Narrative Report Contents:

I. INTRODUCTION
II. DATA OF PATIENT
III. DIAGNOSIS/SUBJECT
IV. HISTORY PAST/PRESENT
V. LABORATORY TEST/
DIAGNOSIS PROCEDURE
VI. PATIENT MANAGEMENT
VII. OUTCOME/ EVALUATION
 I. INTRODUCTION
ABRUPTIO PLACENTA

Abruptio placentae is defined as the premature

separation of the placenta from the uterus. Patients with abruptio
placentae, also called placental abruption, typically present with
bleeding, uterine contractions, and fetal distress. A significant
cause of third-trimester bleeding associated with fetal and
maternal morbidity and mortality, placental abruption must be
considered whenever bleeding is encountered in the second half
of pregnancy. Placental abruption is demonstrated in the image
below.

Signs and Symptoms

Acute abruptio placentae may result in bright or dark red blood
exiting through the cervix (external hemorrhage). Blood may also
remain behind the placenta (concealed hemorrhage). Severity of
symptoms and signs depends on degree of separation and blood
loss. As separation continues, the uterus may be painful, tender,
and irritable to palpation. Hemorrhagic shock may occur, as may
signs of DIC. Chronic abruptio placentae may cause continued or
intermittent dark brown spotting.
 Classification of placental abruption
Classification of placental abruption is based on extent of
separation (ie, partial vs complete) and location of separation (ie,
marginal vs central). (See Clinical.) Clinical classification is as
follows:
Class 0 - Asymptomatic
Class 1 - Mild (represents approximately 48% of all cases)
Class 2 - Moderate (represents approximately 27% of all cases)
Class 3 - Severe (represents approximately 24% of all cases)
A diagnosis of class 0 is made retrospectively by finding an
organized blood clot or a depressed area on a delivered placenta.
Class 1 characteristics include the following:
No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress
Class 2 characteristics include the following:
No vaginal bleeding to moderate vaginal bleeding
Moderate to severe uterine tenderness with possible tetanic
contractions
Maternal tachycardia with orthostatic changes in BP and heart
rate
Fetal distress
Hypofibrinogenemia (ie, 50-250 mg/dL)
Class 3 characteristics include the following:
No vaginal bleeding to heavy vaginal bleeding
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, < 150 mg/dL)
Coagulopathy
Fetal death
Diagnosis
Combination of clinical, laboratory, and ultrasonographic findings

Diagnosis is suggested if any of the following occur during late

pregnancy:

Vaginal bleeding (painful or painless)

Uterine pain and tenderness
Fetal distress or death
Hemorrhagic shock
DIC
Tenderness or shock disproportionate to the degree of vaginal
bleeding

The diagnosis should also be considered in women who have had

abdominal trauma. If bleeding occurs during late pregnancy, placenta
previa, which has similar symptoms, must be ruled out before pelvic
examination is done; if placenta previa is present, examination may
increase bleeding.

Evaluation includes the following:

Fetal heart monitoring

CBC
Blood and Rh typing
PT/PTT
Serum fibrinogen and fibrin-split products (the most sensitive
indicator)
Transabdominal or pelvic ultrasonography
Kleihauer-Betke test if the patient has Rh-negative bloodto
calculate the dose of Rh0(D) immune globulin needed

Fetal heart monitoring may detect a nonreassuring pattern or fetal

death.

Transvaginal ultrasonography is necessary if placenta previa is

suspected based on transabdominal ultrasonography. However,
findings with either type of ultrasonography may be normal in abruptio
placentae.
Complications

Hemorrhage into the decidua basalis occurs as the placenta

separates from the uterus. Vaginal bleeding usually follows,
although the presence of a concealed hemorrhage in which the
blood pools behind the placenta is possible.

