Pregn ancy in cri sis

Placental abruption: By Elizabeth Heavey, PhD, RN, CNM, and Mary Dahl Maher, PhD, MPH, RN, CNM

transported emergently to the labor and delivery unit, where painful uterine contractions and vaginal bleeding continued and her abdomen was rigid. AR was disoriented and lethargic, moaning through her tetanic contractions. Her nurse immediately suspected a placental abruption and began taking steps to stabilize both AR and her baby. This article describes the nurse’s role in caring for a patient experiencing placental abruption. What’s a placental abruption? Placental abruption (also called abruptio placentae) refers to bleeding at the decidual-placental interface that causes partial or total placental detachment from the uterine wall prior to delivery of the fetus.1 It can be so mild that the patient and fetus remain asymptomatic, or it can result in a severe hemorrhage that can jeopardize the life of both the patient and the fetus.1 Although the exact etiology of placental abruption isn’t known, the immediate mechanism of action is the rupture of maternal vessels in the decidua basalis.1 This results in the detachment of the anchoring villi in the placenta from the uterine wall. Up to 20% of

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AR, A PRIMIGRAVIDA, age 18, presented to the labor and delivery unit of the local hospital with irregular contractions every 6 to 20 minutes. She reported she’d had no prenatal care. Upon examination, gestation was estimated to be at 37 weeks (term is 37 or more weeks of gestation). After reassuring maternal and fetal assessments, prenatal blood work, and an unremarkable urinalysis, she was encouraged to ambulate around the unit for several hours. Her contractions decreased in frequency and her cervix remained unchanged at 2 cm, 50% effaced, and vertex at –2 station. (See Quick guide to pregnancy-related terminology.) After I.V. hydration with lactated Ringer’s solution, she was discharged to home with instructions to rest, stay well hydrated, and follow up with a healthcare provider and social worker in the prenatal clinic the next day. AR left the obstetric unit with one of her friends at approximately 0130. Twenty minutes later, AR was back in the ED with the friend’s assistance. AR reportedly had used crack cocaine in the parking lot to “relieve pain and speed labor along.” After fetal membranes ruptured in the ED and abrupt vaginal bleeding was noted, AR was

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Are we going to lose them both?

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placental abruptions present as “concealed abruptions,” in which signs of preterm labor occur with scant or no vaginal bleeding. The blood is trapped internally between the placenta and the uterine wall.1 (See Looking into placental abruptions.) This type of presentation may make the correct diagnosis more difficult to determine until the presenting signs and symptoms become severe. Certain risk factors contribute to the likelihood of an abruption occurring. (See Risk factors associated with placental abruption.) Several of these risk factors were involved in AR’s case. Using cocaine, amphetamines, or nicotine produces vasoconstriction, which can result in placental abruption. Abruption is more common with cocaine binging than with regular use of this substance.2 Rapid decompression of the uterus, including after rupture of the fetal membranes, can also contribute to the risk of placental abruption.3 A significant placental abruption is a medical emergency requiring rapid intervention. AR’s presentation was one such scenario.

Quick guide to pregnancy-related terminology9 • Primigravida. A woman who’s pregnant for the first time. • Vertex. Cephalic presentation; this means the fetal head enters the pelvis first. • Tetanic contractions. When contractions come so close together they “merge” and last over 3 minutes without sufficient uterine relaxation in between. This can compromise the oxygenation status of a fetus and produce fetal distress. • Cervical status assessment: – Dilation. Measurement of cervical opening at the base of the uterus (10 cm is considered fully dilated). – Effacement. The process of cervical softening and shortening as the tissue thins out to facilitate passage of the fetal head through the cervix (0% to 100%). – Station. The relationship of the presenting fetal part (usually the head) to the ischial spines (0 station), measured in centimeters from –5 above (negative station) to +5 below (positive station).

