4. PLACENTA PRAEVIA
•When the placenta is implanted partially or
completely over the lower uterine segment it is
called placenta praevia.
5. INCIDENCE
0.5-1% amongst hospital deliveries.
One third of all cases of antepartum
haemorrhage are due to placenta previa.
Higher incidences have been reported in
multiparous, multiple pregnancies, elderly woman
[ over 35 years]
6. ETIOLOGY
-Exact etiology is unknown.
Dropping theory
•The fertilized ovum drops down and implanted in
the lower uterine segment. Poor decidual reaction
in the upper uterine segment may be the cause.
This explains the formation of central placenta
previa.
7. Persistence of chorionic activity
•Chorionic activity in the deciduas capsularis and
its subsequent development into capsular placenta
which comes in contact with decidua vera of the
lower segment can explain the formation of lesser
degrees of placenta previa.
8. Defective deciduas
•It results in the spreading of the chorionic villi
over wide area in the uterine wall to get
nourishment. During this process not only the
placenta become membraneous but encroaches
onto lower segment. Such a placenta may invade
the underlying decidua or myometrium to cause
placenta accrete, increta or percreta.
9. Big surface area of the placenta
•Big placenta as in twins may encroach onto lower
segment.
10. PREDISPOSING FACTORS
Multiparity
Increased maternal age
History of previous caesarean section or any
other scars in the uterus.
Placental size
Smoking
Leiomyomas distorting uterine cavity
Congenital malformations of the uterus.
Prior curettage
11. PATHOLOGICAL ANATOMY
Placenta
•The placenta may be large and thin. This is often
tongue shaped extension from the main placental
mass. Extensive areas of degeneration with
infarction and calcification may evident. The
placenta may be morbidly adherent due to poor
decidual formation in the lower segment.
12. Umbilical cord
•The cord may be attached to the margin or into
the membranes. The insertion of the cord may be
close to the internal os or the fetus blood vessels
may run across the internal os in velamentous
insertion due to poor placental formation
13. Lower uterine segment
•Due to increased vascularity, the lower uterine
segment and the cervix becomes soft and more
friable.
16. Dangerous placenta previa is the name given
to the type-II posterior placenta previa.
•Because of curved birth canal major thickness of the
placenta overlies the sacral promontory, thereby
diminishing the antero-posterior diameter of the
inlet and prevents engagement of the presenting
part. This hinders effective compression of the
separated placenta to stop bleeding.
•Placenta is more likely to compressed if vaginal
delivery is allowed.
•More chance of cord compression or cord
prolapsed.
17. CAUSE OF BLEEDING
•Progressive dilatation of lower segment & the
inelastic placenta shears off the wall of lower
segment
•May be provoked by trauma including vaginal
examination, coital act, external version or during
high rupture of membranes.
18. •Thrombosis of the open sinuses.
•Mechanical pressure by the presenting part .
•Placental infarction.
Mechanism of spontaneous control of bleeding
20. Signs
Abdominal examination
•Size of the uterus is proportionate to the period
of gestation.
•The uterus feels relaxed, soft and elastic
without any localized areas of tenderness.
•Persistence of malpresentations
•The head is floating in contrast to the period of
gestation.
21. •The FHS is usually present unless there is major
separation of the placenta. Slowing of the FHS on
pressing the head down into the pelvis which soon
recovers promptly as the pressure is released is
suggestive of the presence of low lying placenta
specially of posterior type it is known as
Stallworthy’s sign.
22. Vulval inspection :
•Only inspection is to be done to check whether
bleeding is still occurring or has ceased
•In placenta praevia the blood is bright red as the
bleeding occurs from the separated utero placental
sinuses close to the cervical opening and escape
out immediately.
•Vaginal examination must not be done outside
the operation theatre in the hospital.
23. DIAGNOSIS
History and clinical features
• Painless and recurrent vaginal bleeding
in the second half of pregnancy should be
taken as placenta praevia unless proved
otherwise.
24. Placentography
•Sonography
Transabdominal
•The accuracy after 30th week of gestation is about
98%.
Transvaginal (TVS)
•The probe is very close to the target area. it is
more accurate than TAS.
Transperineal (TPS)
•It is well accepted by patients. Internal os is
visualized in 97-100% of cases.
25. Color doppler flow study
•Prominent venous flow in the hypo-echoic areas
near the cervix is consistent with the diagnosis of
placenta praevia.
MRI
•It is a non invasive method without any risk of
ionizing radiation.
26. Clinical confirmation of placenta preavia
•Double set up examination (vaginal
examination)
• it is less frequently done these days. Indications
are
•inconclusive USG report
•USG reveals type I placenta preavia
•USG facilities not available
27. Visualization of the placental implantation on the
lower segment can be confirmed during caesarean
section.
