Posted in Maternal-Newborn

Placental abruption (abruptio placentae) and placenta previa are two closely related disorders that are easy to mix up even though they have very distinct pathways, treatments and interventions. To prepare for your NCLEX, nursing school exams and clinical, it’s important to understand the key differences between the two and nursing interventions for each.

Placental Abruption

What is placental abruption?

The key point about placental abruption is that it occurs in a placenta that was implanted normally. Abruptions are classified from 0 to 3 based on the extent of the abruption. 

  • A Grade 0 abruption essentially has no symptoms and is only discovered after the placenta has been delivered. Involves less than 10% of the placental surface being detached.
  • A Grade 1 abruption (10-20% detachment) involves a small amount of vaginal bleeding with no signs of fetal distress present. Mom likely does not have hypotension but may be having some uterine contractions. 
  • A Grade 2 abruption (20-50% detachment) involves mild to moderate amounts of bleeding (may be internal or vaginal) and the fetus may be showing signs of distress as measured by fetal heart rate. Mom will be having contractions with a Grade 2 and is typically hemodynamically stable.
  • A Grade 3 abruption (50% or more detachment) involves moderate to severe vaginal or internal bleeding with fetal demise. Mom is hemodynamically unstable with unrelenting, severe uterine contractions (tetany). Disseminated intravascular coagulation (DIC) is often present with higher grade abruptions.

Assessing for the presence of placental abruption

The woman experiencing a placental abruption will typically have a sudden onset of symptoms, which typically include bleeding, pain, hypotension, tender uterus that is firm or even hard. It typically occurs after 20 weeks gestation and is a leading cause of maternal death. 

Lab tests will show that hemoglobin and hematocrit are reduced (especially in higher grade abruptions). Coagulation studies may show that DIC is present and a Kleihauer-Betke test may be done to assess for fetal blood in maternal circulation, though studies show it has poor sensitivity for diagnosing placental abruption. 

Who is at risk for placental abruption?

  • Smoking and cocaine use (both cause vasoconstriction)
  • Moms with gestational or chronic hypertension
  • Moms experiencing premature rupture of membranes (PROM)
  • Moms with traumatic injury to the abdomen
  • Moms pregnant with twins, triplets, etc…

Treatment for placental abruption

Treatment for a placental abruption will depend on the severity of the abruption. If the abruption is mild and the mom is near her delivery date, the MD may induce labor mom and attempt a vaginal delivery. If the abruption is moderate to severe, then a cesarean section is likely once any coagulopathies have been addressed. Mom may also receive packed red blood cells to maintain a hematocrit above 30% and IV fluids to maintain volume. Coagulation tests will show if any abnormalities are present. 

Nursing interventions for placental abruption

  • Draw labs, include getting a Type and Cross in anticipation of possible blood transfusion
  • Establish a large-bore IV for both fluids and blood products
  • Perform continuous fetal monitoring, watch for signs of fetal distress
  • Monitor mom’s blood pressure, heart rate, respiratory rate, urine output, skin signs, level of consciousness and any signs of shock or hemodynamic instability
  • Monitor for bleeding, keep track of blood loss
  • Assess uterine tone, monitor contractions
  • Keep mom on bedrest
  • Keep mom NPO in case an emergent c-section is needed
  • If baby is premature, mom will get betamethasone to speed up lung development in the fetus

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Placenta Previa

What is placenta previa?

Placenta previa is a condition in which the placenta has implanted abnormally, either near or completely covering the cervix. It is classified based on location.

  • Total placenta previa: the placenta is completely covering the cervix
  • Partial placenta previa: the placenta is partially covering the cervix
  • Marginal placenta previa (also called low-lying): the placenta is located near the cervix

Who is at risk for placenta previa?

  • Moms at advanced maternal age (> 35 years)
  • Moms with a prior delivery
  • Moms who have had surgery such as cesarean delivery, D & C or fibroid removal
  • Moms who smoke or use cocaine
  • Moms with a history of placenta accreta
  • Moms carrying multiples
  • Moms with a history of placenta previa

Assessing for the presence of placenta previa

The woman with placenta previa will often have insidious symptoms. Pain is typically not present (unless mom is in labor) and the uterus is soft though fundal height may be higher than expected. There will be bright red vaginal bleeding, and the fetus is not in distress. When assessing fetal position, the presentation is often abnormal and without engagement. 

