Placenta, Umblical cord, Amniotic fluid, and Hematological disorders in pregnancy..pptx

Learn about placental abnormalities, amniotic fluid disorders, umbilical cord maternal-fetal complications and hematological disorders in pregnancy especially during the antenatal period.

1. P lacenta, Umblical cord, Amniotic fluid, and Hematological disorders in pregnancy. NABIDDO VIOLA MNS STUDENT NURSE- MIDWIFERY BScN-MUST Presented by

2. Learning O bjectives Differentiate between types of placental abnormalities and their maternal and fetal consequences. Recognize amniotic fluid abnormalities. Gain knowledge about umbilical cord complications during pregnancy. Understand the maternal- fetal complications related to hematological disorders

3. Placental D isorders 01 Marked variations including; Abnormal placental size or structure Abnormal placement within the uterus Abnormal attachment S mall placenta; Intrauterine infection and IUGR. L arge and edematous; Maternal diabetes and fetal polyps .

4. Bilobed placenta/ bilobata ; Two roughly equal-sized lobes separated by a membrane. Succenturiata ; H as an accessory lobe or cotyledon separate from primary placental mass. Extrachorial ; Chorionic plate (fetal) smaller to basal plate (maternal). Circummarginate ; Maternal side surrounds fetal side smoothly and Circumvallate; T here is valve-like thickening. Battledore placenta ; Umbilical cord is inserted at the margin of placenta. Velamentous placenta ; Umbilical cord is inserted into membranes at a varying distance from the placenta.

5. Abnormalities of implantation of the placenta to the myometrium instead of decidua (endometrium). *Hemorrhage is anticipated in all cases of placenta accrete with increta and percreta being life threatening and may require hysterectomy to control bleeding. * Ultra sound scan not able to diagnose in all cases * MRI for staging the severity. Placenta accrete (accreta, increta, & percreta)

6. Placenta Previa A bnomal implantation of the placenta extending over the internal cervical os. Total/ complete Partial Low-lying Exact cause unknown Uterine endometrial scarring or damage in the upper segment incites placental growth in unscarred lower segment. Uteroplacental under perfusion increases surface area for placental attachment .

7. R isk factors for placenta previa P revious uterine scarring prior uterine surgery and C/S M ultiparity A dvanced maternal age >35years C igarette smoking and cocaine use N onwhite race M ultifetal gestation M ale fetus Infertility treatment H ypertension or diabetes S hort interval between pregnancies. A symptomatic diagnosed in 2 nd trimester using ultra sound scan.

8. Complications of previa are placental abruption, maternal Hemorrhage and premature birth. R ecommended scan at 32 and 36weeks and if still previa at 36, vaginal birth is contraindicated, and sexual intercourses to avoid direct trauma to cervix or uterine contractions . M anagement may include bed rest or a cesarean section , depending on severity . N ursing management: I t involves history taking, physical examination, fetal wellbeing monitoring, pain asessment administration of fluids, and blood products . I n case of bleeding ,a transvaginal USS and MRI may be done.

9. Abruptio Placenta I s the premature separation of the normally implanted placenta from the uterine wall after 20 th week of gestation prior to birth. L eads to hemorrhage (2 nd and 3 rd ), loss of placental function which causes fetal hypoxia and possibly death. M aternal complications ; severe abdominal pain, obstetric hemorrhage, need for blood transfusion, emergency hysterectomy, DIC, sheehan syndrome/ postpartum gland necrosis and renal failure. F etal complications ; LBW, preterm birth, asphyxia, stillbirths, perinatal death Early diagnosis is crucial to prevent maternal and fetal complications.

10. Most cases develop from HTN and preeclampsia . Classification according to extent of separation (partial or complete) and amount of blood loss (concealed or apparent). Grade 0 ; Clinically unrecognizable before birth, dx made retrospectively after birth. Grade 1 ; Mild ; no sign of vaginal bleeding or minimal bleeding (<50ml), marginal separation, tender uterus, no coagulopathy, no sign of shock, no fetal distress. Grade 2 ; Moderate ; no sign of vaginal bleeding or bleeding between 1000-1500ml, moderate separation, continuous abdominal pain, mild shock, maternal tachycardia, evidence of fetal distress. Grade 3 ; Absent to moderate bleeding >1500, severe separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased maternal BP, significant maternal tachycardia and development of DIC.