Examination of the placenta following vaginal
delivery reveals;
•a tongue shaped, thin segment of placental tissue
projecting beyond the main placental mass with
evidences of degeneration.
•Rent on the membranes on the margin of the
placenta.
•Abnormal attachment of the cord.
30. During labour
•Early rupture of membranes.
•Cord prolase.
•Slow dilatation of the cervix.
•Intrapartum haemorrhage.
•Increased incidence of operative interference.
•Post partum haemorrhage
•Retained placenta
31. During puerperium
•Sepsis is increased due to operative interference.
Placental site near the vagina
Anemia and devitalized state of the
patient
•Subinvolution
•Embolism
32. •Fetal complications
•Low birth weight
•Asphyxia:
Early separation of placenta
Compression of the placenta
Compression of the cord
•Intrauterine death
•Birth injuries
•Congenital malformation
33. PROGNOSIS
Maternal death reduction due to:
•Early diagnosis
•Omission of internal examination outside the
hospital.
•Free availability of blood transfusion facilities.
•Potent antibiotics.
•Wider use of caesarean section with expert
anaesthetist.
•Skill and judgement with which the cases are
managed.
34. Fetal(Perinatal) death reduction due to:
judicious extension of expectant treatment
thereby reducing the loss from prematurity
liberal use of caesarean section which greatly
lessens the loss from anoxia
improvement in the neonatal care unit.
36. Management at home
•The patient is immediately put to bed.
•Assess the blood loss- clothing with blood, vital
signs, degree of anemia.
•Quick but gentle abdominal examination.
•Vaginal examination must not be done.
37. •Hospital treatment
•Shift the patient to an equipped hospital-
emergency CS, NICU etc.
•An intravenous dextrose saline drip.
•Patient should be accompanied by 2/3 persons fit
for donation of blood if necessary.
•All cases of APH should be admitted.
38. TREATMENT ON ADMISSION
1. Immediate attention
•Amount of blood loss.
•Blood samples are taken for grouping, cross
matching and Hb.
•A large bore IV cannula is sited and an infusion of
normal saline is started.
•Gentle abdominal palpation.
•Inspection of the vulva.
•Confirmation of diagnosis from history, PE,
Sonography.
39. •Formulation of line of treatment
Expectant management
Active (Definite)management
40. Expectant management
The policy was advocated by Macafee
&Johnson
•Vital prerequisites
•Availability of blood for transfusion
•Facilities for caesarean section 24 hrs
•Selection of cases
•Mother is in good health status.(Hb >10 gm%,
haematocrit >30%)
•Duration of pregnancy is <37 weeks.
•Active vaginal bleeding is absent.
•Fetal well being is assured by USG.
41. Expectant management
•Bed rest.
•Investigations-Hb, Blood Grouping, Urine for
protein
•Periodic inspection of vulval pads & USG 2-3 weeks
•Supplementary haematinics.
•When the patient is allowed out of bed a gentle
speculum examination is made to exclude local
cervical and vaginal lesions for bleeding.
•Use of tocolytics(MgSO4)
•Cervical encirclage is not helpful.
•Rh immunisation to Rh negative unsensitised
mothers
42. •Expectant management at home
•Patient lives close to hospital
•24 hour transportation is available
•Bed rest assured
•Patient is well motivated to understand the risks
43. Termination of the expectant treatment
•The expectant management is carried upto 37
weeks of pregnancy. By this time baby become
mature.
•Premature termination is done in conditions such
as
Presence of brisk haemorrhage and which is continuing.
The fetus is dead.
The fetus is found congenitally malformed on
investigation.
Steroid therapy
• It is indicated when duration of pregnancy is
<34 weeks. Betamethasone reduces the risk of
respiratory distress of the new born when preterm
delivery is considered.
44. Active management (Delivery)
•Bleeding occurs at or after 37 weeks of pregnancy.
•Patient is in labour
•Patient in exsanguinated state on admission.
•Bleeding is continuing and of moderate degree.
•Baby is dead/congenitally deformed.
46. Vaginal examination
•Contraindications
•Patient in exsanguinated state
•Diagnosed cases of major degrees of placenta
preavia confirmed by USG.
•Associated complications like malpresentations,
elderly primigravida, pregnancy with h/o previous
caesarean section, contracted pelvis etc.
47. Low rupture of membranes
• Low rupture of membrane is done using long
Kocher’s forceps in lesser degrees of placenta
praevia (type I & type II anterior).
Precautions during vaginal delivery
•steps to restore the blood volume.
