INTRODUCTIONDeath from hemorrhage still remains a leadingcause of maternal mortality. Is one of theleading causes of ante partum hospitalization,maternal morbidity, and operative intervention.MEDICAL EMERGENCY !It is the per vagina blood loss after 20weeks’ gestation. Complicates close toand is a
Here do nonwhite Gender familial ethnicity Race abortion PreviousAge (35- Predisposing Factors: Previous 40) placenta VBAC previa Lifestyle (vaginal Endome (smoking, birth after Multiple etc.) cesarean tritis births delivery) Damage to endometrium Defective decidual vascularization exists (2 to inflammatory or atrophic changes) Incomplete development of the fibrinoid layer
Adherence of embryo (embryonic plate) in the lower uterusAttachment of placenta to lower uterine segmentAccreta Covers cervical opening as placenta Increases in sizeTotal P. Previa Partial P. Previa Marginal P. Previa
Thinning of the area (implantation site) Disruption of placental attachment Uterus unable to contract/ Unable to stop flow of blood from the open vessels
.Promote contractionBleeding at the implantation siteRelease of Thrombin from the bleeding sites bleedingPromote contraction Placental Contraction separation
The most characteristic event in placenta previa is painless hemorrhage.(This usually occurs near the end of or after the second trimester)The initial bleeding is rarely so profuse as to prove fatal.It usually ceases spontaneously, only to recur. Placenta previa may be associated withplacenta accreta, placenta increta orpercreta. Coagulopathy is rare with placenta previa.
Placenta previa or abruption should always be suspected in women with uterine bleeding duringthe latter half of pregnancy.The possibility of placenta previa should not be dismissed until appropriate evaluation, includingsonography, has clearly proved its absence. Thediagnosis of placenta previa can seldom beestablished firmly by clinical examination. Suchexamination of the cervix is never permissibleunless the woman is in an operating room withall the preparations for immediate cesareandelivery, because even the gentlest examinationof this sort can cause torrential hemorrhage.
The simplest and safest method of placental localization is provided by transabdominalsonography.Transvaginal ultrasonography has substantively improved diagnostic accuracy of placenta previa.MRI At 18 weeks, 5-10% of placentas are low lying. Most ‘migrate’ with development of thelower uterine segment.
MANAGEMENTAdmit to hospital NO VAGINAL EXAMINATION IV access Placental localization
Determine the amount and type of bleeding Inquire as to presence or absence of pain inassociation with the bleeding Recordmaternal and fetal VS Palpate for thepresence of uterine contractionsEvaluate laboratory data on HCT and HGB Assess fetal status with continuous fetalmonitoringNever perform a vaginal examination when pt is bleeding
Altered Tissue Perfusion related to excessive bleeding causing fetal compromise Frequently monitor mother and fetusAdminister IV fluids as prescribed Position onside to promote placental perfusionAdminister oxygen as facemask as indicated(8-10 per minute)
Fluid volume deficit related to excessive bleedingEstablish and maintain a large-bore IV line, as prescribedand draw blood for type and screen for blood replacementPosition in a sitting position to allow weight of fetus tocompress the placenta and decrease bleedingMaintain strict bed rest during any bleeding episodePrepare woman for a cesarean deliveryAdminister blood or blood products protocol per institutionalpolicy
Risk for infection related to excessive blood loss Use aseptic technique when providing care Evaluate temperature q4h unless elevated;then evaluate q2hEvaluate WBC and differential count Teach perineal care and hand washing techniquesAssess odor of all vaginal bleeding or lochia
Placenta accreta Immediate hemorrhage, with possible shock and maternal deathIncreased risk for anemia secondary to increased blood lossinfection secondary to invasive procedures to resolve bleedingIntrauterine growth restriction (IUGR) Congenital anomalies Fetal mortality resulting from hypoxia in utero prematurity
Defined as the premature separation of the normally implanted placenta.The Latin abruptio placentae, means "rending asunder of the placentaOccurs in 1-2% of all pregnancies Perinatal mortality rate associated with placental abruption was 119 per 1000 birthscompared with 8.2 per 1000 for all others.
premature separation of the implanted placenta before the birth of the fetusHemorrhage can be either occult(covert) or apparent(overt).With an occult hemorrhage, the placenta usually separates centrally, and a largeamount of blood is accumulated under theplacenta. When the apparent hemorrhage is present, the separation is along the placental margin,and blood flows under the membranes andthrough the cervix.