Two large-bore venous accesses were obtained, one for I.V. fluids and one for blood products. A rush order was placed on the blood samples collected earlier that evening and coagulation studies were ordered. AR was hypotensive (BP, 92/44), tachycardic (heart rate, 120), tachypneic (respiratory rate, 28), and afebrile. AR was placed in a left lateral position and administered 100% oxygen via a nonrebreather face mask. Both the attending obstetrician and anesthesia team were immediately notified, and the OR

staff prepared for an emergency cesarean delivery due to maternal and fetal instability. Vital signs, oxygen saturation, and level of consciousness were assessed by the nurse every 5 minutes and reported to the team in the room. AR exhibited generalized pallor with cold extremities and continued to be disoriented but responsive to verbal stimulation and pain. The nurses couldn’t determine if her altered mental status was due to her recent drug use or the pathophysiology of placental abruption.

Looking into placental abruptions

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Continuous fetal monitoring was immediately initiated; the fetal heart rate was tachycardic at 180 (normal fetal heart rate, 110 to 160). The neonatal team was immediately notified. Lactated Ringer’s solution was infused via one venous access and a blood transfusion via the other using a fluid warmer and a rapid infuser.4 As the nurse began to insert an indwelling urinary catheter, the fetal head could be seen at the vaginal opening. An internal fetal scalp electrode was placed. It recorded a fetal heart rate of 180 to 190 with minimal variability, indicating fetal distress. In addition to hypovolemic effects, uterine hypertonicity and tetanic contractions are frequently associated with placental abruption and can result in fetal oxygen desaturation even with minimal blood loss.5 Maternal and fetal status warranted operative delivery; however, AR quickly proceeded to vaginally deliver a 5 lb 2 oz (2.3 kg) baby girl with Apgar scores of 2, 6, and 7. (See Understanding Apgar scores.) Cocaine exposure during pregnancy can cause congenital anomalies, brain malformation, and cardiovascular

Risk factors associated with placental abruption10 • younger or older maternal age • multiple pregnancies and deliveries close together, particularly in younger women • cigarette smoking • drug use (specifically cocaine and amphetamine and their derivatives) • multifetal pregnancies • hypertension (chronic and preeclampsia) • premature rupture of membranes • oligohydramnios • chorioamnionitis • poor nutrition • trauma • coagulopathies • intrauterine infections.

Understanding Apgar scores The Apgar score is used for a rapid standardized assessment of an infant’s initial status after delivery and early in the neonatal transition period. The score is calculated at 1 minute of life and repeated at 5 minutes of life. Five measures are assessed and scored as 0, 1, or 2 points each and then totaled. A 5-minute Apgar score of 7 or greater is considered normal. Most healthy infants won’t have an Apgar score of 10 because acrocyanosis, or blue discoloration of the hands and feet, is a normal observation in a healthy infant. If the 5-minute Apgar score is less than 7, it’s recommended that the infant continue to be assessed and the score recalculated every 5 minutes for up to 20 minutes. The Apgar score isn’t a predictor of future health status; rather, it’s an assessment of initial infant status. Points

0

1

2

Respiratory effort

None

Weak cry, hypoventilation

Strong cry; rate and effort of breathing are normal

Heart rate

None

100 bpm

Muscle tone

Limp

Some flexion

Active motion

Reflex irritability

None

Grimace

Cry or active withdrawal

Color

Blue or pale

Acrocyanotic

Normal

Source: Adapted from ACOG (2006, reaffirmed 2010). Committee Opinion #333: The Apgar score. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co333.pdf?dmc=1&ts =20141206T0645151146.

