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Course: Maternity Nursing

Topic: Placental Abruption and Infection

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Module Goals

The learner will be able to:

Define placental abruption
Define chorioamnionitis
Identify their signs and symptoms
Describe their diagnosis and treatment management

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Placental Abruption (Abruptio Placentae)

Complete or partial separation of placenta from its uterine site before the delivery of the fetus
Etiology of placental abruption not precisely determined
Thought to be a disease of decidua and uterine blood vessels
Two types:

Revealed abruption: Bleeding drains through cervix
Concealed abruption: Bleeding remains within the uterus; forms clots inside uterus

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Placental Abruption: Risk Factors

Patient at increased risk of abruption:

History of placental abruption in previous pregnancy
Pre-eclampsia
Hypertensive disorders of pregnancy
Intrauterine growth restriction
Cigarette smoking
Poor prenatal nutrition
History of abdominal trauma ( fall or trauma to the abdomen)
Drug use (cocaine)

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Placental Abruption: Complications

Maternal blood loss that may result in hemodynamic instability

With or without shock, and/or disseminated intravascular coagulation (DIC)

Fetal compromise (e.g fetal distress, death) or, if abruptio placentae is chronic, growth restriction or oligohydramnios

fetal/maternal transfusion and autoimmunization ( e.g. due to RH sensitization)

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Placental Abruption: Signs/Symptoms

Symptoms and signs:

Initial symptoms may be sudden, sharp, severe pain that persists or evolves into a poorly localized dull ache in lower abdomen or sacral area
Antepartum haemorrhage associated with continuous severe abdominal pain
A history of dark red bleeding with clots
Absence of fetal movements following the bleeding
Preterm labour in 60% of the cases
Patient report nausea, vomiting, or dizziness

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Placental Abruption: Diagnosis

Abdominal examination shows:

Uterus is tonically contracted, hard and tender
Fetal parts cannot be palpated
The uterus is larger than dates suggest
Haemoglobin concentrations is low, indicating severe blood loss.
Fetal heart beat is almost always absent in a severe abruptio placentae

Diagnosis of severe placental abruption can usually be made from the history and physical examination, with or without ultrasonogram to rule out placenta previa

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Placental Abruption: Diagnosis

Evaluation for placental abruption includes:

Fetal heart rate (FHR) monitoring
CBC (complete blood count)
Blood and Rh typing
PT/PTT (prothrombin time/partial thromboplastin time)
Serum fibrinogen and fibrin-split products (the most sensitive indicator)
Transabdominal or pelvic ultrasonography
Kleihauer-Betke test if the patient has Rh-negative blood - to calculate the dose of Rh (D) immune globulin needed
Fetal heart monitoring may detect a nonreassuring pattern or fetal death

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Placental Abruption: Treatment Management

Trial of hospitalization and modified activity if pregnancy is not near term and if mother and fetus are stable
Prompt caesarean delivery is usually indicated if placental abruption with any of the following is present

Maternal hemodynamic instability
Nonreassuring FHR pattern
Term pregnancy (≥ 37 weeks)

Vaginal delivery can be attempted if hemodynamically stable, FHR pattern is reassuring and vaginal delivery not contraindicated

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Placental Abruption: Treatment Management

Assess clotting status using bedside clotting test

Clot time > 7 min or soft clot that breaks down easily suggests coagulopathy.

Transfusion if indicated
If bleeding is heavy (evident or hidden) deliver as soon as possible

If the cervix is fully dilated, assist birth using obstetric vacuum
If vaginal birth is not imminent, perform a caesarean

Be prepared for postpartum hemorrhage in every case of placental abruption.

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Antepartum haemorrhage with symptoms or signs of Placental abruption

Maternal condition

Fetal heart present?

Fetus viable?

Cervix 9 cm or more dilated

and fetal head engaged?

In Shock

Not in Shock

Vaginal Delivery

Vaginal Exam

Resuscitate

Caesarean

section

Rupture membranes

Vaginal

Delivery

Yes

No

Yes

No

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Case study:

A patient who is 32 weeks pregnant, according to her antenatal record, presents with a history of severe vaginal bleeding and abdominal pain. The blood contains dark clots. Since the bleeding the patient has not felt her fetus move. The patient’s blood pressure is 80/60 mm Hg and pulse rate 120 beats per minute.

What are the steps that the nurse should take in management of this patient?

How should this patient be managed if fetal heartbeat is not heard?

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Chorioamnionitis

Inflammation of the placenta, chorion membranes and decidua caused by infection

Clinical chorioamnionitis presents with clinical symptoms

Histologic chorioamnionitis (chronic amnionitis) is a histopathologic diagnosis characterized by inflammatory cell infiltration of the membranes.

May or may not associate with clinical signs/symptoms

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Chorioamnionitis: Causes

May result from ascending infection of cervical or vaginal microbial flora and bacteremia:

Group B streptococcus, E. coli, candida species, sexually transmitted infections

May result from vertical transmission through hematogenous spread, across placenta from bacteremic mother. Most common is Listeria monocytogenes
May result from iatrogenic introductions of bacteria during an invasive procedures like amniocentesis, intrauterine infusion, vaginal exams, cervical cerclage, etc.

