Placenta previa Placenta previa is the development of the placenta in the lower uterine segment, partially or completely covering

the internal cervical os. A. Cause 1. Largerly unknown, although multiparity and advancing age favor occurrence 2. Unfavorable deciduas in upper uterine segment (figbroid tumors, poorly vascularized endometrium) B. Clinical Manifestations 1. Painless vaginal bleeding in the latter half of pregnancy; occurs without warning in the absence of trauma. 2. Initial episode of bleeding is rarely fatal; in each subsequent episode, bleeding is heavier. 3. Placenta previa may not cause bleeding until labor begins or until complete dilation has occurred. 4. Bleeding occurs earlier and is more profuse with total placenta previa. Placenta previa is classified according to the placement of the placenta:


Type I or low lying: The placenta encroaches the lower segment of the uterus but does not infringe on the cervical os. Type II or marginal: The placenta touches, but does not cover, the top of the cervix. Type III or partial: The placenta partially covers the top of the cervix Type IV or complete: The placenta completely covers the top of the cervix

  

Risk Factors


Previous placenta previa, caesarean deliveryor D&C e.g. used for incomplete or missed miscarriage, abortion, to treat or investigate heavy bleeding or other diagnostic purposes.

Women who have had previous pregnancies, especially a large number of closely spaced pregnancies, are at higher risk. Women who are younger than 20 are at higher risk and women older than 30 are at increasing risk as they get older. Women with a large placentae from twins or erythroblastosis are at higher risk. Race is a controversial risk factor, with some studies finding that people from Asia and Africa are at higher risk and others finding no difference.

 

Nursing Interventions Monitor hemoglobin, hematocrit, WBC, and differential counts. Determine amount of bleeding, length of bleeding, any previous episodes. Monitor vital signs, including fetal heart tones. Evaluate contractions, if present. Since the diagnosis is usually made by ultrasound, prepare the woman for the procedure. 6. See that the woman is maintained on bed rest; delivery delayed to increase fetal maturity. 7. Continue to monitor vital signs (including fetal heart rate) and vaginal bleeding, Hb, and Hct. 8. Be ready to prepare the woman for delivery. 9. If profuse hemorrhage occurs, cesarean delivery will be performed using the classic approach to avoid incision into placenta in lower uterine segment. 10. In rare instance, vaginal delivery may be used; membranes are ruptured and pressure of fetal presenting part applies pressure to bleeding site 1. 2. 3. 4. 5. Abruptio Placenta Abruptio placenta is premature separation of the normally implanted placenta. Predisposing Factors 1. 2. 3. 4. 5. Hypertensive disease Renal disease Increased incidence in women over 30 Increased incidence in women with parity of 5 or more Interference of flow of blood to intervillous space

TYPES OF ABRUPTIO PLACENTA: 1. Covert Abruptio Placenta The placenta separates centrally and the blood is trapped between the placenta and uterine wall. 2. Overt Abruptio Placenta The blood passes between the fetal membranes and the uterine wall and escapes vaginally. May develop abruptly or progress from mild to extensive separation with external hemorrhage. 3.Severe Abruptio Placenta Massive vaginal bleeding is seen in the presence of almost total separation

with possible fetal cardiac distress. Clinical Manifestations



Class 0: asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta. Class 1: mild and represents approximately 48% of all cases. 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: moderate and represents approximately 27% of all cases. 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: severe and represents approximately 24% of all cases. 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

Risk Factors
 

Maternal hypertension is a factor in 44% of all abruptions. Maternal smoking is associated with up to 90% increased risk.

Maternal drinking of alcoholic beverages within a year before conception and during pregnancy can increase the risk by a factor 3 to 4 Maternal trauma, such as motor vehicle accidents, assaults, falls or nosocomial infection. Short umbilical cord Prolonged rupture of membranes (>24 hours) Retroplacental fibromyoma Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk. Previous abruption: Women who have had an abruption in previous pregnancies are at greater risk. some infections are also diagnosed as a cause cocaine intoxication

     

 

The risk of placental abruption can be reduced by maintaining a good diet including taking folic acid, regular sleep patterns and correction of pregnancy-induced hypertension.

Nursing Interventions 1. Administer IV fluids and whole blood to replace blood loss, as prescribed. 2. Monitor blood pressure, pulse, respiration, and fetal heart tones to detect impending shock and to assess fetal condition. 3. Monitor vaginal bleeding and height of fundus to detect increasing concealed hemorrhage. 4. Administer fluids or blood as precibed. 5. Monitor fetal heart tones continuously to assess fetal well-being. 6. Provide oxygen therapy of prescribed. 7. Maintain the woman in side-lying position to keep uterus off vena cava, thereby improving blood flow to intervillous spaces. 8. Prepare the woman for immediate delivery-vaginally if the abruption is slight and the cervix dilated; cesarean delivery is used most frequently because it allows immediate delivery of infant.

