Placenta praevia.pptx

ANTEPARTUM HAEMORRHAGE placenta previa

1. ANTEPARTUM HAEMORRHAGE By CHINJU JOSE

2. ANTEPARTUM HAEMORRHAGE It is defined as bleeding from or into the genital tract after the 28th week of pregnancy.

3. CAUSES 1)Placental bleeding (70%) Placenta praevia (35%) abruptio placenta (35%) 2) unexplained (25 %)

4. 3 ) extraplacental (5%) Local cervicovaginal lesions cervical polyp carcinoma cervix varicose vein -local trauma

5. Placenta praevia

6. DEFINATION When the placenta is implanted partially or completely over the lower uterine segment it is called placenta praevia .

7. NORMAL PLACENTA AND PLACENTA PREVIA

8. INCIDENCE • 0.5% among hospital deliveries • 80%- multiparous • Increased beyond the age of 35 • Multiple pregnancy

9. ETIOLOGY Dropping down theory-due to poor decidual reaction in the upper uterine segment fertilized ovum drops down & gets implanted in the lower segment. Persistence of chorionic activity in the decidua capsularis . Defective decidua results in spreading of the chorionic villi Big surface area of the placenta as in twins

10. Predisposing factors

11. PATHOLOGICAL ANATOMY Placenta – Large and thin – Degeneration with infarction and calcification • Umbilical cord – Battledore (margin) – Velamentous (membranes) • Lower uterine segment – Due to increased vascularity LUS becomes soft and friable

12. Types or degrees Type-1(low lying)- major part is attached to the upper segment and only the lower margin encroaches onto the lower segment but not up to the os .

13. Type-II(Marginal)- Placenta reaches the margin of the internal os but does not cover it . Type III(incomplete or partial central )- Placenta covers the internal os partially(covers the internal os when closed but does not entirely do so when fully dilated)

14. Type IV (central or total) Placenta completely covers the internal os even after it is fully dilated.

15. CAUSE OF BLEEDING Placental growth slows down in later months Lower segment progressively dilates Inelastic placenta sheared off the wall of lower segment

16. Opening up of uteroplacental vessels Bleeding

17. SPONTANEOUS CONTROL OF BLEEDING Thrombosis of the open sinuses. Mechanical pressure by the presenting part. Placental infarction.

18. CLINICAL FEATURES Symptoms Vaginal bleeding(sudden onset, painless, causeless, recurrent ) Signs(general condition & anemia are proportionate to the visible blood loss )

19. Abdominal examination Size of the uterus proportionate to the period of gestation. Uterus feels relaxed, soft and elastic without localized area of tenderness. Persistence of malpresentation ( breech,transverse,unstable lie ) Head is floating FHS present

20. Vulval inspection To examine whether the still bleeding is there or not Character of the blood-bright red or dark colored & the amount of blood loss Bleeding is bright red as bleeding occurs from the separated uteroplacental sinuses close to cervical opening & escaped out immediately. Vaginal examination should not be done as it can provoke further separation of placenta with torrential hemorrhage.

21. Confirmation of diagnosis USG-TAS , TVS, color Doppler flow study. • MRI • CLINICAL – Internal examination (double set-up examination) – Direct visualization during LSC’s – Examination of placenta following vaginal delivery

22. Differential diagnosis Abruptio placenta • Vasa praevia (unsupported umbilical vessels in velamentous placenta) • Local cervical lesions

23. COMPLICATIONS Maternal COMPLICATIONS During pregnancy APH with shock Malpresentation Premature labor either spontaneous or induced

24. During labor Early rupture of membranes Cord prolapse Intrapartum haemorrhage Increased operative interferance

25. During Postpartum Imperfect retraction of the lower uterine segment on which the placenta is implanted. • Large surface area of placenta with atonic uterus due to preexisting anemia • Trauma to cervix and lower segment because of extreme softness and vascularity . • Retained placenta(increased surface area,morbid adhesion)

26. PUERPERIUM • Sepsis is increased due to – Increased operative interference – Placental site near to vagina – Anemia & devitalized state of the patient Subinvolution embolism

27. Fetal COMPLICATIONS Low birth weight • Asphyxia due to – Early separation of placenta – Compression of the placenta – Compression of cord

28. Intrauterine death –Severe degree of separation of placenta Maternal hypovolaemia shock Birth injuries-increased intraoperative interference Congenital malformation

29. prognosis Reduction of maternal deaths in placenta praevia due to Early diagnosis Omission of internal examination Free availability of blood transfusion facilities. Potent antibiotics Wider use of caesarean section with expert anesthetist Skill & judgment with which the cases are managed

30. fetal Fetal mortality ranges from10-25%. Reduction of deaths is principally due to judicious extension of expectant treatment thereby reducing loss from prematurity, liberal use of LSC’s which greatly lessens the loss from anoxia and improvement in the NICU.

31. MANAGEMENT Prevention Adequate antenatal care to improve the health status of the women & correction of anemia. Antenatal diagnosis of low-lying placenta at 20 weeks with routine ultrasound. Significance of warning hemorrhage Family planning & limitation of births

32. Nursing diagnosis Risk for Impaired Fetal Gas Exchange r/t Disruption of Placental Implantation • Fluid Volume Deficit r/t Active Blood Loss Secondary to Disrupted Placental Implantation Active Blood Loss (Hemorrhage) r/t Disrupted Placental Implantation

33. Fear r/t Threat to Maternal and Fetal Survival Secondary to Excessive Blood Loss Activity Intolerance r/t Enforced Bed Rest During Pregnancy Secondary to Potential for Hemorrhage Altered Diversional Activity r/t Inability to Engage in Usual Activities Secondary to Enforced Bed Rest and Inactivity During Pregnancy.

34. Nursing interventions If continuation of the pregnancy is deemed safe for patient and fetus administer magnesium sulfate as ordered for premature labor Obtain blood samples for complete blood count and blood type and cross matching Institute complete bed rest

35. If the patient and placenta previa is experiencing active bleeding , continuously monitor her blood pressure, pulse rate , respiration, central venous pressure, intake and output, and amount of vaginal bleeding as well as the fetal heart rate and rhythm Assist with application of intermittent or continuous electronic fetal monitoring as indicated by maternal and fetal status .