Having a Baby After a Severe Placental Apruption

Continuing Education Activity

Placental abruption is the early separation of the placenta from the lining of the uterus earlier the completion of the second stage of labor. It is i of the causes of bleeding during the second half of pregnancy and is a relatively rare but serious complication of pregnancy that places the well-beingness of both mother and fetus at risk. This activity describes the pathophysiology of placental abruption and highlights the part of the interprofessional squad in managing affected patients.

Objectives:

Summarize the etiology of placental abruption.
Draw the pathophysiology of placental abruption.
Review the presentation of a patient with placental abruption.
Outline strategies for the interprofessional care team to employ for optimal management for patients with placental abruption.

Admission free multiple pick questions on this topic.

Introduction

Placental abruption is the early separation of a placenta from the lining of the uterus before completion of the second stage of labor. It is i of the causes of bleeding during the second half of pregnancy. Placental abruption is a relatively rare just serious complication of pregnancy and placed the well-being of both female parent and fetus at risk. Placental abruption is likewise chosen abruptio placentae.[1][two]

Etiology

The exact etiology of placental abruption is unknown. Nevertheless, a number of factors are associated with its occurrence. Risk factors can exist thought of in iii groups: wellness history, including behaviors, and by obstetrical events, current pregnancy, and unexpected trauma. Factors that tin be identified during the health history that increment the take chances of placental abruption include smoking, cocaine use during pregnancy, maternal age over 35 years, hypertension, and placental abruption in a prior pregnancy. Conditions specific to the electric current pregnancy which may precipitate placental abruption are multiple gestation pregnancies, polyhydramnios, preeclampsia, sudden uterine decompression, and short umbilical cord. Finally, trauma to the abdomen such as a motor vehicle accident, fall, or violence resulting in a blow to the abdomen may lead to placental abruption.

Placental abruption occurs when there is a compromise of the vascular structures supporting the placenta. In other words, the vascular networks connecting the uterine lining and the maternal side of the placenta are torn away. These vascular structures deliver oxygen and nutrients to the fetus. Disruption of the vascular network may occur when the vascular structures are compromised considering of hypertension or substance employ or by conditions that cause stretching of the uterus. The uterus is a musculus and is elastic whereas the placenta is less elastic than the uterus. Therefore, when the uterine tissue stretches suddenly, the placenta remains stable and the vascular structure connecting the uterine wall to the placenta tear away.[3][iv]

Epidemiology

Placental abruption is a relatively rare condition but requires emergent management. The bulk of placental abruptions occur before 37-weeks gestation. Placental abruption is a leading crusade of maternal morbidity and perinatal mortality. With placental abruption, the woman is at risk for hemorrhage and the need for claret transfusions, hysterectomy, bleeding disorders specifically disseminated intravascular coagulopathy, renal failure, and Sheehan syndrome or postpartum pituitary gland necrosis.

With the availability of blood replacement, maternal expiry is rare but continues to be higher than the overall maternal mortality rate. Neonatal consequences include preterm nascency and low birth weight, perinatal asphyxia, stillbirth, and neonatal death. In many countries, the rate of placental abruption has been increasing, even with improved obstetrical intendance and monitoring techniques. This suggests a multifactorial etiology that is not well understood.[v][3]

Pathophysiology

Placental abruption occurs when the maternal vessels tear away from the placenta and bleeding occurs betwixt the uterine lining and the maternal side of the placenta. Every bit the blood accumulates, it pushes the uterine wall and placenta apart. The placenta is the fetus' source of oxygen and nutrients likewise equally the way the fetus excretes waste products. Diffusion to and from the maternal circulatory arrangement is essential to maintaining these life-sustaining functions of the placenta. When accumulating blood causes separation of the placenta from the maternal vascular network, these vital functions of the placenta are interrupted. If the fetus does non receive enough oxygen and nutrients, it dies.[half-dozen][7]

The clinical implications of a placental abruption vary based on the extent of the separation and the location of the separation. Placental abruption tin can be complete or partial and marginal or cardinal. The classification of placental abruption is based on the following clinical findings:

Class 0: Asymptomatic

Discovery of a blood clot on the maternal side of a delivered placenta
Diagnosis is made retrospectively

Course one: Balmy

No sign of vaginal haemorrhage or a small corporeality of vaginal haemorrhage.
Slight uterine tenderness
Maternal blood pressure and center rate WNL
No signs of fetal distress

Grade 2: Moderate

No sign of vaginal bleeding to a moderate amount of vaginal bleeding
Significant uterine tenderness with tetanic contractions
Change in vital signs: maternal tachycardia, orthostatic changes in blood pressure.
Evidence of fetal distress
Clotting contour alteration: hypofibrinogenemia

Class 3: Astringent

No sign of vaginal haemorrhage to heavy vaginal bleeding
Tetanic uterus/ board-like consistency on palpation
Maternal shock
Clotting profile alteration: hypofibrinogenemia and coagulopathy
Fetal death

Nomenclature of 0 or 1 is usually associated with a partial, marginal separation; whereas, classification of 2 or 3 is associated with complete or fundamental separation.

