11/2/2020

Placental Abruption

Not all are emergent

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Definition •Premature separation of a normally implanted placenta before birth

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1 11/2/2020

Incidence • Overall incidence • 1 in 100 births • Range is • 1 in 80 to 1 in 250 deliveries • Accounts for approximately 1/3 of all antepartum bleeding • 40 to 60% of abruptions occur prior to 37 weeks gestation

Francois and Foley, 2017, p. 397

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Risk Factors • Increasing parity and/or maternal age • Maternal substance abuse • Cigarette smoking • Dose-response relationship • Compared with nonsmokers, smokers have a 40% increased risk of fetal death from placental abruption with each pack of cigarettes smoked • Smoking and hypertensive disease appear to have an additive effect on likelihood of abrupton • Cocaine abuse • Trauma • Francois and Foley, 2017, p. 397

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2 11/2/2020

Risk Factors

• Maternal diseases • Hypertension • 5x increased risk for abruption • Hyperthyroidism • Asthma • Francois and Foley, 2017, p. 397

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Risk Factors • Preterm premature rupture of membranes • Rapid uterine decompression associated with • Multiple gestation • Polyhydramnios • Uterine and placental factors • Anomalies • Fibroids • Cesarean scar • Abnormal placental formation • Chronic ischemia • Francois and Foley, 2017, p. 397

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3 11/2/2020

Risk Factors

• Prior abruption • After one abruption • Recurrence risk is 5 to 15% • Risk increases to 20 to 25% after two abruptions • Risk of recurrence greater after a severe abruption • Francois and Foley, 2017, p. 398

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Risk Factors

• Thrombophilia • Inconsistent data regarding association • Hyperhomocysteinemia • (a fasting homocysteine level greater than 15 µmol/L) • May be associated with recurrent abruption • Francois and Foley, 2017, p. 398

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4 11/2/2020

Possible Signs & Symptoms • Pain • Lower back pain • Uterine pain or tenderness • FHR • Late decelerations, loss of variability, sinusoidal pattern, tachycardia or bradycardia • Uterine hypertonus • Low amplitude, high frequency contractions • Restlessness • Occasionally; Nausea and vomiting • Bleeding…...(not always) • The amount of bleeding may not be proportionate to the amount of placental separation

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Some bleed

• Less pain • Blood usually dark (venous)

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5 11/2/2020

Some don’t

• The margins aren’t abrupted, or… • The presenting part holds back the escape • Pressure will build • Pain • Rising fundal height • Uterine couvelaire • uterine irritability OR board-like uterus

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On The Fetal Monitor Strip

• Watch for: • uterine tachysystole • minimal or absent variability • recurrent late decelerations • bradycardia or tachycardia • sinusoidal pattern

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6 11/2/2020

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Maternal Complications

• Shock • Disseminated intravascular coagulation • Infection • Postpartum hemorrhage • Renal failure • Pituitary necrosis (Sheehan syndrome) • Death

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7 11/2/2020

Fetal and Neonatal Complications

• Perinatal morbidity and mortality • Fetal hypoxia and acidosis • Neonatal prematurity • Small for gestational age • Neurologic defects (cerebral palsy) • Fetal-to-maternal hemorrhage

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Nursing Assessments/Interventions

• Monitor blood flow • Be specific about amount of loss • Assess pain • Monitor fetus closely • Observe for S/S of shock • Vital signs are a late sign…. • Narrowing of pulse pressure • Assess mental status • Assess color and skin temperature

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8 11/2/2020

Nursing Assessments/Interventions

• Observe for • rising fundal height • rigid or firm uterus • increasing discomfort • worsening fetal status • uterine irritability • I&O • Be prepared for operative delivery • Be prepared for neonatal resuscitation

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Clinical Interventions

• IV fluid/blood therapy and replacement • Ultrasound • may not help • If stabilizes • watch and wait depending on fetal status • If emergent • C/S • Be prepared to deal with hemorrhage/DIC

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9 11/2/2020

Placenta Previa

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Defined

• Placenta implants in lower uterine segment • As cervix dilates, placenta separates • Typically presents with painless vaginal bleeding • Initial episode often stops with clot formation

