The sudden, premature, partial, or complete detachment of the placenta from a normal uterine site of implantation. The incidence of abruptio placentae is 1:120 births, and the risk of recurrence in later pregnancies is much higher than that for cohorts.

SYN: ablatio placentae




See: placenta

ETIOLOGY
The cause is unknown; however, the condition often is associated with pregnancy-induced hypertension (PIH) and may occasionally be related to current cocaine abuse or intimate partner violence.

SYMPTOMS
Abruptio placentae is classified according to type and severity. Grade 1: vaginal bleeding with possible uterine tenderness and mild tetany; neither mother nor baby is in distress; approximately 10% to 20% of placental surface is detached. Grade 2: uterine tenderness; tetany, with or without uterine bleeding; fetal distress; mother is not in shock. Approximately 20% to 50% of the total surface area of the placenta is detached. Grade 3: Uterine tetany is severe; the mother is in shock, although bleeding may be covert; and the fetus is dead. Often the patient develops coagulopathy. More than 50% of the placental surface is detached.

PATHOLOGY
Extravasation of blood occurs between the placenta and the uterine wall, occasionally between muscle fibers of the uterus. Hemorrhage can be concealed or covert, causing consumptive coagulopathy (disseminated intravascular coagulopathy).

TREATMENT
This varies with the type and extent of abruption. Women experiencing only a small marginal separation of the placenta from the uterine wall may be confined to bed and monitored closely for signs of further threat to maternal or fetal status. If prematurity also is a factor, the woman may be given betamethasone to expedite development of fetal pulmonary surfactant. If the woman is at or near term, induction of labor and vaginal delivery may be an option.
See: betamethasone
Supportive treatment and prompt surgical intervention are indicated for women who have moderate to severe abruptions. Complete detachment calls for immediate cesarean delivery, concomitant treatment of shock and, sometimes, management of a coagulation defect. The massive loss of blood jeopardizes the mother's survival; fetal mortality is 100%. If the uterus fails to contract after the surgical delivery, immediate hysterectomy may be necessary.
See: Couvelaire uterus

PROGNOSIS
Although maternal mortality is unusual, other than as noted, the perinatal mortality is between 20% and 30%.

PATIENT CARE
Early recognition and prompt management of the event and any associated complications are vital. The woman's vital signs, fundal height, uterine contractions, labor progress, and fetal status data are monitored, including heart rate and rhythm. Any changes are noted, such as prolonged decelerations in fetal heart rate or alterations in baseline variability; uterine tetany; complaints of sudden, severe abdominal pain; and the advent of or increase in vaginal bleeding. Vaginal blood loss is estimated by weighing perineal pads and subtracting the known weight of dry pads. The interval between pad changes, the character and amount of the bleeding, and the degree of pad saturation are noted. Prescribed IV fluids and medications are administered through a large-bore catheter. A central venous pressure line may be placed to provide access to the venous circulation, and an indwelling catheter is inserted to monitor urinary output and fluid balance. A calm atmosphere is maintained, and the patient's verbalization is encouraged. The patient is assisted in coping with her fears and anxiety. Questions are answered truthfully, comfort measures are implemented, and reassurance is provided as possible and consistent with the current situation and prognosis. All procedures are explained, and the woman and her family are prepared for induction of labor, vaginal delivery, or cesarean birth, as appropriate. The possibility of neonatal death should be tactfully mentioned; the neonate's survival depends primarily on gestational age, blood loss, and associated hypertensive disorders.
See: Nursing Diagnoses Appendix

Main entry:
abruptio