bleeding in late pregnancy health1.pdf · in placenta previa, the placenta starts forming very...
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BLEEDING in LATE PREGNANCY
1-Placenta previa
Definition
Condition in which placenta is partially or totally implanted over
the lower uterine segment. Simpson, 2009)
Pathophysiology
The placenta is usually formed along the upper part of the uterus,
allowing enough space for the fetus to grow. In placenta previa, the
placenta starts forming very close to or even over the cervix (the opening
of the uterus that leads to the vagina). This obstruction impairs normal
vaginal delivery of the baby at birth.
Degrees of placenta previa
1- Low-lying placenta previa or placenta previa lateralis:
Occurs when the placenta is implanted in the lower uterine
segment. In this variation, the edge of the placenta is near the internal os
but does not reach it.
2- Marginal placenta previa
Occurs when the part of the placenta is implanted over the lower
uterine segment and its margin reaches the internal os but does not cover
it completely
3- Partial central placenta previa
Occurs when the internal os is partially covered by the placenta.
4-Complete central placenta previa
Occurs when the whole placenta is implanted over the lower
uterine segment, with the internal OS located at the center of the placenta.
Thus the placenta covers the internal OS completely even when it is fully
dilated
The causes and risk factors for placenta previa are:
The lining of the uterus (endometrium) has abnormalities such as
fibroids or scarring (from previous previa, incisions, caesarean
sections or abortions). The placenta formed abnormally.
The pregnancy is multiple (i.e., twins or triplets). The chances of
developing placenta previa are doubled for these pregnancies.
The mother may have had several previous pregnancies. The
chances of developing placenta previa are increased to 1 in 20 for
women who have had 6 or more pregnancies.
The mother smokes or uses cocaine. Smoking and cocaine use can
increase the risk of this condition.
The mother is older. The risk of developing placenta previa is 3
times greater in women over 30 years of age than in women under
20 years of age.
The pregnancy has been conceived with the help of assisted
reproductive technology, such as in-vitro fertilization.
A history of a past placenta previa
Symptoms
Slight and occasional bleeding may occur during the first and
second trimester of pregnancy.
The color of the blood may be bright red and it may start and stop
then restart after several days or weeks.
Sudden and excessive bleeding may occur in the third trimester of
pregnancy
Bleeding is usually not accompanied by pain, although uterine
cramping may occur at the time of bleeding in some women. In 7%
to 30% of women there may be no bleeding at all.
The bleeding occurs because as the pregnancy progresses, the
placenta gets detached from the uterine walls. In the third trimester
the uterine walls become thinner and spread to accommodate the
growing fetus. If placenta previa is present, the placenta is attached
very low on the uterine wall. This thinning makes the placenta
stretch and tear away from the uterine wall, leading to bleeding.
Some women with placenta previa do not have any symptoms.
Complications of placenta previa
1-Risks for the baby include:
Problems for the baby, secondary to acute blood loss
Intrauterine growth restriction (IUGR) due to poor placental
perfusion
Increased incidence of congenital anomalies
2-Risks for the mother include:
Life-threatening hemorrhage
Cesarean delivery
Increased risk of postpartum hemorrhage
Increased risk placenta accreta (Placenta accreta is where the
placenta attaches directly to the uterine muscle.)
A condition called placenta abruptio. This means that the placenta
breaks away from the wall of the uterus before the baby has been
born.
Severe bleeding in the mother before or during delivery. This can
be very dangerous for both the mother and the baby. If the placenta
has attached or grown into the wall of the uterus (known as
placenta accreta, placenta increta, or placenta percreta), the
bleeding can be heavy enough to require a hysterectomy.
Having to deliver the baby too early.
Treatment
The kind of treatment you will have depends on:
How much you are bleeding.
How the problem is affecting your health and your baby’s health.
How close you are to your due date.
Treatment
When the diagnosis of placenta previa confirmed, medical
intervention are based on condition of expectant mother and fetus.
The woman is evaluated to determine amount of hemorrhage, and
electronic fetal monitoring is initiated to evaluate fetus. Fetal gestational
age is third considerations
1. Conservative management
If mother cardiovascular status is stable, and fetus immature and
has reassuring status by ultrasound examination and monitoring.
Delaying birth may increase birth weight and maturity. Administration of
corticosteroid to mother speed maturation of fetal lung (Branch, 2008)
2. Home care
Criteria for home care
No evidence of active bleeding is present
The woman is able to maintain bed rest at home
Home is reasonable distance from hospital
Teaching mother to assess color and amount of vaginal discharge
or bleeding, assessing fetal activity, assessing uterine activity, and
refraining from intercourse to prevent disruption of placenta
3. Inpatient care
Periodic electronic fetal monitoring is necessary to determine
whether there are fetal heart activity changes in association with
fetal compromise.
Delivery is scheduled if fetus older than 36 weeks and lung mature.