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Chorioamnionitis: Complications

During pregnancy:

Preterm labour
Weaken membranes causing rupture of membranes

In fetus/infant:

Still birth/abortion
Retinopathy
Low birth weight
Impaired brain development in the premature infant
Chronic lung disease in infant

Puerperal sepsis

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Chorioamnionitis: Risk Factors

Preterm labor
Prolonged rupture of membranes
Prolonged labor
Meconium- stained fluid
Multiple vaginal exams post rupture of membranes
Coitus during the second half of pregnancy
Exposure of the membranes due to dilatation of the cervix
Women with known bacterial or viral infection
Cervical incompetence
Polyhydramnios

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Chorioamnionitis: Signs/ Symptoms

Clinical chorioamnionitis signs and symptoms:

Maternal fever
Uterine tenderness
Fetal tachycardia
Drainage of offensive liquor/amniotic fluid, if the membranes have ruptured

Histologic chorioamnionitis may or may not have symptoms, and the placenta or cultures may not show evidence of chorioamnionitis

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Chorioamnionitis: Diagnosis

Clinical criteria commonly used for diagnosis

Maternal fever more than 37.8°C, and
Two or more of the following:

Maternal leukocytosis of 15,000/mm³ or more
Maternal tachycardia > 100 beats/min
Fetal tachycardia >160 beats per minute
Uterine tenderness
Foul-smelling amniotic fluid

Low grade maternal fever may arise from other sources, other non-obstetric causes of fever should be excluded

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Chorioamnionitis: Diagnosis

Tests to aid in the diagnosis:
Measurement of maternal C-reactive protein
Examination of amniotic fluid for leukocytes or bacteria by gram stain
Amniotic fluid for -culture, glucose concentrations, leukocyte esterase
Amniotic fluid or vaginal cytokines
Fetal activity by ultrasonography

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According to Gravett, M, Glob. libr. women's med.,2008:

Apart from maternal C-reactive protein and ultrasonography, other tests require amniotic fluid for analysis. The risk for amniocentesis must be weighed against the possibility of infection.

Many of these tests are unavailable due to expensiveness.

According to Fowler JR, Simon LV. Chorioamnionitis. [Updated 2020 Sep 10]. In: StatPearls [Internet]

· Initial evaluation for chorioamnionitis includes a thorough clinical assessment of the mother and fetus.

· Recent studies show WBC count does not identify the presence of microbial invasion or inflammation and has low sensitivity and specificity.

· Bacterial cultures taken from the cervix are not indicated and do not correlate with infections secondary to chorioamnionitis

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Chorioamnionitis: Treatment Management

Primary management: Antibiotic therapy

Most common antibiotics used: Ampicillin and Gentamicin.

Alternative antibiotics include: Clindamycin, Cefazolin,Vancomycin

According WHO 2017 Managing complications in pregnancy and childbirth:

Woman with confirmed Group B Streptococcal colonizations treat with amoxicillin 500 mg PO TID for 7 days
Woman with ruptured membrane or clinical signs of infection

Oral erythromycin 250 mg QID for 10 days (or until birth)
OR, ampicillin 2 g IV QID

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Case study:

An unscheduled patient presents with a five-day history of ruptured membranes. She is pyrexial with lower abdominal tenderness and is draining odorous liquor/fluid. She is uncertain of her dates but abdominal examination suggests that she is at term. Treatment has been started with oral amoxicillin.

What is the nurse’s priority?

Is the infant at increased risk for neonatal complications? Explain.

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What would the priority of the nurse be?

The priority of the nurse would be:

Obtain vital signs, Listen for fetal heart rate. Notify care giver. Anticipate starting an intravenous infusion for antibiotics. Do abdominal Leopold exam to determine fetal lie and position. Draw blood work to determine infection. Give antipyretic and cool sponge bath for fever.

Management of infections with appropriate antibiotic
Delivery of the baby through induction, if abdominal examination suggests she is at term.

Why is the infant at increased risk for neonatal complications?

The chorioamnionitis has already spread to the liquor as this is offensive. Therefore, the fetus may also be infected and may present with congenital pneumonia or septicemia at birth.

Is the oral amoxicillin antibiotic appropriate?

She is pyrexial, with lower abdominal tenderness and she has offensive liquor. She will required intravenous antibiotics.

The infant is at risk for sepsis and respiratory problems.

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Reference:

Gravett, M, Glob. libr. women's med., (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10176. Retrieved from: https://www.glowm.com/section_view/heading/Intra-amniotic%20and%20Postpartum%20Infections/item/17 6

Bettercare, (n.d.). Learning Programmes/Newborn Care/12,Infection. Retrieved from: https://bettercare.co.za/learn/newborn-care/text/12.html#chorioamnionitis

Dulay, A.T. (June 2019). Abruptio Placentae. MSD Manual Professional Version. Retrieved from: https://www.msdmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/abruptio-placentae

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Reference:

Fowler, J.R., & Simon, .LV. (2020). Chorioamnionitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532251/

WHO (2017). Managing complications in pregnancy and childbirth: a guide for midwives and doctors (2nd ed.) Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://apps.who.int/iris/handle/10665/255760

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