Histopathology

Once the placenta has been delivered, the presence of a retroplacental clot is most always seen. In some cases, there may be evidence of blood extravasation into the myometrium- resulting in purple discoloration of the serosa of the uterus.

History and Physical

Placental abruption is one of the causes of vaginal bleeding in the second half of pregnancy. A focused history and physical is disquisitional to differentiate placental abruption and other causes of vaginal haemorrhage. Because a definitive diagnosis of placental abruption tin only be fabricated after nascence when the placenta is examined the history and physical exam are disquisitional to the advisable management of the maternal/fetal dyad. Placental abruption is a potentially life-threatening situation. Therefore, authentic assessment of the patient is critical to developing an appropriate management plan and to prevent a potentially poor outcome.

The history begins with a review of the prenatal course, especially placental location on prior sonograms and if there is a history of placental abruption in previous pregnancies. Exploring the woman'south behaviors, specifically whether she smokes or uses cocaine is a critical component of history. Asking about potential trauma, peculiarly in the abdominal expanse needs to exist washed in a tactful and supportive fashion. Specially in situations of partner abuse, the woman may be reluctant to reveal that she sustained trauma to her abdomen.

The almost useful mechanism for recognizing the onset of placental abruption is an assessment of the patient. The physical examination includes palpation of the uterus. The uterus is palpated for tenderness, consistency, and frequency and duration of uterine contractions, if present. The vaginal area is inspected for the presence of bleeding. However, a digital exam of the cervix should exist delayed until a sonogram is obtained for placental location and to rule out a placenta previa. If haemorrhage is nowadays, the quantity and characteristic of the blood, likewise equally the presence of clots, is evaluated. Remember, the absence of vaginal bleeding does not eliminate the diagnosis of placental abruption.

Evaluation of vital signs to notice tachycardia or hypotension, which may exist indicators of a concealed hemorrhage are taken. Claret specimens such every bit a complete claret count (CBC), fibrinogen, clotting profile, and type and RH may be nerveless. These laboratory values will non aid in the diagnosis of placental abruption simply will provide baseline data confronting which to evaluate the patient's condition over time.

Evaluation of fetal well-existence is also included in the test. Begin with auscultation of fetal heart sounds and inquire virtually fetal movement, specifically recent changes in activity patterns. Continuous electronic fetal monitoring is initiated to identify prolonged bradycardia, decreased variability, and the presence of late decelerations.

Evaluation

There are no laboratory tests or diagnostic procedures to definitively diagnose placental abruption. Notwithstanding, some studies may be conducted in the effort to eliminate other conditions equally well as to provide baseline data.[eight][nine][10]

An ultrasound examination is useful in determining the placental location and eliminating the diagnosis of placenta previa. Notwithstanding, the sensitivity of ultrasound in visualizing placental abruption is low. During the astute phase of placental abruption, the hemorrhage is isoechoic or similar to the surrounding placental tissue. Therefore, visualization and differentiation of the curtained hemorrhage associated with placental abruption from the surrounding placental tissue are difficult.

A biophysical profile may be used in the management of patients with marginal placental abruption who are being conservatively treated. A score of six or below is an indicator of compromised fetal status.

Claret work, including a CBC, clotting studies (fibrinogen and PT/a-PTT), and BUN provide baseline parameters to evaluate changes in the patient's condition. A type and Rh take been obtained if a claret transfusion is necessary.

A Kleihauer-Betke test, which detects fetal claret cells in maternal circulation may be ordered. A Kleihauer-Betke test does not diagnose the presence of placental abruption simply quantifies the presence of fetal blood into the maternal circulation. This knowledge is important in women who are Rh-negative, considering the mixing of fetal blood in the maternal apportionment may pb to isoimmunization. Therefore, if a significant fetal-maternal drain is present, the Kleihauer-Betke exam results will help to determine the needed dose of Rh (D) allowed globulin to forbid isoimmunization.