abnormalities; these all impact growth, behavior, cognition, and language development. It’s also associated with other factors that negatively affect a fetus, including inadequate prenatal care, tobacco and alcohol use, poverty, poor nutrition, abuse, and sexually transmitted infections.2 The additional complications of hypoxia and hypovolemia related to the abruption process can further exacerbate damaging effects on the infant. All infants born to mothers who used cocaine during pregnancy should be evaluated by a neonatal/pediatric team qualified to assess these concerns.6 After delivery, the baby was quickly transported to the neonatal intensive care unit (NICU). The placenta was delivered spontaneously accompanied by approximately 600 mL of blood and a large clot. Bimanual uterine massage was begun. Uterotonic drugs, including oxytocin and methylergonovine, were administered to minimize further blood loss related to uterine atony.7 The patient’s bleeding began to

resolve and her vital signs began to stabilize (BP, 106/72; heart rate, 100; respiratory rate, 24). AR became somewhat less disoriented and began to take in her surroundings and ask questions. The nurses reassured AR and explained what was happening with her baby and the neonatal team in the room next door. Continuing care AR was monitored closely for signs and symptoms of coagulopathy, such as bleeding from the venous access insertion sites or epistaxis. Because uterine atony is still a concern during the postpartum period, AR’s vital signs were frequently assessed and she was closely monitored for vaginal bleeding. Fundal height and tone were assessed regularly, and perineal pads were weighed and counted.4 Urine output was maintained at more than 30 mL/hour. Serial hemoglobin and hematocrit results were monitored to identify the need for additional blood products.3 AR’s

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identified risk factors were addressed postpartum, including smoking cessation, substance abuse treatment, and management of underlying health issues, such as hypertension. Women like AR who have a placental abruption should be counseled to seek early and regular prenatal care for any future pregnancies because the risk of recurrence in a subsequent pregnancy ranges from 6% to 17%.8 Contraception options were also discussed with AR. During the postpartum period, AR continued to have short periods of uterine atony, which were treated with I.V. oxytocin, and she required an additional blood transfusion. She remained in the hospital for 72 hours. After assessment by a social worker, home-care follow-up was arranged. She was discharged

home with a prescription for oral iron supplements and referrals for drug abuse treatment and followup care. Her baby remained in the NICU for an extended stay secondary to complications relating to cocaine exposure and possible prematurity. Child protective services was notified of the infant’s positive toxicology screen. ■ REFERENCES 1. Anath CV, Kinzler WL. Placental abruption: clinical features and diagnosis. UpToDate. 2014. http://www.uptodate.com. 2. Keegan J, Parva M, Finnegan M, Gerson A, Belden M. Addiction in pregnancy. J Addict Dis. 2010;29(2):175-191. 3. McLaurin R, Geraghty S. Placenta praevia, placental abruption and amphetamine use in pregnancy: a case study. Women Birth. 2013;26(2):138-142. 4. American Congress of Obstetricians and Gynecologists, District II. Optimizing Protocols in Obstetrics: Management of Obstetric Hemorrhage. Series 2. 2012. https://www.acog.org/~/media/Districts/ District%20II/PDFs/Final_Hemorrhage_Web.pdf.

5. Heuser CC, Knight S, Esplin MS, et al. Tachysystole in term labor: incidence, risk factors, outcomes, and effect on fetal heart tracings. Am J Obstet Gynecol. 2013;209(1):32.e1-e6. 6. Behnke M, Smith VC; Committee on Substance Abuse; Committee on Fetus and Newborn. Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics. 2013;131(3): e1009-e1024. 7. Belfort MA. Management of postpartum hemorrhage at vaginal delivery. UpToDate. 2015. http://www.uptodate.com. 8. Han CS, Schatz F, Lockwood CJ. Abruptionassociated prematurity. Clin Perinatol. 2011;38(3): 407-421. 9. Warren R, Arulkumaran S, eds. Best Practice in Labour and Delivery. Cambridge, UK: Cambridge University Press; 2009. 10. Hasegawa J, Nakamura M, Hamada S, et al. Capable of identifying risk factors for placental abruption. J Matern Fetal Neonatal Med. 2014;27(1):52-56. Elizabeth Heavey is an associate professor of nursing at The College at Brockport, State University of New York, in Brockport, N.Y., and Mary Dahl Maher is an assistant professor of nursing at Nazareth College in Rochester, N.Y. Dr. Heavey is also a member of the Nursing2015 editorial board. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000463662.37982.73

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Placental abruption: are we going to lose them both?

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