11. Ma nagement Its often unexpected, sudden, and intense and requires immediate treatment. Strict bed rest and left lateral position to prevent pressure on the venacava and ensure fetal perfusion. Fetal monitoring is vital and fetal wellbeing guides the plan of care. Life-threatening – hysterectomy. Referral to maternal-fetal medicine.

12. Amniotic Fluid disorders 02 Amniotic fluid is crucial for fetal development, providing cushioning and facilitating movement . Normal levels (1000 ml until beginning of 3 rd trimester and 800ml at term) vary, but too much ( polyhydramnios) or too little ( oligohydramnios ) can lead to complications, necessitating careful monitoring .

13. Oligohydramnios L ow amniotic fluid less than 5 00ml between 32 and 36weeks, AFI <5cm in third trimester in singleton and Deepest vertical Pocket for each sac in multiple is more reliable. Causes include ROM , placental insufficiency, congenital anomalies, viral diseases, post term pregnancy , HTN , DM, IUGR, post-term pregnancy, and any condition that prevent fetus from making urine. C an lead to fetal compression, impaired growth , perinatal morbidity and mortality. M aybe suspected on clinical examination but needs confirmation by scan . Management strategies may involve increased fetal monitoring e.g. NST, BPP and possibly umbilical doppler studies or early delivery if necessary . A mnioinfusion can be done which involves transvaginal infusion of crystalloid fluid to compensate the lost amniotic fluid.

14. Polyhydramnios Excessive amniotic fluid more than 2,000ml between 32 and 36weeks, AFI; >24cm or >35cm in severe cases. A ssociated with maternal DM, multiple pregnancies, fetal infection, fetal structural and chromosomal anomalies like upper GI obstruction or atresias, neural tube defects, anterior abdominal wall defects, impaired swallowing in fetuses with chromosomal abnormalities e.g trisomy 13 and 18 and anacephaly. C omplications include preterm labor, PROM, Malpresentation, cord prolapse, abruptio placenta, dysfunctional labour, PPH and maternal discomfort. Management often involves monitoring and possible intervention if complications arise.

15. Umbilical Cord Disorders 03 Velamentous insertion : Cord is inserted in the membrane. A span of vessels not protected with Wharton’s jelly. If it crosses the internal cervical os, its referred to as Vasa previa . Scan may or may not identify the abnormality hence the diagnosis is often made after birth. Risk factors ; placenta previa, multifetal gestation, ART, obesity and smoking. Abnormal insertions Single umbilical artery Coiling Knots and twists

16. Single umbilical artery Normally there are two arteries and one vein but some fetus can have one artery and vein. Maybe due to atresia and common in congenital abnormalities and stillborn. Screening for anatomical abnormalities like cardiac and renal is important. If no other abnormalities; increased risk for SGA, preeclampsia, preterm birth and perinatal mortality . Excessive or low coiling associated with perinatal morbidity. Knots or twists in the umbilical cord can occur as a result of fetal movement. While often harmless, severe cases may restrict blood flow and oxygen to the fetus. Monitoring through ultrasounds and non-stress tests can be essential to assess fetal well-being.

17. Cord Prolapse Cord prolapse occurs when the umbilical cord slips ahead of the presenting fetal part during labor risking compression. Treatment options include repositioning the mother , immediate delivery via cesarean section, or utilizing medical interventions to ensure fetal safety and minimize risks.

18. Impact on Fetal Health In case of vasa previa: Avoid cervical dilation during delivery F etal surveillance Corticosteroids to stimulate fetal lung maturity Planned preterm cesarean at gestational week 34. Abnormalities in the umbilical cord can lead to serious fetal complications, including hypoxia and growth restrictions . Early detection during pregnancy can help mitigate potential risks and ensure better outcomes. Ultrasound scan Antepartum surveillance Continuous fetal heart rate monitoring during labor. Gentle delivery of placenta/ avoid tearing the cord off.

19. Hematologic Disorders 04 Microcytic anemia Iron- deficiency anemia Macrocytic anemia Glucose-6- phosphate dehydrogenase deficiency Thrombocytopenia Hemoglobinopathies Alpha-thalassemia Beta- thalassemia Sickle cell disease Coagulation disorders Thrombophilia Venous thromboembolism (VTE) Anemia is generally defined in pregnancy as Hb below 11g/dl in 1 st and 3 rd trimester and 10.5 in 2 nd trimester.