Characteristic Onset Bleeding Pain and uterine tenderness Fetal heart tone Presenting part Shock Delivery

Abruptio Placentae Third trimester

Placenta Previa Third trimester ( commonly in eighthmonth) May be concealed, external dark Mostly external, small to profuse in hemorrhage, or bloody amniotic fluid amount, bright red Usually present; irritable uterus, progresses Usually absent; uterus soft to board-like consistency May be irregular or absent Usually normal May or may not be engaged Usually not engaged Moderate to severe depending on extent of Usually not present unless bleeding is concealed and external hemorrhage excessive Immediate delivery, usually by cesarean Delivery may be delayed, depending on size of fetus and amount of bleeding

Pregnancy-Induced Hypertension Hypertensive disorders induced by pregnancy or complicated by pregnancy rank among the leading causes of maternal mortality and make a significant contribution to prenatal mortality. Types of Hypertensive Disorders A. Gestational Edema The occurrence of a general and excessive accumulation of fluid in the tissues of greater than 1+ pitting edema after 12 hours rest in bed, or of a weight gain of 2 kg. (5 lbs.) or more in a week caused by pregnancy. B. Gestational Proteinuria The presence of proteinuria during pregnancy, in the absence of hypertension, edema, renal infection, or known intrinsic renovascular cause. C. Gestational Hypertension The development of hypertension during pregnancy or within the first 24 hours postpartum in a previously normotensive woman. D. Preeclampsia 1. The development of hypertension with proteinuria, edema, of both caused by pregnancy or a recent pregnancy. 2. It occurs after the 20th week of gestation by may not develop before this time in the presence of trophoblastic disease. 3. Preeclampsia is predominantly a disease of primigravidas. E. Eclampsia The occurrence of one or more convulsions, not attributable to other cerebal disorders such as epilepsy or cerebal hemorrhage, in a patient with preeclampsia. F. Chronic hypertensive Disease The presence of persistent hypertension, of whatever cause, before pregnancy or prior to the 20th week of gestation, or persistent hypertension beyond the 42nd day of the postpartum period. Etiology 1. Unknown 2. Theories include; a. Uterine ischemia b. The woman is extremely sensitive to vasopressor agents ( implicated catecholamines, prolactin, vasopressin, prostaglandins) c. Autoimmune disease d. Deficiency of dietary protein 3. Contributing factors

a. Age and parity appears most frequently in young primigravidas b. Socioeconomic status-greater incidence in lower socioeconomic groups c. Greater incidence in women with diabetes, multiple pregnancies, polyhydramnios, molar pregnancies, obesity, and history or previous hypertension in pregnancy

Symptoms and signs of Preeclampsia Signs and Symptoms Mild preeclampsia Hypertension Definition Increase of 30mm. Hg or more systolic, or systolic level of 140 mm. Hg or more; increase of 15mm. Hg or more diastolic, or diastolic level 90 mm. Hg Or more +1 +2 or 1 gm./liter in midstream or catheterized urine specimen (found in 2 specimens at least 6 hours apart) Generalized, facial, hands, and fingers; reflected in a rapid weight gain of over 0.7 kg. (1.5 lbs.) per week 160/110 mm. Hg or above 5 gm. Or more in 24 hours urine collection or +3 or +4 reading on turbidometric analysis In addition to generalized edema, possibly pitting edema; weight gain may be 0.9 kg. (2 lbs.) or more over a period of 1 week or less

Proteinuria

Edema

Severe preeclampsia Hypertension Proteinuria Edema

Headache Blureed vision Oliguria (less than 400 ml. in 24-hours urine collection) Epigatric pain Clinical manifestation A. B. C. D. E. Weight gain first indication, over 0.7 kg. (1.5 lbs.) per week, as early as the 20th week Ankle edema, digital swelling, periorbital edema, then pretible fluid collection Hypertension 140/90 or increase of 30 mm. Hg systolic or 15mm. Hg diastolic Proteinuria Cerebral and neulogic involvement frontal headache, vertigo, tinnitus, visual disturbance, drowsiness, hyperreflexia, apprehension, exciatablility, nausea, and vomiting

F. Positive rollover rest a procedure carried out between the 20th and 32nd weeks in which the blood pressure is checked with the woman first on their side and then on their back. A test is positive then there is an increase of 20mm. Hg in diastolic pressure. Eighty percent to ninty percent of women with a positive rollover test develop pregnancy-induced hypertension. Some clinicians report less success with the test as a screening device.