Hematoma formation further separates the placenta from the

uterine wall, causing compression of these structures and
compromise of blood supply to the fetus. Retroplacental blood
may penetrate through the thickness of the uterine wall into the
peritoneal cavity, a phenomenon known as Couvelaire uterus.
The myometrium in this area becomes weakened and may
rupture with increased intrauterine pressure during contractions. A
myometrium rupture immediately leads to a life-threatening
obstetric emergency.
Treatment/Management
Sometimes prompt delivery and aggressive supportive measures
(eg, in a near-term pregnancy or for maternal or possible fetal
instability)
Trial of hospitalization and modified rest if the pregnancy is not
near term and if mother and fetus are stable

Prompt cesarean delivery is usually indicated if any of the following

is present, particularly if vaginal delivery is contraindicated:

Maternal hemodynamic instability

Nonreassuring fetal heart rate pattern
Near-term pregnancy (eg, > 36 wk)

Once delivery is deemed necessary, vaginal delivery can be

attempted if the mother is hemodynamically stable, fetal heart rate
pattern is reassuring, and vaginal delivery is not contraindicated (eg,
by placenta previa or vasa previa); labor can be carefully induced or
augmented (eg, using oxytocin and/or amniotomy). Preparations for
postpartum hemorrhage should be made.

Hospitalization and modified rest are advised if all of the following

are present:

Bleeding does not threaten the life of the mother or fetus.

The fetal heart rate pattern is reassuring.
The pregnancy is not near term.

This approach ensures that mother and fetus can be closely

monitored and, if needed, rapidly treated. (Modified rest involves
refraining from any activity that increases intra-abdominal pressure for
a long period of timeeg, women should stay off their feet most of the
day.) Corticosteroids should be considered (to accelerate fetal lung
maturity) if gestational age is < 34 wk. If bleeding resolves and
maternal and fetal status remains stable, ambulation and usually
hospital discharge are allowed. If bleeding continues or if status
deteriorates, prompt cesarean delivery may be indicated.
 II. DATA OF PATIENT
Name: Luz Alberio Librado
Birthday: December 21, 1992
Age: 23 y/old
Place of Birth: Baybay,Leyte
Civil Status: Not Married
Occupation: Housewife
Citizenship: Filipino
Religion: Roman Catholic

Husbands Name: Gilberto L. Non

Age: 26 y/old
Civil Status: Not Married
Occupation: Factory Worker
Citizenship: Filipino
Religion: Roman Catholic
Address: Occidental, Mindoro
 III. DIAGNOSIS/SUBJECT
Admitting Diagnosis:

G2P1 (1001) Pregnancy Uterine 30 5/7 weeks age of gestation by

LMP, cephalic in preterm labor previous cesarean section I for
dystocia (2015) preeclampsia with severe appearance.

Final Diagnosis:

G2P2 (1002) Pregnancy Uterine 30 5/7 weeks age of gestation by

LMP, cephalic, left with low transverse cesarean section,
preeclampsia with severe, dystocia painless cesarean section I
(2015) abruptio placentae 25%, with chronic anemia.

Principal Operational Procedure:

Emergency direct low transverse cesarean section II under spinal

anesthesia.

IV. HISTORY PAST/PRESENT

Previous
C/S Section I 2015 (dystocia)
Chronic Anemia
Present
C/S Section II 2016
Abruptio Placentae
 V. LABORATORY TEST/
DIAGNOSIS PROCEDURE
Urinalysis
Clinical Evaluation

PIT ------- 6.5

Specific Gravity
Glucose ------- Negative Urobilinogen ------- Normal
Protein ------- +3 Nitrate ------- Negative
Bilirubin ------- Negative Leucocytes ------- Negative
Ketone ------- Negative RBC ------- 0-2 hpt
Blood ------- Trace Pus Cell ------- 0-2 hpt

Complete Blood Count

Normal Value
Hemoglobin ------- 87.1 ------- 120-170
Hematocrit ------- .30 ------- 0.37-0.54
RBC ------- 3.85 ------- 4.1-5.1
MCV ------- 77.7 ------- 80-90
MCH ------- 22.0 ------- 27-31
MCHC ------- 29.1 ------- 24-30
WBC ------- 18.8 ------- 4.5-11
Ultrasonography
Single live intrauterine pregnancy in cephalic presentation 30
weeks 2 days average sonographic age, placenta anterior high lying
grade 2, normal amniotic fluid volume.