•Methergine 0.2 mg.
•Proper examination of the cervix should be done
soon following delivery.
•Baby’s blood Hb level is to be checked.
48. Caesarean section
Indications
•Severe degree of placenta praevia(type-II
posterior, type-III,type-IV)
•Lesser degree of placenta praevia where
amniotomy fails to stop bleeding or fetal distress
appears.
•Complicating factors associated with lesser
degrees of placenta praevia where vaginal delivery
is unsafe.
49. Caesarean section without internal
examination
•If precise location of placenta.
•It should be performed by senior obstetrician with
the help of a senior anesthetist.
•Regional anaesthesia is generally avoided.
•If patient is in shock, and the bleeding continues,
operation has to be performed immediately along
with restorative measures.
•Low transverse abdominal incision is to be
avoided; infra umbilical longitudinal incision is
preferred.
50. NURSING CONSIDERATIONS
•Strict bed rest
•Patient teaching
•Home visits for comprehensive fetal and maternal
assessment
•Specific, information about the condition of the
fetus.
•Make the family understand.
In patient care
•Nursing assessments
•Periodic electronic fetal monitoring
•Immediate delivery
51. ABRUPTIO PLACENTAE-
DEFINITION
•It is one form of anteparum hemorrhage where
the bleeding occurs due to premature separation of
normally situated placenta.
53. ETIOLOGY
•Exact etiology is obscure in majority of
cases.
Prevalence is more with:
•High birth order pregnancies with gravid
5 and above- three times more common
than in first birth.
•Advancing age of the mother.
•Poor socio economic condition.
•Malnutrition.
•Smoking
55. PATHOGENESIS
•premature separation is initiated by haemorrhage
into the deciduas basalis. (decidual haematoma)
•The decidual hematoma may be small and self
limited
•If major spiral artery ruptures, a big hematoma is
formed.
•As the uterus remains distended by the
conceptus, it fails to contract and therefore fails to
compress the torn bleeding points.
56. •Couvelaire Uterus( Utero placental apoplexy)
It is a pathological entity in association
with severe form of concealed abruption placentae.
There is massive intravasation of blood into the
uterine musculature upto the serous coat. The
condition can only be diagnosed on laprotomy.
57. •Changes in other organs
•In the liver presence of fibrin knots in the
hepatic sinusoids.
•Kidneys may show acute cortical necrosis or
acute tubular necrosis.
•Shock protenuria, due to renal anoxia
58. Blood coagulopathy:
•Blood coagulopathy is due to excess
consumption of plasma fibrinogen due to
disseminated intravascular coagulation and retro
placental bleeding.
59. Clinical Classification(Page’s
classification)
•Grade -0 :
•Clinical features may be absent .The diagnosis
is made after inspection of placenta following
delivery.
•Grade -1 (40% ) :
•Vaginal bleeding is sight .
•Maternal BP and fibrinogen levels unaffected.
•No evidence of maternal shock
•FHS is good.
60. •Grade -2 (45% ):
•Vaginal bleeding mild to moderate.
•Uterine tenderness is always present .
•Maternal pulse is always increased, BP maintained.
•Shock or even death occurs.
•Grade -3 (15% ):
•Bleeding is moderate to severe or may be
concealed
•Uterine tenderness is marked .
•Maternal shock
•Fetal death
•Associated coagulation defect
61. CLINICAL FEATURES OF
ABRUPTIO PLACENTAE
The clinical features depend on :
•Degree of separation of placenta ,
•Speed at which separation occurs and
•Amount of blood concealed inside the uterine
cavity
62. CLINICAL FEATURES OF
ABRUPTIO PLACENTAE
Mild cases:-
-Slight vaginal bleeding
-mild abdominal pain
-Uterus is normal with lacalised tenderness
-FHS & urine output is normal
-coagulation profile is normal
Moderate cases:-
-sudden severe attack of pain,then vaginal bleeding starts.
-Tachycardia
-Tender uterus, FHS absent
Severe cases:-
-Acute abdominal pain, shock and collapse
-Tense and tender uterus
-Hypotension, diminished urine output
-FHS not heard.
63. DIFFERENTIAL DIAGNOSIS
Revealed type:
•Confusion with intermediate causes of APH is
difficult to eliminate.
Mixed or concealed type:
•Rupture uterus, rectus sheath hematoma,
appendicular or intestinal perforation, Twisted
ovarian tumour, Volvulus, acute hyramnios, tonic
uterine contraction.
64. COMPLICATIONS OF ABRUPTIO
PLACENTA
Maternal
•In revealed type
•maternal risk is proportional to the visible
blood loss and maternal death is rare.
