8/2/2015 1 mrs. mahdia samaha kony. 8/2/2015 2 mrs. mahdia samaha kony

04/19/231Mrs. Mahdia Samaha Kony

04/19/23 2Mrs. Mahdia Samaha Kony

Placenta previa occurs when any part of the placenta implants in the lower uterine segment in advance of the fetal presenting part.

Bleeding condition that occurs during the last two trimesters of preg.


Occurs in approximately 1 in 200 pregnancies.

More than 90% of placenta previas diagnosed in the second trimester resolve as pregnancy advances, secondary to differential growth of the placental trophoblastic cells toward the fundus.


Total (complete) placenta previa occurs when the entire internal cervical os is covered by placenta.

Partial (incomplete) placenta previa occurs when part of the internal cervical os is covered by placenta.

Marginal placenta previa occurs when the placental edge extends to within 2 cm of the internal cervical os.

Low-lying pp: occurs when the placenta is implanted in the lower uterine segment and is near the internal os but doesn’t reach it.


The cause of placenta previa is unknown

Endometrial damage from previous pregnancies and defective decidual vascularization have been postulated as possible mechanisms.


Maternal age. Placenta previa is three times more common at age 35 than at age 25.

Increasing parity. Previous uterine scar. Prior placenta previa. Tobacco and cocaine use. Multiple gestation. Previous myomectomy to remove fibroid


Sudden onset of painless vaginal bleeding in the second or third trimester.

Bleeding and uterine contractions without uterine tetany.

Malpresentation. Coagulation disorders are rare in cases

of placenta previa.


Immediate delivery1. In a pregnancy of 36 weeks or greater with

documented fetal lung maturity, the neonate should be delivered by cesarean delivery.

2. In the case of marginal placenta previa, with documented fetal lung maturity, double-setup examination should be performed to determine whether the patient is a candidate for a trial of vaginal delivery.

3. Low vertical uterine incision is probably safer in patients with an anterior placenta previa.

4. Cesarean delivery may be performed regardless of gestational age if hemorrhage is severe and jeopardizes the mother or fetus.


Monitor amount of blood loss, pain level, and uterine contractility.

Assess maternal vital signs Monitor the lab results. Emotional support Bed rest Kick count Prevent vaginal examination FHS monitoring Administer Rh immunoglobulin if the client Rh negative at

28 weeks Prepare for CS Monitor tocolytic agents


Occurs when a normally implanted placenta completely or partially separates from the decidua basalis after the 20th week of gestation and before the third stage of labor


Placental abruption occurs in approximately 1 in 100 deliveries

Accounts for 15% of perinatal mortality


Grade 1, mild (10- 20% marginal seperation):

1. Vaginal bleeding is slight or absent (<500 ml).

2. Uterine tenderness.3. No fetal heart rate abnormalities are

present.4. There is no evidence of shock or

coagulopathy.


Grade 2, moderate (20-50%):1. External bleeding may be absent to moderate

(1000-1500 ml).2. Uterine tone may be increased. Tetanic uterine

contractions and uterine tenderness may be present.

3. Fetal heart tones may be absent and, when present, often show evidence of fetal distress.

4. Maternal tachycardia, narrowed pulse pressure, and orthostatic hypotension may be present.

5. Early evidence of coagulopathy


Grade 3, severe (>50%):1. External bleeding may be moderate or

excessive (>1500 ml) but may be concealed.

2. The uterus is tetanic and tender to palpation.

3. Fetal death is common.4. Maternal shock is usually present.5. Coagulopathy is frequently present.


Pre-eclampsia and hypertensive disorders History of placental abruption (recurrence rate

approximately 10%) High multiparity Extremes of age ( <20 years or > 35 years old Trauma Cigarette smoking Cocaine use Excessive alcohol consumption Preterm, premature rupture of the membranes Rapid uterine decompression after delivery of the

first fetus in a twin gestation, or rupture of membranes with polyhydramnios


Vaginal bleeding is present in 80% of patients and concealed in 20%.

Pain is present in most cases of placental abruption and is usually of sudden onset, constant, and localized to the uterus and lower back.

Localized or generalized uterine tenderness and increased uterine tone.

The uterus may increase in size with placental abruption when the bleeding is concealed.


Amniotic fluid may be bloody. Shock is variably present. Fetal compromise is variably present. Placental abruption may cause preterm

labor.


Proteinuria Consumptive coagulopathy Placental separation precedes the onset of the

consumptive coagulopathy, which in turn progresses until the uterus is evacuated.

Coagulation occurs retroplacentally as well as intravascularly, with secondary fibrinolysis.

Levels of fibrinogen, prothrombin, and platelets are decreased.

Fibrin split products are elevated, adding an anticoagulant effect.

Hypofibrinogenemia occurs within 8 hours of the initial separation.


Ultra sound: visualize concealed or active Hge, aid in identifying retro placental hematoma.

NST


Mild placental abruption close observation fetal monitoring Maternal hematologic parameters should

be monitored and abnormalities corrected tocolytics may be carefully undertaken

with consideration of an immature fetus. Magnesium sulfate is the tocolytic of

choice


Careful maternal and fetal monitoring to minimize long-term complications.

Vigorous management of shock Fresh whole blood should be used to

replace blood loss. Clotting factors may be replaced using

cryoprecipitate or fresh-frozen plasma.


Hourly I&O. V/S Observe bleeding( dark or bright red) IV line Avoid VE Pain medication Evaluate fundal height Observe signs of DIC Observe fetal distress Assess oxygen sat. by pulse oxymetry


Delivery should be expedited in all but the mildest cases once the mother has stabilized.

As long as maternal and fetal surveillance is reassuring, with adequate progress of labor and appropriate volume replacement, the time interval to delivery is less crucial.

Amniotomy should be performed because it may facilitate delivery and decrease thromboplastin release into the circulation.

Oxytocin augmentation may be used. Vaginal delivery is preferred. Cesarean section is indicated in the following cases:

› Fetal distress without impending vaginal delivery› Severe abruption, threatening the life of the mother› Failed trial of labor.


Hemolysis, abnormal liver function tests, and thrombocytopenia have long been recognized as complications of preeclampsia and eclampsia.


8/2/2015 1 mrs. mahdia samaha kony. 8/2/2015 2 mrs. mahdia samaha kony

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