H:\Abruptioplacenta[1]

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H:\Abruptioplacenta[1]

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

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