Placenta Abruptio

• Understand the different types of placenta abruptio and how they’re classified.
• Educate patients on predisposing factors that increase the risk for placenta abruptio.
• Treatment plans for patient’s experiencing placenta abruptio.

Placenta abruptio is the separation of the normally implanted placenta from the inner wall of the womb before the baby is born.  The condition can deprive the baby of oxygen and nutrients and is considered a serious pregnancy complication.

A medical diagnosis is required and some of the symptoms include vaginal bleeding, pain in the belly, contractions, and back pain that typically occurs in the last 12 weeks of pregnancy.  Supportive care is the most common treatment and includes bed rest or a cesarean section based on the degree of placental separation and how close the baby is to being full-term.

Types of Placenta Abruptio

Placenta abruptio is classified by clinical manifestations and symptoms.  The following are the different types:

Classification by the presence or absence of vaginal bleeding:

Revealed abruption

• active vaginal bleeding
• blood passes through cervix and vagina
• accounts for 65%-80% of cases

Concealed abruption

• no vaginal bleeding
• blood accumulates behind placenta with no external bleeding
• accounts for 20%-35% of cases

Classification by the degree of separation:

Total abruption

• detachment of entire placenta
• about 7% of cases

Partial abruption

• detachment of only part of placenta
• about 93% of cases

Classification by severity of abruption:

Grade 0 abruption

• asymptomatic
• small retro placental clot detected

Grade 1 abruption

• about 40% of cases
• vaginal bleeding
• uterine tenderness
• no signs of fetal or maternal distress

Grade 2 abruption

• about 45% of cases
• uterine contractions
• vaginal bleeding
• no signs of maternal shock but signs of fetal distress are present

Grade 3 abruption

• about 15% of cases
• hypertonic uterus and/or “wooden hard” uterus
• persistent abdominal pain
• severe bleeding (revealed or concealed)
• signs of maternal shock and fetal distress or death

Risk Factors and Predisposing Factors

The exact cause of placenta abruptio is unknown; however, its risk factors are:

• Hypertension
• Preterm premature rupture of membranes
• Smoking
• Maternal trauma
• Trauma related to intimate partner violence
• Cocaine abuse

The predisposing factors for placenta abruptio are:

• A short umbilical cord
• Thrombophilia
• Fibroids- especially those located behind the placental implantation site
• Severe diabetes
• Renal disease
• Advanced maternal age
• Vena cava compression
• Chronic bronchitis and upper respiratory tract infections

Treatment

The following should be considered and completed if placenta abruptio is suspected: 

If the fetus is immature, less than 37 weeks, and the abruption is mild, conservative treatment is given that includes bedrest, tocolytic agents (drugs that inhibit uterine contractions) oxygen, and constant maternal and fetal surveillance.  It is important to keep in mind that conservative treatment is rare because aggressive treatment is beneficial compared to the risk of placenta abruptio.

Maintain an intravenous (IV) line for the administration of IV fluids and have the cross match of the patient completed for a needed blood transfusion.  Give Rho(D) immune globulin (RhoGAM) if the patient is Rh-negative due to the increased chance of fetal cells entering the maternal circulation.

If a vaginal delivery is indicated and no regular contractions are occurring, infuse oxytocin cautiously to induce the labor.

If the patient’s condition is severe, monitor the vitals and fetal heart rate closely.  Give Lactated Ringer’s solution IV via a large-gauge peripheral catheter.  At times, the nurse may need to maintain two IV catheters, especially if a blood transfusion is anticipated and the fluid loss is severe.

In cases where fluid and blood loss is severe, monitor the central venous pressure.  A normal CVP of 10cm H2O is the goal.

If the mother or the fetus is in distress, plan an emergency cesarean section.  In the presence of fetal distress symptoms such as flat variability, late decelerations, bradycardia, and tachycardia, turn the patient to her left side, increase the rate of IV infusions, administer oxygen via face mask, and notify the physician soon.

During antenatal visits, inform the patient about the risk factors and relationship between alcohol and substance abuse with placenta abruptio.  Inform the patient to visit the emergency soon if they experience vaginal bleeding or cramps.

After delivery, check the patient for the degree of bleeding and perform fundal checks frequently.  The fundus should be firm, midline, and at or below the level of the umbilicus.  Check the mother’s Rh status.  If the patient is Rh-negative and the fetus is Rh-positive with a negative Coombs test, administer RhoGAM.

Pharmacological Treatment

Drugs commonly used in placenta abruptio are:

Magnesium sulfate

• Dose: 4–6 g IV loading dose, 1–4 g/hr IV maintenance
• Generally, it is an anticonvulsant; however, with placenta abruptio, it is used as a tocolytic agent. It relaxes the uterus muscle and slows the abruption.

Oxytocin

• Dose: 10–20 U in 500–1,000 mL of IV fluid

It is an oxytocin hormone that helps the uterus contract post-delivery to prevent

The Bottom Line

Placenta abruptio needs to be treated promptly.  Inform the patient during antenatal visits to report if they experience vaginal bleeding, muscle cramps, backache, or abdominal pain as all of these could be a potential sign of placenta abruptio.  It is important to seek treatment early in order to have more positive outcomes for both the patient and baby. 

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