abruptio placentae

abruptio /ab·rup·tio/ (ab-rup´she-o) [L.] separation.

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abruptio placen´tae  premature detachment of the placenta.

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ab·rup·ti·o pla·cen·tae (-brpsh- pl-snt)

n.

The premature detachment of a normally situated placenta.

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abruptio placentae

Etymology: L, ab, away from, rumpere, to rupture

premature separation of the placenta implanted in normal position in a pregnancy of 20 weeks or more or during labor before delivery of the fetus. It occurs in approximately 1 in 200 deliveries, and, because it often results in severe hemorrhage, it is a significant cause of maternal and fetal mortality. Hypertension and preeclampsia are associated with increased rates of occurrence; in many cases, however, there is no explanation. Complete separation (1 in 500 to 700 deliveries) causes immediate death of the fetus. Bleeding from the site of separation causes abdominal pain, uterine tenderness, and tetanic uterine contraction. Bleeding may be concealed within the uterus or may be evident externally, sometimes as sudden massive hemorrhage. In severe cases, shock and death can result in minutes. Cesarean section must be performed immediately and rapidly. Extensive extravasation of blood within the uterine wall may deplete fibrinogen, prolong clotting time, cause intractable bleeding, lead to disseminated intravascular coagulation, and by damaging the uterine musculature, prevent the uterus from contracting well after delivery. Hysterectomy may be necessary to prevent exsanguination. Partial separation may cause little bleeding and may not interfere with fetal oxygenation. If the pregnancy is near term, labor may be permitted or induced by amniotomy. A premature pregnancy may be allowed to continue under close observation of the mother on bed rest. The nurse must be alert to the possibility that bleeding is present but concealed internally and that if all the blood can escape, there may be little pain. Also called ablatio placentae, accidental hemorrhage, placenta abruptio, placental abruption. See also Couvelaire uterus. Compare placenta previa.

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abruptio [ab-rup´she-o] (L.)

separation.

abruptio placen´tae premature separation of a normally situated but improperly implanted placenta; it usually occurs late in pregnancy, but may take place during labor. Separation of the placenta before the 24th week of pregnancy is considered a spontaneous abortion if the abruption is so severe that the pregnancy is lost.

Contributing factors include multiple pregnancies (grand multiparity), chronic hypertensive disease, direct trauma to the uterus, or sudden release of amniotic fluid.

Premature separation of the placenta is classified from Grade 0 to Grade 3 according to the degree of separation. In Grade 0 mother and fetus are asymptomatic. Diagnosis is made after delivery when the placenta is examined and a clot is found adhering to the maternal surface. Grade 1 is minimal separation that causes some vaginal bleeding and changes in maternal vital signs. Fetal distress and hemorrhagic shock are absent. Grade 2 is moderate separation in which there is evidence of fetal distress and maternal symptoms of a tense uterus and pain on palpation. Grade 3 is the most serious. There is extreme separation which, without prompt intervention, can lead to maternal shock and fetal death.

 Abruptio placentae. A, Mild abruption with concealed hemorrhage. B, Severe abruption with external hemorrhage. C, Complete separation with concealed hemorrhage.

Patient Care. Treatment and patient care are based on the grade of separation and maternal and fetal status. Maternal vital signs are monitored and blood loss is assessed. The uterus is assessed for any tenderness, tension, or rigidity. The location and nature of pain reported by the mother are noted; for example, a sharp stabbing pain high in the fundus can occur when separation begins. Pain that is in addition to the pain of contractions is also significant.

Oxygen may be administered to the mother to limit fetal anoxia. Fetal heart sounds are monitored for signs of fetal distress. The patient is kept in a lateral rather than supine position during labor to prevent pressure on the vena cava and further inhibition of fetal blood supply. Vaginal or pelvic examinations and an enema are restricted lest the placenta be disturbed further.

Grade 2 and Grade 3 separations require delivery as soon as possible, either vaginally or by cesarean section. Without prompt and effective intervention, abruptio placentae can lead to maternal death from hemorrhage, shock, and circulatory collapse. Fetal prognosis depends on the extent of hypoxia suffered by the fetus during labor and delivery.

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abruptio placentae

Ablatio placentae, abruptio, premature separation of placenta Obstetrics The premature separation of the placenta from its site of implantation in the endometrial before the delivery of the fetus; some degree of AP occurs in 1:85 deliveries; severe AP with total separation of the placenta is an obstetric emergency which occurs about 1 in 500-750 deliveries, and is accompanied by fetal death Clinical Constant abdominal and/or back pain, irritable, tender or hypertonic uterus, vaginal bleeding—seen in most; 30% are asymptomatic Predisposing factors Preeclampsia-eclampsia, chronic HTN, DM, chronic renal disease; mechanical causes are rare–1-5% and include transabdominal trauma, sudden decompression, as occurs in the delivery of a 1^st twin or rupture of membranes in hydramnios, or traction of a short placenta Management Expectant therapy if fetus is immature and bleeding limited, treat shock if present, vaginal delivery if possible, C-section Complications DIC, acute cor pulmonale, renal cortical and tubular necrosis, uterine apoplexy, transfusion hepatitis