Immediate delivery may be necessary regardless of fetal
immaturity if bleeding is excessive, or signs of fetal compromise
are present
2-Abruption placenta
Definition
Separation of normally situated placenta before fetus is born
(Berman2009)
Risk Factors:
Uterine anomalies
Multiparity
Previous cesarean delivery
Abnormally large placenta
Short umbilical cord
Woman over the age of 35
Are pregnant with twins or triplets
Have had a previous placental abruption
Experience trauma to the abdomen
Hypertension/Pre-eclampsia - 44% of all cases
Smoking – 40% increase for each year smoked
Cocaine – hypertension/catecholamine release
Types of Abruption placenta:
Concealed hemorrhage the placenta separation centrally, and a
large amount of blood is accumulated under the placenta.
External (revealed) hemorrhage the separation is along the
placental margin, and blood flows under the membranes and
through cervix.
Combined: Some blood is retained inside the uterus and some is
expelled through the cervix.
Types of abruptio placenta
Signs and symptoms:
These depend on the type of hemorrhage present.
Revealed accidental hemorrhage:
Vaginal bleeding.
Signs of blood loss are present (pale, irritable, air hunger, increased
pulse) Blood pressure is usually not affected.
Laxed uterus between contractions.
Fetal parts are easily felt.
Fetal head may be fixed or engaged in the pelvis.
FHS are heard if less than half of the placenta is separated.
Back pain
Concealed accidental hemorrhage:
Sudden severe abdominal pain followed by fainting and vomiting.
Shock is always present.
Patient becomes pale and irritable.
Systolic pressure decreases while diastolic remain increased.
The uterus is very hard and larger than expected.
If severe shock, no uterine contractions are felt.
Some scanty dark bleeding.
Edema of lower limbs
Restlessness, confusion, or feelings of fear or anxiety.
Shallow, rapid breathing.
Moist, cool skin or possibly profuse sweating.
Weakness.
Thirst, nausea, or vomiting.
Combined accidental hemorrhage:
The blood is partially revealed and partly concealed.
Signs and symptoms depend on the amount of blood loss and
whether it is more revealed or concealed.
Abruption Placenta – Complications
Maternal
Hemorrhagic /Hypovolemic SHOCK
Coagulopathy DIC/Hypofibrinogenaemia
Uterine rupture
Renal Failure
Ischemic Necrosis distal organs
Fetal
Hypoxia - Fetal distress –
Anemia
Growth Retardation - if treated conservatively and survives
CNS Abnormalities
Intra Uterine Death
Treatment
Treatment depends on the severity of the separation, location of the
separation and the age of the pregnancy. There can be a partial
separation or a complete (also called a total) separation that occurs.
There can also be different degrees of each of these which will
impact the type of treatment recommended.
In the case of a partial separation, bed rest and close monitoring
may be prescribed if the pregnancy has not reached maturity. In
some cases, transfusions and other emergency treatment may be
needed as well.
In a case with a total or complete separation, delivery is often the
safest course of action. If the fetus is stable, vaginal delivery may
be an option. If the fetus is in distress or the mom is experiencing
severe bleeding, then a cesarean delivery would be necessary.
Unfortunately, there is no treatment that can stop the placenta from
detaching and there is no way to reattach it.
Any type of placental abruption can lead to premature birth and
low birth weight. In cases where severe placental abruption
occurs, approximately 15% will end in fetal death.
Nursing Management:
Continuous evaluate maternal and fetal physiologic status,
particularly:
Vital Signs
Bleeding
Electronic fetal and maternal monitoring tracings
Signs of shock – rapid pulse, cold and moist skin, decrease
in blood pressure
Decreasing urine output
Never perform a vaginal or rectal examination or take any
action that would stimulate uterine activity.
Asses the need for immediate delivery. If the client is in active
labor and bleeding cannot be stopped with bed rest, emergency
cesarean delivery may be indicated.
Provide appropriate management.
On admission, place the woman on bed rest in a lateral
position to prevent pressure on the vena cava.
Insert a large gauge intravenous catheter into a large vein for
fluid replacement. Obtain a blood sample for fibrinogen
level.
Monitor the FHR externally and measure maternal vital
signs every 5 to 15 minutes. Administer oxygen to the
mother by mask.
Prepare for cesarean section, which is the method of choice
for the birth
Provide client and family teaching.
Address emotional and psychosocial needs. Outcome for the
mother and fetus depends on the extent of the separation, amount
of fetal hypoxia and amount of bleeding
Prevention
Treat maternal hypertension.
Prevent maternal trauma/domestic violence.
Prevent smoking and substance abuse.
Diagnose placental abruption at an early stage in high-risk groups
(eg, maternal hypertension, maternal trauma, association with domestic
violence, smoking habit, substance abuse, advanced maternal age,
premature ruptured membranes, uterine fibromyomas, and
amniocentesis).