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H:\Abruptioplacenta[1]
 

H:\Abruptioplacenta[1]

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placental problems 2

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    H:\Abruptioplacenta[1] H:\Abruptioplacenta[1] Presentation Transcript

    • Placenta Abruption Donna Adelsperger RN, M. Ed.
    • Abruptio Placenta: Predisposing Factors
      • Medical
        • chronic hypertension
        • congenital hypofibrinogenemia
        • low levels of Vitamins A, E, & B-carotene
        • diabetes
      • Life style
        • unmarried
        • sex in past 24 hours
        • trauma
        • cigarette smoker or cocaine use
        • snake bite
    • Abruptio Placenta: Predisposing Factors
      • Pregnancy
        • preeclampsia/eclampsia
        • preterm premature ROM
        • twin gestation
        • chronic ureaplasma urealyticum infectionsupine hypotension syndrome
        • short umbilical cord
        • lack of prenatal care
        • increased parity
        • maternal age <20 years
        • previous abruptio placenta
    • Abruptio Placenta: Predisposing Factors
      • Fetal factors
      • male gender
      • small for gestational age
      • congenital anomalies
    • Abruptio Placenta: Diagnosis
      • Diagnosis is based on clinical findings
        • vaginal bleeding present @ 80% of time
        • uterine tenderness or back pain frequently present
        • classic, rigid , board-like abdomen occurs @ 15% of time
        • if patient is preterm diagnosis is usually idiopathic PTL
    • Abruptio Placenta: Diagnosis
      • The typical case of abruptio placenta occurs @ 15% of time
      • Symptoms
        • vag bleeding
        • tightly contracted uterus (board-like)
        • uterine tenderness
        • no FHR
        • Shock
    • Abruptio Placenta: Classification
      • Grade 0 = retrospective diagnosis
      • Grade 1 = only vag bleeding
      • Grade 2 = vag bleeding concealed hemorrhage, uterine tenderness, fetal distress
      • Grade 3 = vag bleeding,
      • concealed hem, uterine tenderness, fetal death and sometimes DIC
    • Abruptio Placenta: US for Diagnosis
      • US may show detachment with retroplacental collection of blood in a few cases
      • normal findings on US can exclude abruption
      • US is useful in excluding previa
    • Abruptio Placenta: Maternal Complications
      • Hemorrhagic shock
      • DIC
      • ischemic necrosis of other organs e.g.
        • kidneys or bilateral cortical necrosis characterized by oliguria or anuria
    • Abruptio Placenta: Fetal Complications
      • hypoxia
      • anemia
      • growth retardation
      • increased incidence of anomalies
      • death
    • Abruptio Placenta: Management
      • IV fluids
      • supplement O2
      • type and crossmatch (usually 4 units packed red cells )
      • Foley catheter for close monitoring of I & O
      • EFM for continuous assessment of fetal wellbeing
    • AbruptioPlacenta Interventions Hem Shock
      • Vigorous blood & volume replacement with packed RBC & crystalloids to maintain Hct at or above 30% & urinary output >30ml/hr
      • Platelet count
    • AbruptioPlacenta Interventions Hem Shock
      • Fibrinogen level & serum Potassium level after each 4-6 units of packed RBCs
      • Sometimes invasive monitoring (CVP or pulmonary artery wedge pressure)
    • Abruptio Placenta: Interventions Hem Shock
      • Test for DIC q 4 hrs
      • Quantification of fibrin split products (FSPs )
        • FSPs are most sensitive lab test helpful but do not help guide therapy
      • fibrinogen levels and platelet counts
      • delivery which helps resolve DIC
    • Abruptio Placenta: Hypertension as Etiology
      • Hypertension is most common associated condition
      • frequency of abruptio with AP eclampsia, HELLP,or hypertension with superimposed PIH = @ 15%
      • frequency with severe preeclampsia = 10% and hypertension alone = 4%
      • approx half of abruptions severe enough to kill the fetus are associated with hypertensive disorders of pregnancy
    • Abruptio Placenta: Preterm Delivery
      • Risk of abruption is increased almost 22 times in preg of LBW fetus (<2500gm )
      • Factors include:
        • no prenatal care
        • smoking
        • abdominal trauma
        • IV drug use
        • hypertensive disorders of preg
    • Abruptio Placenta: Preterm Premature ROM
      • PPROM complicates 1% of all pregnancies
      • associated risk for abruption = @ 5.5%
      • if abruption occurs with PPROM bleeding occurs before and after ROM
    • Abruptio Placenta: Smoking
      • Incidence of abruption increased to 32 per 1000 if more than 10 cigarettes/day for > 6 years
      • necrosis of the decidua at placental margin of placenta developed in smokers
      • decidual necrosis could develop from ischemia due to decreased uterine perfusion of placenta for 15 min after each cigarette
    • Abruptio Placenta: Maternal Age
      • Occurs more in older women and also increased parity
    • Abruptio Placenta: Clinical Presentation
      • Classic symptoms
        • vag bleeding
          • abdominal pain
          • uterine contractions
          • uterine tenderness
      • may be evidence of maternal hypovolemia or fetal distress
    • Abruptio Placenta: Origin of Bleeding
      • Most blood lost is from mother
      • potentially bleeding could be maternal or fetal
      • Actual blood lost is commonly under estimated
    • Abruptio Placenta: Interventions Hem Shock
      • If CS necessary and platelet count < 50,000 or fibrinogen is < 100mg / 100ml replacement of platelets & fibrinogen should be replaced
      • Fibrinogen replaced with FFP or cryoprecipitate
    • Abruptio Placenta: Risk of Recurrence
      • Estimated that 5.5%-16.6% of subsequent preg will be complicated with abruption
      • Risk increases to 25% during a 3rd preg if there have been 2 consecutive abruptions
      • Can’t predict which pregnancies will be affected & at what gest age abruption will occur
    • Abruptio Placenta: Trauma
      • Only @ 1% of abruptions caused from trauma
      • Trauma = leading cause of death in women from 15 - 33 yrs of age
      • @ 1/2 of deaths from trauma due to auto accidents
      • Most common cause of fetal death in an auto accident = death of mother
      • IF Mother survives the most common cause of fetal death = abruptio placenta