Abruptio Placenta (Original)


Published on

Published in: Health & Medicine
No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Abruptio Placenta (Original)

  3. 3. <ul><li>ABRUPTIO PLACENTA is separation of the placenta (the organ that nourishes the fetus) from the site of uterine implantation before delivery of the fetus. </li></ul><ul><li>Also referred to as premature separation of placenta, accidental hemorrhage, ablatio placenta, placental abruption. </li></ul><ul><li>Placenta affects about 9 in 1,000 pregnancies. </li></ul>
  4. 4. <ul><li>It usually occurs in the third trimester of pregnancy, but it can occur any time after the 20 th – 24 th weeks and before the birth of the baby. </li></ul><ul><li>Up to 15% of abruptions aren't obvious until labor is in progress or after delivery. </li></ul><ul><li>Fetal distress appears early in the condition in approximately 40-50% of cases. The infants who live have a 40-50% chance of complications. </li></ul>
  5. 5. <ul><li>After 1 placenta abruptio, a woman has a 4% to 17% chance of having another in a later pregnancy. After two pregnancies complicated by placenta abruptio, a woman has a 25% chance of having another. </li></ul>
  6. 7. <ul><li>Risk Factors </li></ul><ul><li>1.Multiparity </li></ul><ul><li>2.Hypertension </li></ul><ul><li>3.Blunt external abdominal trauma/direct </li></ul><ul><li>4.Smoking </li></ul><ul><li>5.Poor nutrition </li></ul><ul><li>6.Age older than 35 yrs old </li></ul><ul><li>7.Short umbilical cord </li></ul><ul><li>8.Coccaine </li></ul><ul><li>9.Previous third trimester bleeding </li></ul><ul><li>10. Alcohol use </li></ul>
  7. 8. Signs and symptoms <ul><li>1. Sharp abdominal pain/ back pain </li></ul><ul><li>Due to myometrium rupture because retroplacental blood penetrated through the uterine wall into the peritoneal cavity </li></ul>
  8. 9. <ul><li>2. Uterine tenderness </li></ul><ul><li>The blood is concealed between the placenta and the deciduas while pressure builds up, forcing blood through the fetal membranes into the amniotic sac. </li></ul><ul><li>The build up of blood cause uterine tenderness. </li></ul>
  9. 10. <ul><li>3. Vaginal bleeding </li></ul><ul><li>Due to decidual necrosis, blood vessels rupture. Bleeding occurs due to distended uterus. It cannot close the opened blood vessels. </li></ul>
  10. 11. <ul><li>4. Signs of maternal shock </li></ul><ul><li> -When blood accumulates between the separated placenta and the uterine wall, and there is bleeding into the myometrium resulting in tissue damage, increased tonicity and inability of the uterus to relax between contractions </li></ul>
  11. 12. <ul><li>5. Fetal distress </li></ul><ul><li>Abruption interferes with fetal circulation. Decreased uterine perfusion, maternal hypovolemia, and uterine hypertonus disrupt the maternal and fetal (uteroplacental) blood exchange thus if a significant amount of blood is lost, fetal distress occurs. </li></ul>
  12. 13. Baseline fibrinogen( if bleeding is extensive, fibrinogen reserve may be used up in the body’s attempt to accomplish effective clot formation NO IE or rectal examination, no enema Keep IV open for possible blood transfusion May lead to couvelaire uterus (blood infiltrating the uterine musculature) forming a hard, board-like uterus without apparent bleeding FHT monitoring; VS monitorng Fetal distress (altered FHR) Oxygenation to limit fetal anoxia Abdomen is tender, painful, and tense (board-like) Keep woman in lateral (not supine) position Painful (sharp stabbing) vaginal bleeding
  13. 14. Management