Treatment / Management

The onset of placental abruption is often unexpected, sudden, and intense and requires immediate treatment. Prehospital intendance for the patient with a suspected placental abruption requires advanced life support and transport to a infirmary with a full-service obstetrical unit and a neonatal intensive care unit. Following arrival at the hospital, most women will receive intravenous (IV) fluids and supplemental oxygen besides every bit continuous maternal and fetal monitoring, while the history and concrete is completed. Subsequent treatment volition vary based on the data collected during the assessment, the gestation of the pregnancy, and the degree of distress existence experienced by the woman and/or the fetus.[xi][12]

Women classified with a class i or mild placental abruption and no signs of maternal or fetal distress and pregnancy less than 37 weeks gestation may exist managed conservatively. These patients are usually admitted to the obstetrical unit of measurement for close monitoring of maternal and fetus status. Intravenous access and blood work for blazon and cross-friction match is part of the plan of care. The maternal-fetal dyad volition continue to be monitored until there is a change in condition or until fetal maturity is reached.

If the nerveless data results in course 2 (moderate) or grade 3 (severe) classification and the fetus is viable and alive, commitment is necessary. Because of the hypertonic contractions, a vaginal birth may occur quickly. Given the potential for coagulopathy, vaginal birth presents less gamble to the female parent. Still, if in that location are signs of fetal distress an emergency cesarean birth is necessary to protect the fetus. During the surgical procedure, careful direction of fluids and circulatory volume is important. Postal service-operatively the patient needs to be monitored for postpartum hemorrhage and alterations in the clotting profile. A neonatal team needs to exist nowadays in the delivery room to receive and manage the infant.

Differential Diagnosis

Bleeding during the second half of pregnancy is usually due to either placental abruption or placenta previa. Differentiating these 2 conditions is important to the intendance of the patient. The information below compares the presentation of placental abruption and placenta previa on common parameters included in an obstetrical exam.

The onset of symptoms is sudden and intense for placental abruption only quiet and insidious for placenta previa
Bleeding may be visible or concealed with placental abruption and is external and visible with placenta previa
The degree of anemia or stupor is greater than the visible blood loss in placental abruption and is equal to the blood loss in placenta previa.
Pain is intense and acute in placental abruption and is unrelated to placenta previa.
The uterine tone is firm and board-like in placental abruption and soft and relaxed in placenta previa.

Prognosis

The prognosis depends on when the patient presents to the hospital. If the haemorrhage continues, both maternal and fetal lives are at pale. Partial placenta separation is associated with low mortality compared to total separation; notwithstanding in both cases, without an emergent cesarean section, fetal demise may occur. Today, the condition accounts for 5 to 8% of maternal deaths.

Complications

Severe hemorrhage
Fetal demise
Maternal death
Delivering premature baby
Coagulopathy
Transfusion-associated complications
Hysterectomy
Cesarean section means future deliveries will all exist via cesarean section
Recurrence has been reported in 4 to 12% of cases
Increased risk of adverse cardiac events accept been reported in women with placental abruption

Enhancing Healthcare Team Outcomes

Placental abruption is a serious complication of pregnancy and is best managed past an interprofessional team of healthcare professionals that include an obstetrician, radiologist, hematologist, obstetric nurse, and intensivist. The triage nurse should be aware of this condition and immediately acknowledge and notify the emergency department physician. While the patient is being resuscitated, the obstetrician should exist called ASAP. Immediate transfer to an ICU setting is highly recommended and blood should be crossed and typed in instance needed. Placental abruption is a true obstetric emergency and requires collaboration between the anesthesiologist and a radiologist. Operating room nurses should be informed of the patient so that they have the room prepared. In case the fetus is premature, the neonatal ICU team should be notified. Merely with a team approach can the morbidity and mortality of this disorder be lowered.

While the condition cannot be prevented, the patient must be encouraged to terminate smoking to lower the risk. Another major risk factor is the abuse of cocaine, which must exist curtailed. Some patients may benefit from drug counseling and or drug rehabilitation.[13][xiv] [Level five]

Outcomes

Placental abruption is a life-threatening disorder for both the mother and the fetus. If the bleeding is not arrested, and then the lives of the female parent and fetus are in jeopardy. If there is consummate separation or near separation of the placenta, expiry is inevitable, unless an immediate cesarean section is performed. Fetal bloodshed rates of ane-xl% have been reported, but this as well depends on the historic period of the fetus and the extent of separation. Each yr in the United states, about 1 to 5% of maternal deaths are linked to placental abruption. Besides the hemorrhage, the other morbidity is related to blood transfusions, the prematurity of the fetus, hysterectomy, and cesarean section (which will make the need for future cesarean sections more than likely). Recurrence rates of 3-ten% are reported. [ii][fifteen] [Level 5]

Review Questions

Effigy

Illustration of placental abruption. Marginal separation, fractional separation, complete separation with concealed hemorrhage. Cervical bleeding. Contributed by Chelsea Rowe

References

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Source: https://www.ncbi.nlm.nih.gov/books/NBK482335/