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10 11/2/2020

Risk Factors • Intrinsic Maternal Factors • External Maternal Factors • Increasing parity • Cigarette smoking • Advanced maternal age • Associated with as high as a 3x • Older than 35 years of age increased risk • More than 4x increased • Cocaine use risk • 4x increased risk • Older than 40 years of age • Residence at a higher elevation • 9x increased risk • ?due to need for increased • Maternal race placental surface area • Asian women appear to have • Infertility treatments the highest rates

Francois and Foley, 2017, p. 401

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Risk Factors • Fetal factors • Multiple gestations • controversial • Male fetus • ?due to larger placental sizes • ?due to delayed implantation of the male blastocyst in the lower uterine segment • Prior placenta previa • Prior uterine surgery and cesarean delivery • Thought to occur due to endometrial scarring

Francois and Foley, 2017, p. 401-402

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11 11/2/2020

Prior Cesarean Delivery

• In the pregnancy following a cesarean delivery • Risk of previa ranges from 1% to 4% • Risk increases in a linear fashion with the number of prior cesarean deliveries

Francois and Foley, 2017, p. 401-402

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Prior Cesarean Delivery

• Placenta previa occurs in • 0.9% of women with one prior cesarean • 1.7% of women with two prior cesareans • 3% of women with 3 or more cesareans • In women who have had 4 or more cesareans • Risk is reported to be as high as 10% • Francois and Foley, 2017, p. 402

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12 11/2/2020

Marginal

• May not start separation until cervix is >4cm • May have one bleed and stop • If presenting part tamponades, may deliver vaginally

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Partial

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13 11/2/2020

Total

• Most dangerous

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Implications

• Lower segment less contractile • Results in more postpartum hemorrhage -May result in hysterectomy

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14 11/2/2020

Nursing Assessments/Interventions • Never check if bleeding • Keep track of bleeding • Assess FHR • Assess vital signs • Bedrest w/ bathroom privileges (if NOT bleeding) • Be prepared to respond to hemorrhage • Fluid/blood replacement • Emergency cesarean • Cesarean birth indicated • Be prepared for postpartum hemorrhage

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Placenta Accreta (Placenta Accreta Spectrum)

• Be prepared for an accreta • In patients with placenta previa risks increase with increasing number of cesareans • For 1st CS risk is 3% • For 2nd CS risk is 11% • For 3rd CS risk is 40% • For 4th CS risk is 61% • For 5th or more CS risk is 67% • ACOG & SMFM (2018). Obstetric Care Consensus Placenta Accreta Spectrum. Obstetrics & Gynecology, 132 (6), e 259-e275.

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15 11/2/2020

References • ACOG & SMFM (2018). Obstetric Care Consensus Placenta Accreta Spectrum. Obstetrics & Gynecology, 132 (6), e 259-e275. • Cunningham, F. G., et al. (2018). Obstetrical hemorrhage. Chapter 41 in Cunningham et al. William’s Obstetrics, 25th ed. New York: McGraw-Hill. • Francois, K. E., & Foley, M. R. (2017). Antepartum and postpartum hemorrhage. Chapter 18 in Gabbe, S.G., Niebyl, J.R., Simpson, J.L., Landon, M. B., Galan, H.L., Jauniaux, E.R. M. & Driscoll, D. A., et al. Obstetrics Normal and Problem Pregnancies (7th ed). Philadelphia, PA: Elsevier/Saunders.

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• Hull, A. D., Resnik, R., & Silver, R. M. (2019). Placenta previa and accreta, vasa previa, subchorionic hemorrhage, and abruptio placentae Chapter 46 in Robert Resnik et al. (eds). Creasy and Resnik’s Maternal- Fetal Medicine Principles and Practice, 8th ed. Philadelphia: Elsevier. • Salera-Vieira, J. (2021). Bleeding in pregnancy. Chapter 6 in Simpson, K. R., & Creehan, P. A. (eds) AWHONN Perinatal Nursing, 5th ed. Philadelphia: Wolters Kluwer.

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