  14. 15. MEDICAL MANAGEMENT <ul><li>The woman is hospitalized and monitored carefully for signs of increasing separation. </li></ul><ul><li>Ultrasound is necessary to differentiate abruptio placenta from placenta previa. </li></ul><ul><li>Monitor fetal heart rate. </li></ul><ul><li>Monitor vital signs. </li></ul><ul><li>Check urine output, hematocrit, platelet counts and fibrinogen concentration determination. </li></ul><ul><li>Cesarean birth delivery. </li></ul><ul><li>Blood replacement. </li></ul>
  15. 16. SURGICAL MANAGEMENT <ul><li>Classical CS </li></ul><ul><li>Classic uterine incision – the uterus is incised vertically above the attachment of the bladder. The bladder is not dissected of the lower uterine segment. This approach is rarely used but may be necessary for a fetus in transverse presentation or for multiple fetuses. It may be indicated for a low anterior placenta, varicosities of the lower uterine segment, or cervical cancer. A major disadvantage is the high incidence of rupture with subsequent pregnancy. </li></ul>
  16. 18. PREVENTION <ul><li>1 .Avoid drinking, smoking or using other drugs during pregnancy. </li></ul><ul><li>2. Keep a regular schedule of prenatal checks throughout your pregnancy. </li></ul><ul><li>3. If you have high blood pressure, carefully follow your health professionals treatment recommendations. </li></ul><ul><li>4. Take prenatal vitamins with folate [ 400ug ( 0.4 mg ) ], since low folate has a possible link to placental problems & abruption. </li></ul>
  17. 19. THANK YOU
  19. 21. ECTOPIC PREGNANCY <ul><li>A. Pregnancy in which implantation occur outside of the uterus, mostly in the Fallopian tube </li></ul><ul><li>B. May be diagnosed by ultrasonography </li></ul><ul><li>C. Pattern in tubal pregnancy: </li></ul><ul><li>-spotting after one or two missed menstrual periods </li></ul><ul><li>-    sudden, sharp, knife-like lower abdominal pain radiating to the shoulder </li></ul><ul><li>-   concealed bleeding from site of rupture leads to sudden shock </li></ul>
  20. 22. <ul><li>Therapeutic Interventions </li></ul><ul><li>Diagnosis confirmed by ultrasound examination, laparoscopy, culdocentesis </li></ul><ul><li>Immediate blood replacement if blood loss is severe </li></ul><ul><li>Surgical repair or removal of ruptured fallopian tube </li></ul>
  21. 23. Gestational sac in tube in UTZ Visualization of pelvic organs through culdoscopy Presence of bloody fluid Administration of RHOGAM to Rh negative mothers Vaginal spotting or bleeding may be present Provide emotional support for the grieving process Rigid, tender abdomen on palpation Shock monitoring and management before and after surgery Unilateral LQ (abdominal or pelvic pain Prepare for surgery Amenorrhea with (+) PT
  22. 24. <ul><li>Nursing Care </li></ul><ul><li>Assess continuously for signs of shock </li></ul><ul><li>Administer analgesics as ordered </li></ul><ul><li>Provide emotional support </li></ul><ul><li>Administer Rhogam to Rh-negative client </li></ul>
  23. 25. TROPHOBLASTIC DISEASE <ul><li>A. Definition </li></ul><ul><li>1.       A group of disorders in which there is an abnormal proliferation of tissues and high HCG levels </li></ul><ul><li>2.      Includes Hydatidiform mole, invasive mole, and Choriocarcinoma </li></ul><ul><li>B. Clinical Findings: </li></ul><ul><li>1.       Types include; </li></ul><ul><ul><li>a. Molar pregnancy – no fetus or amnion </li></ul></ul>
  24. 26. <ul><li>a. Partial Molar Pregnancy – a fetus or amnion sac is present </li></ul><ul><li>b.      Invasive mole – locally invasive to surrounding tissues </li></ul><ul><li>c. Choriocarcinoma – may occur years after an H- mole </li></ul><ul><li>1.       Uterus is generally larger for a period of gestation and fetal parts are not palpable </li></ul><ul><li>2.      Symptoms of PIH and hyperemesis are common </li></ul><ul><li>3.      Potential for uterine perforation and hemorrhage </li></ul><ul><li>4.      Confirmed by UTZ </li></ul><ul><li>  </li></ul>
