Search This Blog

What is Abruptio placentae and Its Pathophysiology:Nursing Case Study

Saturday, 8 March 2014


Abruptio placentae refers to the premature separation of a normally implanted placenta from the uterine wall. This condition usually occurs after 20 weeks of pregnancy but may occur as late as during the first or second stage of labor. It's most common in multigravidas—usually in women age 35 and older—and is a common cause of bleeding during the second half of pregnancy.

Abruptio placentae is classified according to the amount of placental separation and maternal symptoms. Classification also correlates with fetal symptoms. Classes range from 0 (asymptomatic, only recognized after delivery) to 3 (severe, medical emergency, usually resulting in fetal death).

Pathophysiology
The primary cause of abruptio placentae is unknown, but the physical mechanism follows a characteristic pattern. Blood vessels at the placental bed spontaneously rupture due to a lack of resiliency or to abnormal changes in uterine vasculature. An enlarged uterus, which can't contract sufficiently to seal off the torn vessels, and hypertension complicate the situation. As blood enters the muscle fibers, complete relaxation of the uterus becomes impossible, increasing uterine tone and irritability. If bleeding continues unchecked, the placenta may be partially or completely sheared off. Accumulation of this blood (known as Couvelaire uterus or uteroplacental apoplexy) may prevent delivery of the placenta.

Possible complications
■ Maternal mortality
■ Postpartum vascular spasm
■ Hemorrhage or intravascular clotting
■ Renal failure from shock
■ Fetal mortality
■ Neonatal complications (such as hypoxia, prematurity, and anemia)

Assessmen
Health perception and management
■ Smoking or substance abuse (particularly cocaine)
■ Abdominal trauma

Activity and exercise
■ Hypertension or gestational hypertension

Cognition and perception
■ Marked pain (class 2 or 3)
■ Uterine pain (localized or diffused, unrelenting, excruciating)
■ Back pain

Self-perception and self-concept
■ Real or imagined loss of baby
■ Anxiety
■ Helplessness
■ Fear and apprehension
■ Guilt

Sexuality and reproduction
■ Vaginal bleeding
■ Uterine contractions
■ Placental abruption with previous pregnancy

Physical examination

General appearance and nutrition

■ Pallor
■ Diaphoresis

Mental status and behavior

■ Anxiety
■ Facial expressions of pain

Integumentary
■ Cold, moist skin

Eyes, ears, nose, and throat
■ Dry mucous membranes

Respiratory
■ Tachypnea
■ Increasingly shallow respirations

Cardiovascular
■ Tachycardia
■ Hypotension
■ Syncope
■ Cyanosis

Gastrointestinal
■ Abdominal tenderness to touch

Neurologic
■ Vertigo
■ Confusion

Renal and urinary
■ Proteinuria (in class 3)
■ Oliguria or anuria

Reproductive
■ Uterine tenderness or tension, ranging from absent or minimal to boardlike
■ Vaginal bleeding, ranging from none or scant to profuse and dark red
■ Increased uterine size
■ Increased uterine tone
■ High to engaged presenting part

Diagnostic studies
■ Ultrasonography reveals placental implantation site; gestational age; fetal viability, position, and station; and, possibly, the hemorrhage site and retroplacental blood clots. It rules out placenta previa.
■ Electronic fetal monitoring reveals late decelerations related to uteroplacental insufficiency, fetal hypoxia, or the absence of fetal heart tones (FHTs).
■ Hemoglobin (Hb) level, hematocrit (HCT), and platelet count may decrease.
■ Prothrombin time (PT) and partial thromboplastin time (PTT) may increase.
■ Fibrinogen levels may decrease.
■ Fibrin split products may increase.
■ Blood urea nitrogen (BUN) and creatinine levels may increase.

Teaching checklist
■ Signs and symptoms of abruptio placentae
■ Laboratory testing
■ Procedure for electronic fetal monitoring
■ Nonpharmacologic and pharmacologic pain management options
■ Delivery options: vaginal versus cesarean section
■ Risk factors for abruptio placentae (for future pregnancies)
– Drinking, smoking, and drug use
– Poor prenatal care
– Noncompliance with the management of chronic conditions, such as hypertension and diabetes
Share This to Your Love Ones Share information!