placenta preavia and abruptio placentae

1. PRESENTED BY
HEMALATHA H
Assistant Professor
M.Sc Nursing (OBG Nursing)
Sri Kalabyraveshwara college of
Nursing
Bangalore

2.  Vaginal Bleeding : Bleeding from the genital tract.
 Couvelaire uterus : Bruised or oedematous uterus.
 Stallworthy’s sign: Slowing of the fetal heart rate on pressing the
head down into the pelvis is suggestive of the presence of low lying
placenta in posterior type
 Vasa praevia: The unsupported umbilical vessels in velamentous
placenta, lie below the presenting part and run across the cervical os.
 Abruptio placentae: It is one form of antepartum hemorrhage
where the bleeding occurs due to premature separation of normally
situated placenta.

3.  DEFINITION
Bleeding from or into the genital tract after the
28th week of pregnancy but before the birth of the
baby.

4. CAUSES
APH
Placental bleeding
(70%)
Unexplained
(25%)
Extra placental (5%)
Placenta
praevia (35%)
Abruptio
placenta (35%)
Local Cervico-vaginal lesions,
Cervical polyp, Ca cervix, Varicose
vein, Local trauma

5. ANTEPARTUM HAEMORRHAGE
PLACENTA PRAEVIA ABRUPTIO PLACENTAE

6.  DEFINITION
Placenta is partially or totally implanted over
the lower uterine segment either on the anterior or
posterior wall of the lower uterine segment.

7.  Dropping down theory.
 Persistence of chorionic activity.
 Defective decidua.
 Large placenta as in twin pregnancy.

8.  First degree ( TYPE – I )
 Second degree ( TYPE – II )
 Third - degree ( TYPE – III )
 Fourth - degree ( TYPE – IV )

10.  The placenta is
near the edge of
the cervix

11.  The placenta is
partially over the
cervix

12.  The placenta
completely covers
the cervix

13.  It is the type – II posterior placenta praevia.
It may lead to fetal anoxia and death due to
cord compression or cord prolapsed and
also placenta is compressed.

14. OTHER DEGREES OF PLACENTA PRAEVIA
Mild degree Major degree
placenta praevia placenta praevia
Type – I
Type – 2
anterior
Type – 2
posterior
Type – 3 Type – 4

15. › Sudden in onset
› causeless,
› painless and
› recurrent bright-red vaginal bleeding.

16.  General examination
 Abdominal examination
STALLWORTHY’S SIGN
 Vaginal examination

17.  Laboratory diagnosis / Placentography
 Clinical diagnosis

18.  Transabdominal
sonography
 Transvaginal
sonography
 Transperineal
sonography

19.  Color doppler flow study
 Magnetic resonance imaging

20.  Double set-up examination ( Vaginal examination)
 Direct examination or visualisation of the placenta
during caesarean section

21. Maternal:
 During pregnancy
 Abortion, Preterm labour
 Malpresentation and non-engagement.

22. During labour:
 Premature rupture of membranes.
 Cord prolapse, Uterine Inertia.
 Obstructed labour.
 Postpartum haemorrhage.
 Retained placenta.

23. Puerperium:
 Sepsis.
 Subinvolution.
 Embolism.

24. Foetal
 Foetal mortality rate is 20 %.
 Prematurity, Asphyxia.
 Congenital malformations (2%).
 Intrauterine death.
 Birth injuries.

25. Prevention:
 Adequate antenatal care- prevention of
anaemia
 Antenatal diagnosis
 Warning signs care
 Significance of warning hemorrhage
 Family planning and limitation of births.

26.  AT HOME
 AT HOSPITAL

27. Diagnosis :
 Altered Tissue Perfusion related to excessive
bleeding causing fetal compromise
 Fluid volume deficit related to excessive
bleeding
 Risk for infection related to excessive blood loss
 Anxiety related to excessive bleeding
 Fear related to outcome of pregnancy after
episodes of bleeding

28.  DEFINITION
Abruptio placentae is
defined as the
detachment of part or
all of the placenta from
its implantation site.