  25. 27. <ul><li>Nursing Care </li></ul><ul><li>The same as with clients who have undergone abortion </li></ul><ul><li>Teach about the importance of follow up care </li></ul>
  26. 28. Hydatidiform Mole <ul><li>Definition: Developmental (degenerative) anomaly of the placenta converting the chorionic villi into mass of clear visicle </li></ul>
  27. 29. Increased nausea and vomiting If there is no rise in HCG, further treatment (hysterectomy or chemotherapy) is required. No FHT Educate on the need to monitor HCG for 1 year (biweekly until low then monthly fr six months, then every two months for the next six months) Elevated HCG levels Educate on avoiding pregnancy for at least 1 year UTZ findings (no fetus) Mole is removed by vacuum aspiration or curettage Persistent bleeding (dark red/ brown vaginal fluid with passage of grapelike clusters Monitoring and management of shock by blood transfusion or IV therapy Uterus large for gestational age
  28. 30. INCOMPETENT CERVIX <ul><li>A. Definition </li></ul><ul><li>Cervical dilatation and effacement after the second trimester </li></ul><ul><li>Usually results from previous forceful dilation and curettage, difficult birth or congenitally short cervix </li></ul><ul><li>B. Clinical findings </li></ul><ul><li>1.       Painless contraction in midtrimester </li></ul><ul><li>2.      Birth of dead or nonviable fetus </li></ul>
  29. 31. PLACENTA PREVIA <ul><li>Definition: abnormal implantation of the placenta in the lower uterine segment, partially or completely covering the internal cervical os </li></ul>
  30. 32. <ul><li>Spotting (during first and second trimester) </li></ul><ul><li>Bleeding that is sudden, profuse and PAINLESS (during end of second trimester, or during third trimester) </li></ul><ul><li>Note: Bleeding may occur until onset of cervical dilatation causing the placenta to loosened from the uterus. Total placenta has earlier more profuse bleeding. </li></ul><ul><li>UTZ showing the location and degree of obstruction </li></ul>
  31. 33. <ul><li>Four degrees of Placenta Previa </li></ul><ul><li>Low lying (lower rather than upper implantation) </li></ul><ul><li>Marginal (placenta edge approaches cervical os) </li></ul><ul><li>Partial (implantation occludes a portion of the cervical os) </li></ul><ul><li>Total – implantation totally obstruct cervical os) </li></ul>
  32. 34. <ul><li>Bleeding is an Emergency (Fetal oxygen supply may be compromised and premature labor may begin) </li></ul><ul><li>Assessment (amount of blood loss in layman’s estimate term; duration, accompanying pain if any. </li></ul><ul><li>Bedrest with oxygen as prescribed. </li></ul><ul><li>Positioning: Sidelying or trendelenburg 72 hours. (Sitting position for fetus to compress the placenta- Lippincott) </li></ul><ul><li>No IE or Rectal exam, as it may initiate massive hemorrhage! (If necessary must be done in OR with double set up). </li></ul><ul><li>Monitor fetal status (FHT and movement) </li></ul><ul><li>Determine fetal lung maturity (amniocentesis) </li></ul><ul><li>Keep IV line and make blood available (Blood typed and crossmatched) </li></ul><ul><li>Note: Has a greater risk for post partum hemorrhage, as lower uterine segment does not contract as efficiently as the upper segment. Endometritis is also common as placental site is close to cervix (portal of entry) </li></ul>
  33. 35. <ul><li>C. Therapeutic interventions </li></ul><ul><li>1. At the end of pregnancy, CS birth or cutting of suture for vaginal birth </li></ul><ul><li>2.   Bed rest </li></ul><ul><li>  </li></ul><ul><li>Nursing Care </li></ul><ul><li>Maintain on bed rest for 24 hour after cerclage </li></ul><ul><li>Monitor for rupture of membranes or bleeding </li></ul><ul><li>Monitor FHR </li></ul><ul><li>  </li></ul><ul><li>  </li></ul>