Cross Match

Blood Type A+

Serologic Test Result

HBsAg/Ab Non Reactive
HCVAg/Ab Non Reactive
HIVAg/Ab Non Reactive
Syphilis Non Reactive
Malaria Negative
 VI. PATIENT MANAGEMENT
Begin continuous external fetal monitoring for the fetal heart
rate and contractions
Obtain intravenous access using a large-bore intravenous
lines
Institute crystalloid fluid
Type and crossmatch blood
Begin a transfusion if the patient is hemodynamically
unstable after fluid resuscitation
Administer coagulopathy, if present
Administer immune globulin if the patient is RH negative

Vaginal Delivery
This is the preferred method of delivery for the fetus that has
died secondary to placental abruption
The ability of the patient to undergo vaginal delivery
depends on her remaining hemodynamically stable
Delivery is usually rapid in this patients secondary to
increased uterine tone and contraction

Cesarean Delivery
Is often necessary for fetal and maternal stabilization
While cesarean delivery facilitate rapid delivery and direct
access to the uterus and its vasculature, it can be
complicated by the patients coagulation status. Because of
this a vertical skin incision, which has been associated with
less blood loss, is often use when the patient appears to
have D&C
The type uterine incision is dictated by the gestational age of
the fetus with a vertical or classic uterine incision often
necessary in the preterm patient
 If hemorrhage cannot be controlled after delivery, a
cesarean hysterectomy may be required to save the patients
life

Before proceeding to hysterectomy, other procedures,

including correction of coagulopathy, ligation of the uterine
artery, administration of uterotonics (if atony is present)
packing of the uterus and other techniques to control
hemorrhage may be adopted

Patient Medication
Hydralazine 5mg IV push (prn) as needed
MgSO4 5gms slow IV then 5gms deep IM at each buttocks
30 mins apart as loading dose
Methyldopa 250mg two tablets every 8hrs
Tramadol 50mg q 8hrs x 3dose
Ketorolac 30mg q 6hrs x 4dose (anst)
Magnesium Sulfate
The medicine can be used intravenously (through an IV) to control
seizures in pregnant women and certain children. It can also be
used to treat a dangerous arrhythmia, lower high blood pressure,
slow down contractions during labor, and treat other conditions as
determined by your doctor.
Hydralazine
Hydralazine is used to treat high blood pressure. Hydralazine is in
a class of medications called vasodilators. It works by relaxing the
blood vessels so that blood can flow more easily through the
body.
Amlodipine
Amlodipine is an oral drug thats used to treat high blood
pressure, coronary artery disease, and angina.
Amlodipine is a calcium channel blocker that dilates (widens)
blood vessels and improves blood flow.
Ketorolac
Ketorolac is only intended for short-term (up to 5 days) treatment
of moderately severe pain.
Tramadol
Tramadol is a narcotic-like pain reliever. Used to treat moderate
to severe pain.

Dexamethasone
The dexamethasone is used to treat conditions that cause
inflammation, conditions related to immune system activity, and
hormone deficiency. It is also use for lungs surfactant
 VII. OUTCOME /EVALUATION
Keep the diastolic blood pressure below 100mmhg to
prevent maternal cardiovascular complication by
continuing medication
Give psychological support since her neonate was born
prematurely and in the intensive care nursery
Kept inform about the infant condition also introduce the
nurse on duty to keep in touch accordingly
The father was inform also and visit her wife regularly to
show his care and extra support because her wife will be
separated from her infant for a couple of days

Outcome Evaluation

Continue on medical Patient vital signs was

treatment
Patients might be
concerned and understand
about the condition of their
baby inside intensive care
nursery
stable diastolic blood
pressure below 100mmHg
Mother provide regular
breastfeeding to her baby
inside intensive care
nursery