29.  Bleeding occurs due to
premature separation
of normally situated
placenta.

30.  Revealed
 Concealed
 Mixed

32.  High birth order
 advanced maternal age
 poor socio-economic status
 Malnutrition
 smoking

34.  Grade-0
 Grade-1
 Grade -2
 Grade-3

36. Sl.n
o
Revealed Concealed
1 symptoms Abdominal pain followed by bleeding
(slight)
Acute intense abdominal pain followed
by slight vaginal bleeding. Pain is
continuous
2 Characteristics
of bleeding
Slight to moderate, continuous, dark
colored
Continuous, dark color, or blood stained
serous discharge
3 General
condition
Proportionate to the amount of blood
loss. Shock absent
Shock is pronounced
4 pallor Related to the amount of blood loss Severe
5 Feature of
eclampsia
May be absent Usually present
6 Uterine height Proportionate to the gestational period Disproportionately enlarged and globular
7 Uterine feel Normal feel with localized tendernes Tense, tender and rigid
8 Fetal parts Can be identified easily Difficult to make out
9 F.H.S Usually present Usually absent

37.  Woman’s history and physical examination
and laboratory studies.
 It is suspected in the woman presenting with
sudden onset, intense, usually localized
uterine pain, with or without vaginal bleeding.

38. Sl.
no
MARGINAL SEPARATION MODERATE SEPARATION SEVERE SEPARATION
1 Bleeding: external,
vaginal
Minimal Absent or moderate Absent to moderate
2 Color of blood Dark red Dark red Dark red
3 Shock Absent Common Very common: often
sudden
4 Coagulopathy Rare Occasional Common
5 Uterine tonicity Normal Increased Tetanic, persistent uterine
contraction: boardlike
uterus
6 Tenderness(pain) Usually absebt; if present , is
localized
Increased – usually diffuse
over uterus
Agonizing unremitting
uterine pain
7 ULTRASONOGRAPHY
Location of placenta
Normal- upper uterine
segment
Normal- upper uterine
segment
Normal- upper uterine
segment
8 Station of presenting
part
Variable to engaged Variable to engaged Variable to engaged
9 Fetal position Usual distribution Usual distribution Usual distribution

39. MATERNAL
• Maternal shock
• Postpartum hemorrhage
• Acute respiratory distress syndrome
• Renal tubular necrosis
• Rapid labor and delivery
• Maternal and fetal death
• Prematurity

40.  Prematurity
 Anoxia due to
placental separation
 Fetal death

41. Prevention: elimination of known factors likely
to cause placental separation, avoidance of
trauma, correction of anaemia, prompt
decision and treatment.
TREATMENT
 At Home: treatment as that of placenta
praevia.

42.  Ineffective tissue perfusion (placental)
related to excessive bleeding, hypotension,
and decreased cardiac output, causing fetal
compromise
 Acute Pain related to increase uterine
activity
 Fluid volume deficit related to excessive
bleeding
 Risk for infection related to excessive blood
loss
 Fear related excessive bleeding procedures
and unknown outcome

43. Placenta praevia Abruptio placentae
Clinical features:
Nature of bleeding Painless, causeless and
bleeding is always revealed
Painful
Bleeding is revealed,
concealed or usually mixed
Character of blood Bright red Dark coloured
Feature of pre-
eclampsia
Not relevant Present in one- third cases
Abdominal
examination:
Height of the uterus
Proportionate height disproportionate
Feel of the uterus Soft and relaxed Tensed, tender, rigid
Malpresentation common Not common
FHS present Absent in case of concealed
type
Placentography Placenta in lower segment Placenta in upper segment

44. This include a variety of clinical entities where a
confident diagnosis of placenta praevia or abruptio
placenta cannot be made or there is no local lesion.
Possible causes:
 marginal sinus haemorrhage
 circumvallate placenta
 excessive show.

45. The unsupported umbilical vessels in
velamentous placenta, lie below the
presenting part and run across the cervical
os. These vessels are torn either
spontaneously or during rupture of
membranes. Color-flow Doppler is helpful for
antenatal diagnosis. Fetal mortality is high
(50%) due to fetal exsanguinations.

47.  If patient is not in labour and pregnancy less
than 38 weeks; expectant treatment as in
placenta praevia.
 At 38 weeks; if placental tissue is not felt in
the lower segment, LROM is done. Oxytocin
infusion maybe added.