•In concealed variety
•Haemorrhage
•Shock
•Blood coagulation disorders
•Oliguria and anuria
•Postpartum haemorrhage
• puerperal sepsis.
65. Fetal :
•In revealed type, the fetal death is to extent of
25- 30% .
•In concealed type, however, the fetal death is
appreciably high, ranging from 50-100%.
66. MANAGEMENT OF ABRUPTIO
PLACENTAE
Prevention:
•Elimination of known factors likely to produce
placental separation.
•Correction of anemia during antenatal period so
that the patient can withstand blood loss.
•Prompt detection and institution of the therapy
to minimize the grave complications such as shock,
blood coagulation disorders and renal failure.
67. •Prevention of known factors likely to cause
placental separation are :
•Early detection and effective therapy of pre-
eclampsia
•Needle puncture during amniocentesis should be
under ultra sound guidance.
•Avoidance of trauma–specially forceful external
cephalic version under anesthesia.
•To avoid sudden decompression of the uterus
•To avoid supine hypotension-Left lateral position
•Routine administration of folic acid from early
pregnancy
68. •Treatment:
•At home
•In the hospital :
▫Treatment is based on:
•Amount of blood loss.
•Maturity of the fetus
•Whether the patient is in labor or not (usually
labor starts).
•Presence of any complication.
•Type and grade of placental abruption.
69. •Emergency measures:
•Blood is sent.
•Ringer solution drip is started with a wide bore
cannula and arrangement for blood transfusion is
made for resuscitation.
• Close monitoring of maternal and fetal condition
is done.
70. 1.Definitive treatment
(immediate delivery):
•The patient is in labour:
▫Vaginal delivery is favored in cases with :
Limited placental abruption .
FHR tracing is reassuring .
Facilities for continuous (electronic ) fetal
monitoring is available .
Prospect of vaginal delivery is soon as or
Placental abruption of a dead fetus.
71. The patient is not in labour:
Pregnancy 37 weeks or greater:
Induction is done by low rupture of
membranes with or without oxytocin.
Indications of caesarean section are:
Appearance of fetal distress.
Amniotomy couldn’t be done or amniotomy
fails to control.
Associated complicating factors.
72. •Pregnancy less than 37 weeks:
Oxytocin drip may be added.
Bleeding slight or has stopped- the patient is
put on conservative treatment as outlined in
placenta praevia.
73. Induction of labour is done by low rupture
of membrane
•Oxytocin may be added to expedite delivery.
•Placenta with varying amount of retro-placental
clot is expelled in most often simultaneously with
the delivery of the baby.
•Inj. oxytocin 10.IU IV slowly or IM or Inj.
methergin 0.2 mg IV is given with the delivery of
the baby to minimize postpartum blood loss.
74. Caesarean Section : Indications
•Severe abruption of with live fetus.
•Amniotomy could not be done (un-favorable
cervix).
•Prospect of immediate vaginal delivery despite
amniotomy failed to arrest the process of
abruption (rising fundal height).
•Appearance of adverse (fetal distress, falling
fibrinogen level, oliguria).
•Anesthesia during caesarean section :
• Regional anesthesia is generally avoided when
there is significant hemorrhage.
75. •2.Expectant management in case of
placental abruption is an exception and
not the rule :
•Cases where bleeding is slight and has stopped
(grade I abruption), fetus reactive (CTG ) and
remote from term, may be considered.
•Continuous electric fetal monitoring
•Patient should be observed in the labour ward
for 24-48 hours.
•betamethasone is given to accelerate fetal lung
maturity in the event preterm delivery has to be
contemplated.
76. Management of complications :
The major complications of placental
abruption are :
•Haemorrhagic shock .
•DIC
•Renal failure.
•Uterine atony and post partum haemorrhage.
77. NURSING MANAGEMENT OF
BLEEDING IN LATE PREGNANCY
Nursing assessment:
•Amount and nature of blood
•Pain type and location
•Maternal vital signs.
•Uterine contractions.
•Obstetric history: gravid, para, previous
abortions, preterm infants, previous pregnancy
outcomes.
•Length of gestation:LMP, fundal height, co-
orelation of fundal height with estimated gestation.
•Laboratory data
78. Nursing diagnosis
•Deficient fluid volume related to excessive vascular
lose as evidenced by hypotension, increased pulse
rate, decreased/concentrated urine.
•Ineffective utero-placental tissue perfusion related
to hypovolemia as evidenced by changes in fetal
heart rate and activity.
•Activity Intolerance related to enforced bed rest
during pregnancy secondary to potential for
hemorrhage
•Anxiety related to unknown effects of bleeding and
lack of knowledge of predicted course of
management
