the need for administration of IV fluids and/or blood. Rho(D) immune globulin (RhoGAM) is given if the patient is Rh-negative due to the increased chance of fetal cells entering the patient's circulation.

If the patient's condition is more severe, aggressive, expedient, and frequent assessments of blood loss, vital signs, and fetal heart rate pattern and variability are performed. Give a lactated Ringer solution IV via a large-gauge peripheral catheter. At times, two IV catheters are needed, especially if a blood transfusion is anticipated and the fluid loss has been great. If there has been excessive blood loss, blood transfusions and central venous pressure (CVP) monitoring may be ordered.

If the pregnant person or fetus is in distress, an emergency cesarean section is indicated. If any signs of fetal distress are noted (flat variability, late decelerations, bradycardia, tachycardia), turn the patient to their left side, increase the rate of their IV infusion, administer oxygen via face mask, and notify the physician. If a cesarean section is planned, see that informed consent is obtained in accordance with unit policy, prepare the patient's abdomen for surgery, insert a Foley catheter, administer preoperative medications as ordered, and notify the necessary personnel to attend the operation.

After delivery, monitor the degree of bleeding and perform fundal checks frequently. The fundus should be firm, midline, and at or below the level of the umbilicus. Determine the Rh status of the patient; if the patient is Rh-negative and the fetus is Rh-positive with a negative Coombs test, administer RhoGAM.

Pharmacologic Highlights

Medication or Drug ClassDosageDescriptionRationale
Magnesium sulfate4–5 g IV loading dose, 1–2 g/hr IV maintenanceAnticonvulsantEffective tocolytic; relaxes the uterus, slowing the abruption
Oxytocin (Pitocin)10–40 U in 500–1,000 mL of IV fluidOxytocicAssists the uterus to contract after delivery to prevent hemorrhage

Independent

During prenatal visits, explain the risk factors and the relationship of alcohol and substance abuse to the condition. Teach the patient to report any signs of abruption, such as cramping and bleeding. If the patient develops abruptio placentae and a vaginal delivery is chosen as the treatment option, the patient should not receive analgesics because of the fetus's prematurity; regional anesthesia may be considered. The labor, therefore, may be more painful than most patients experience; provide support during labor. Keep the patient and the significant others informed of the progress of labor as well as the condition of the patient and fetus. Monitor the fetal heart rate for repetitive late decelerations, decreased variability, and bradycardia. If noted, turn the patient on their left side, apply oxygen, increase the rate of the IV, and notify the physician immediately.

Offer as many choices as possible to increase the patient's sense of control. Reassure the significant others that both the fetus and the patient are being monitored for complications and that surgical intervention may be indicated. Provide the patient and family with an honest commentary about the risks. Discuss the possibility of an emergency cesarean section or the delivery of a premature infant. Answer the patient's questions honestly about the risk of a neonatal death. If the fetus does not survive, support the patient and listen to the family's feelings about the loss.

Evidence-Based Practice and Health Policy

Odendaal, H., Wright, C., Schubert, P., Boyd, T., Roberts, D., Brink, L., Nel, D., & Groenewald, C. (2020). Associations of maternal smoking and drinking with fetal growth and placental abruption. European Journal of Obstetrics & Gynecology and Reproductive Biology, 253, 95–102.

  • The authors aimed to determine if the individual and combined effects of smoking and drinking alcohol during pregnancy increased the risk of placental abruption. They analyzed data from 7,000 maternal-neonatal dyads in the United States and South Africa (Safe Passage Study). High smoking constituted 10 or more cigarettes per day, and high drinking was considered four or more binge drinking episodes or 32 or more standard drinks during pregnancy.
  • When compared to the no drinking and no smoking participants, the high drinking and high smoking participants were older, had a higher gravidity, had lower household income, and fewer were employed. The low drinking and low smoking participants had a higher prevalence rate of placental abruption than the no smoking and no drinking group. In addition, the study did not demonstrate an association with increased risk of placental abruption with smoking alone but did determine a significant risk of placenta abruption related to the combined effect of smoking and alcohol consumption.

Documentation Guidelines ⬆ ⬇

Discharge and Home Healthcare Guidelines ⬆

Discharge before delivery (if the fetus is very immature and the patient and infant are stable).

Medications.

Instruct the patient not to miss a dose of the tocolytic medication; usually the medication is prescribed for every 4 hours and is to be taken throughout the day and night. Tell the patient to expect side effects of palpitations, fast heart rate, and restlessness. Teach the patient to notify the doctor and come to the hospital immediately if they experience any bleeding or contractions. Note that being on tocolytic therapy may mask contractions. Therefore, if the patient feels any uterine contractions, they may be developing abruptio placentae.

Postpartum

Give the usual postpartum instructions for avoiding complications. Inform the patient that they are at much higher risk of developing abruptio placentae in subsequent pregnancies. Instruct the patient on how to provide safe care of the infant. If the fetus has not survived, provide a list of referrals to the patient and significant others to help them manage their loss.