  34. 36. <ul><li>Clinical manifestations </li></ul><ul><li>1.       Painless, bright red bleeding, hemorrhage in the third trimester </li></ul><ul><li>2.      Soft uterus in the latter part of pregnancy </li></ul><ul><li>Signs of infection may be present </li></ul>
  35. 37. Therapeutic Interventions <ul><li>Ultrasonography to confirm the presence of placenta previa </li></ul><ul><li>Control bleeding </li></ul><ul><li>Replace blood loss if necessary </li></ul><ul><li>CS if necessary </li></ul><ul><li>Bethamethasone is indicated to increase fetal lung maturity </li></ul><ul><li>  </li></ul>
  36. 38. Nursing Care <ul><li>No admission vaginal examination </li></ul><ul><li>Maintain on bed rest in semi-Fowler’s position </li></ul><ul><li>Monitor fetal heart rate and maternal vital signs continuously </li></ul><ul><li>Assess perineal pads to determine blood loss </li></ul><ul><li>Administer IV therapy or blood replacement </li></ul><ul><li>  </li></ul>
  37. 39. TORCHS <ul><ul><li>T – Toxoplasmosis ( Toxoplasma gondii): can be acquired by eating raw or undercooked meat or by contact with the feces of infected animals; organism crosses the placenta; </li></ul></ul><ul><ul><li>severity of infection related to gestational age; can cause hydrocephalus and intracranial calcification in the infant. </li></ul></ul><ul><ul><li>Incidence of abortion, stillbirths, neonatal deaths, and severe congenital anomalies </li></ul></ul>
  38. 40. TORCHS <ul><ul><li>O – Others (HIV, gonorrhea, [Neisseria gonorrhea], human papillomavirus, varicella zoster, group B streptococcus, hepatitis B, measles, mumps) </li></ul></ul>
  39. 41. <ul><ul><li>R – Rubella (rubella virus): greatest risk to the fetus when maternal infection occurs in first 12 weeks of gestation; baby may be born with encephalitis, ocular abnormalities, cardiac maldevelopment , and other defects; these infants may have active viral infection and should be isolated until pharyngeal mucus and urine are free of virus; for mothers who have not rubella or who are serologically negative, rubella vaccine should be given in the immediate post birth period, not during pregnancy. </li></ul></ul>
  40. 42. <ul><li>Rubella - first trimester in between 3 rd and 7 th week of pregnancy – death </li></ul><ul><li>Early 2 nd trimester – permanent hearing impairment </li></ul><ul><li>Leukemia in childhood has been noted. Thus infected newborns often die in early in infancy. </li></ul>
  41. 43. <ul><ul><li>C – Cytomegalic inclusion disease (cytomegalovirus): pregnant women usually asymptomatic; this sexually transmitted infection may cause hemolytic anemia, hydrocephalus, microcephalus, intrauterine growth retardation, or neonatal death </li></ul></ul>
  42. 44. <ul><ul><li>H – Herpes genitalis (herpesvirus): contracted by the mother during sexual relations characterized by periods of exacerbations and remissions; first attack most severe; intercourse must be avoided during last 4 to6 weeks of pregnancy; during active stage the infant must be delivered by cesarean birth; if delivered vaginally, neonatal infection can be disseminated and result in death; surviving infants suffer CNS involvement </li></ul></ul><ul><ul><li>There is 20 – 50% rate of spontaneous abortion if infection occurs during the 1 st trimester. Infection after the 20th week AOG leads to incidence of premature births but not to teratogenic defects. The neonate can acquire the infection. </li></ul></ul><ul><ul><li>Survivors have permanent visual damage and impaired psychomotor and intellectual development. </li></ul></ul>
  43. 45. <ul><ul><li>S – Syphilis </li></ul></ul><ul><ul><li>Therapeutic interventions: care is directed toward prevention and early treatment in the pregnant woman to eliminate or reduce risk to the fetus </li></ul></ul>