Possible Complications a. b. c. d. e. f. g. Eclampsia Abruption placenta Pulmonary edema Congestive heart failure Cerebral edema Detached retina Renal damage (monitor output carefully for oliguria)

Nursing Interventions 1. When symptoms appear, the woman is placed on bed rest in left lateral recumbent position; increases renal and uterine blood flow promiting diuresis and reducing blood pressure 2. Monitor blood pressure every 4 hours (if at home, family member or friend may do this); deep tendon reflexes are also monitored. 3. Take daily weight; and measure intake and urinary output. 4. Offer high-protein diet and normal fluid intake. 5. Sodium is not restricted unless edema is severe of cardiac complications occur. 6. Fetal condition is monitored via nonstress tests, urinary estriol desterminations and ultrasound measurements of fetal growth. 7. If preeclampsia is severe, drugs may be used to control hypertension; magnesium sulfate (administered intramuscularly in 50% solution with 1% procaine; infection is painful and may cause abscess formation. Continuous IV infusion may be preferred; depress myoneural junction, decreases hyperreflexia, and increases vasodilatation. Nursing Alert: Repeat doses of magnesium sulfate only of (1) deep tendon reflexes are present, (2) respirations are above 12 per minute, and (3) urine output is at least 100 ml. per 6 hours. Calcium gluconate 10% IV must be available to counteract magnesium toxicity. 8. Sedative may be used to promote rest.

9. Pregnancy is maintained until at least the 36th week. 10. In instances of severe eclampsia; a. Provide a quite environment, avoiding stimuli that could provoke seizures. b.Evaluate vital signs through continuous monitoring. c. Provide safety measures; be prepared for sudden seizures. 1) Have padded siderails in place. 2) Have tongue blade available. 3) Have emergency equipment (oxygen, suction, airway, tracheostomy tray) ready for immediate use. 4) Have emergency medications immediately available; IV sedation and inhalation anesthesia may be needed to control convulsions; IV fluids to be initiated 5) Observe for indications of uterine contractions; convulsions may initiate labor. 6) Provide continuous observation and care 7) Position the woman to promote drainage of respiratory passages; maintain clear airway; monitor for pulmonary edema. 8) Insert indwelling catheter to monitor output and renal status.

Medications used in treatment of hypertensive disorders of pregnancy Drug Magnesium Sulfate Use Anticonvulsant depress CNS function, especially at neuromuscular junction; reduces muscle excitability; peripheral vasodilation; inlarge doses acs as osmotic disuretic. Dose IM: 10 initially as 50% solution followed by 5 gm. Every hour until reflexes are reduced. IV: loading dose of 4 gm. Given over 10 minutes; followed by 1 gm./ hour until therapeutic blood levels of 6-7 mEq./ liter are reached IV: up to 0.25 gm. Injected over a 3 minute period IV: 5 mg. IM: 10 mg. Dose is administered every 2 hours until convulsions are controlled Oral: 30-100 mg. BID or TID in preeclampsia IM or IV; large doses for eclampsia IV: when diastolic blood pressure is 110 mm. Hg test dose 5 mg. followed by 10 mg., repeated until diastolic blood pressure is 90-100 mm. Hg (usual dose-5-20 mg.) Adverse reactions Respiratory depression of deep tendon reflexes; IM injections may produce pain and swelling at injection site

Sodium amobarbital ( Soduim Amytal) Diazepam (Valium)

Anticonvulsant; sedative used in eclampsia when convulsion persist Anticonvulsant; used to control or reduce convulsions

Fetal tachycardia and loss of fetal heart rate variability, newborn lethdepression failure to suck Tolerance may develop; rashes; ataxia Chills, fever, depression, headache, palpitations, dizziness, vomiting, tachycardia, sweating

Phenobarbital

Sedative; anticonvulsant (raises threshold for seizures) Antihypertensive; dilation of vascular smooth muscle, especially arterioles

Hydralazine (Apresoline)

SUBMITTED BY: PONCIANO, CHRISTINE GRACE BOLO, SHENNA MARIAN DIO, DANICA NATIVIDAD, BRIAN JOHN SUAREZ, AMADEO

SUBMITTED TO: MS. ANABELLE T. REJANO