The primary cause of placental abruption is unknown, but there are several associatedconditionsIncreased age and parity Preeclampsia Chronic hypertension Preterm ruptured membranes Multifetal gestation Hydramnios Cigarette smoking Thrombophilias Cocaine use Prior abruption Uterine leiomyoma External trauma
Predisposing Heredofamilial Smoking Factors: Age (> Gender Predisposing 35y.o) FactorsPrevious abruptio placenta Abdominal Cocaine use trauma PIH (Chorioamnionitis )Damage in small arterial vessels in the basal layer of decidua Bleeding Splits decidua leaving a thin layer attached to the placenta . , Destruction of the placental tissues OCCULT /APPARENT
Hematoma formation Compression of the basal layer Obliteration of the intervillous space Destruction of the placental tissues Impaired exchange of respiratory gases and nutrients Concealed Bleeding Visible Bleeding Blood passes Concealed Bleeding through theBlood reaches the edge membranes of of the placenta amniotic sac
PATHOGNOMONIC SIGNBlood passes through Port wine the membranes of discoloration of amniotic sac discharges Small amount of blood goes out to the vagina (not an indication of the severity of condition)
Vaginal bleeding companied with abdominal painMild type abruption1/3, apparent vaginal bleedingSevere type abruption > 1/3,large retro placental hematoma,vaginal bleeding companied by persistent abdominalpain,tenderness on the uterus,change of fetal heart rate.shock and renal failure.
Treatment for placental abruption variesdepending on gestational age and the status ofthe mother and fetus.Admit History & examinationAssess blood loss Nearly always more thanrevealed IV access, X match, DIC screenAssess fetal well-being Placental localization
Ultrasonography (Position of placenta,severity ofabruption)survival of fetus Signs-retroplacental hematomaNegative findings do not exclude placental abruptionLaboratory examinationconsumptive coagulopathy:Rt, DIC Function of liver and kidney.
Diagnosis sign and symptomVaginal bleedingUterine tenderness or back painFetal distressHigh frequency contractionsHypertonusIdiopathic preterm laborDead fetusUltrasonography :Differential diagnosis (Placenta previa-Painless bleeding, Pre-rupture of uterus dystocia
Determine the amount and type of bleeding and the presence or absence of pain.Monitor maternal and fetal vital signs, especially maternal BP, pulse, FHR, and FHR variability.Palpate the abdomen Note the presence ofcontractions and relaxations between contractions(if contractions are present)If contractions are not present assess the abdomen for firmnessMeasure and record fundal height to evaluate the presence of concealed bleeding. Prepare for possible delivery.
Evaluate amount of bleeding by weighing all pads.Monitor CBC results and VS Position in the left lateralposition, with the head elevated to enhance placentalperfusion Administer oxygen through a snug face mask at 8-12L per minuteEvaluate fetal status with continuous external fetal monitoringPrepare for possible CS delivery if maternal or fetalcompromise is evident
Instruct patient on the cause of pain to decreaseanxietyInstruct and encourage the use of relaxationtechnique to augment analgesicsAdminister pain medications as needed and asprescribed
Fluid volume deficit related to excessiveEstablish and maintain a large-bore IV line, as prescribed and draw blood for type andscreen for blood replacement Evaluatecoagulation studies Monitor maternal VS andcontractions Monitor vaginal bleeding andevaluate fundal height to detect an increasein bleeding
Use aseptic technique when providing careEvaluate temperature q4h unless elevated; thenevaluate q2h Evaluate WBC and differential countTeach perineal care and hand washing techniquesAssess odor of all vaginal bleeding or lochia
Inform the woman and her family about the status of herself and the fetusExplain all procedures in advance when possible or as they are performed Answer questions in acalm manner, using simple termsEncourage the presence of a support person
Maternal shockAnaphylactoid syndrome of pregnancyPostpartum hemorrhageAcute respiratory distress syndromeSheehan’s syndromeRenal tubular necrosisRapid labor and deliveryMaternal and fetal deathPrematurity