Lab tests may show a decreased hemoglobin and hematocrit, depending on how heavily mom is bleeding. All moms who are bleeding will have the Kleihauer-Betke test to assess for fetal blood in circulation and, most likely, coagulation studies as well.

Treatment for placenta previa

Moms diagnosed with placenta previa will be on strict bedrest and most likely have a cesarean delivery due to the position of the placenta. If imminent delivery is needed and baby is premature, then betamethasone will be given to mom. MD will order CBC, Rh, possibly coagulation studies. The overall goal is to get mom as close to her due date as possible.

Nursing interventions for placenta previa

  • Monitor amount of bleeding
  • Assess fundal height and for contractions
  • Baby may need Leopold maneuvers to get him positioned optimally
  • Give PRBCs and IV fluids, if indicated
  • Avoid inserting anything vaginally or even performing vaginal assessments due to the heightened risk of bleeding
  PLACENTAL ABRUPTION PLACENTA PREVIA
OVERVIEW Premature separation of normally implanted placenta. Classified based on the severity of the disruption (0-3) Placenta is improperly implanted on lower uterine segment. Classified based on position.
RISK FACTORS Smoking, cocaine use, hypertension, PROM, history of previous abruption, trauma, severe abruptions often associated with DIC,
pregnant with multiples		 Multiparity, advanced maternal age, placenta accrete, prior surgery or c-section, recent spontaneous abortion, large placenta
SIGNS & SYMPTOMS Sudden onset
Internal or external bleeding
Dark red blood
Severe, steady pain
Firm uterus
Contractions or tetany
Enlarged uterus
Fetal distress		 “Sneaky” onset
External bleeding
Bright red blood
No pain (unless in labor)
Uterus is soft and relaxed
No signs of engagement
Fetus may be in abnormal position
No signs of fetal distress
MEDICAL
TREATMENT		 If mild, may induce for vaginal birth
If severe, emergent c-section (C/S)
Coagulation studies
Correct coagulopathies*
PRBCs
Fluids
Betamethasone if baby premature
*Severe abruptions often occur with DIC		 Localize placenta via ultrasound
If < 37 weeks, try to get mom to term
if > 37 weeks, may induce or perform C/S*
PRBCs if needed
Fluids if needed
Betamethasone if baby premature
Goal is to get mom to term if possible
*C/S most likely due to position of placenta
NURSING
INTERVENTIONS		 Keep mom on bedrest
Monitor VS
Continuous external fetal monitoring
Measure abdominal girth hourly
Assess fundus height hourly
Assess amount of blood loss		 Keep mom on bedrest
Monitor VS
External fetal monitoring
Monitor blood loss
No vaginal exams
COMPLICATIONS Couvelaire uterus
DIC
Fetal demise
Hemorrhage and shock		 Pre-term birth
Birth defects
Hemorrhage and shock

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References

Atkinson, A. L., Santolaya-Forgas, J., Matta, P., Canterino, J., & Oyelese, Y. (2015). The sensitivity of the Kleihauer-Betke test for placental abruption. Journal of Obstetrics and Gynaecology: The Journal of the Institute of Obstetrics and Gynaecology, 35(2), 139–141. https://doi.org/10.3109/01443615.2014.948398

Davidson, M. R., London, M. L., Ladewig, P. W., & Olds, S. B. (2008). Olds’ maternal-newborn nursing & women’s health across the lifespan (8th ed.). Upper Saddle River, N.J.: Pearson Prentice Hall.

Deglin, Judith Hopfer, and April Hazard Vallerand. Davis’s Drug Guide for Nurses, with Resource Kit CD-ROM (Davis’s Drug Guide for Nurses). Philadelphia: F A Davis Co, 2009. Print.

Hanson-Smith, B.  (2010, April 16). High Risk Labor & Delivery. Maternal-Newborn Nursing. Lecture conducted from CSU Sacramento, Sacramento.

Mayo Clinic. (n.d.). Placenta previa—Symptoms and causes. Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/placenta-previa/symptoms-causes/syc-20352768

Philadelphia, T. C. H. of. (2014, August 23). Bleeding in Pregnancy/Placenta Previa/Placental Abruption [Text]. https://www.chop.edu/conditions-diseases/bleeding-pregnancyplacenta-previaplacental-abruption