20. Iron Deficiency Anemia Iron deficiency anemia is common during pregnancy accounting for 75%-95% and reflects poor nutrition. C auses I ncreased maternal iron needs and demands from growing fetus. I nadequate dietary iron intake I ncreased erythrocyte mass E xpanded maternal blood volume in 3 rd trimester. C linical symptoms ; Fatigue, diminished quality of life, impaired cognitive function, increased risk of thromboembolic events, DM, headache, restless leg syndrome and PICA eating behavioural.

21. C omplications ; preterm delivery, perinatal mortality and post partum depression, low birt weight, cardiovascular strain, and intellectual disability with poor mental and psychomotor performance. Management involves dietary changes, iron supplements, and regular monitoring of hemoglobin levels . Iron supplementation for all pregnant women with ferrous sulphate . Pregnancy causes physiologic anemia due to hemodilution and does not indicate a decrease in oxygen carrying capacity or true anemia. Foods rich on iron include; dried fruits, whole grain, green leafy vegetables, lean meat, peanut butter, iron fortified bread and cereals.

22. Sickle Cell Disease Pregnant women with sickle cell disease face additional risks such as pain crises that interfere with oxgyenation of vessels and organs and have potential complications for the fetus . Women with SCD are more at risk of moderate to severe anemia (Life span is 15days compared to 120 days of normal RBC) , spontaneous abortions, vaso -occlusive crises, preeclampsia, preterm labor , UTIs due to increased free iron in urine, placenta abruption, IUGR, LBW, maternal mortalities . Monitoring during pregnancy is crucial and may include hydration, pain management, and blood transfusions to improve outcomes for both mother and child . Iron supplementation not recommended.

23. Sickle cell trait follows a Mendelian autosomal recessive inheritance pattern and results from a defective hemoglobin molecule (S).

24. Thalassemia Defective synthesis of one or both chains of hemoglobin molecule. Inheritance is autosomal recessive . Types; A lpha-thalassemia (minor) Beta-thalassemia (major) A low Hb , microcytic, hypochromic anemia results .

25. Is an inherited (X-linked recessive) defect in RBCs that protects them from oxidative injury. Ranges from severe hemolytic anemia to asymptomatic. Medications like nitrofurantoin and sulfa derivatives, infections, surgery and certain foods like fava beans. Maternal complications; severe hemolysis. Fetal complication; severe jaundice, and kernicterus Glucose-6 Phosphate Dehydrogenase Deficiency.

26. Defined as low platelet count less than 150,000 cells/ml especially in the 3 rd trimester. Gestational thrombocytopenia typically develops in the 2 nd trimester and PLT level is rarely <70cell/ml. fetal thrombocytopenia does not occur and resolves with in days to months. Immune thrombocytopenia occurs anytime in pregnancy and PLT count can be quite low. Neonatal thrombocytopenia is possible since maternal antibodies can cross the placenta. Thrombocytopenia due to severe preeclampsia or HELLP syndrome. Thrombocytopenia

27. Risk of developing VTE (either DVT or PE) is four-fold higher during pregnancy because pregnancy is a hypercoagulable state. Risk factors ; Previous VTE, family history, age >35years, BMI >30, DM, inflammatory disorders, varicose veins, hospitalization, and multi fetal gestation. Symptoms ; DVT ; P ain, tenderness, swelling, palpable cord, changes in color and limb circumference. PE; dyspnea, tachypnea, tachycardia, cough, pleuritic chest pain, fever, anxiety, cyanosis, hemoptysis. Management ; Increased fetal surveillance and anticoagulant treatment with low molecular weight heparin. Venous thromboembolism

28. Condition where blood has an increased tendency to form clots. Thrombophilias are genetic conditions that increase the risk of thromboembolism. 50-60% of women with these develop VTE. Most women are asymptomatic and un diagnosed. Screening in women with unprovoked or history of VTE is crucial . Thrombophilia

29. A 26-year-old woman at 30 weeks of gestation presents with fatigue and dizziness. Her labs show: Hemoglobin : 9.0 g/ dL , MCV : 72 fL , Ferritin : 10 ng / mL. She has no history of bleeding disorders but follows a vegetarian diet . What is the most likely cause of her anemia? What is the best treatment approach for this patient? When should IV iron or blood transfusion be considered ?

30. 1. Iron deficiency anemia (IDA) based on: Low hemoglobin (9.0 g/ dL ) – Mild-to-moderate anemia. Low MCV (72 fL ) – Suggests microcytic anemia. Low ferritin (10 ng /mL) – Indicates depleted iron stores. Dietary history – A vegetarian diet increases the risk of iron deficiency. 2. Oral iron supplementation ( ferrous sulfate 300 mg daily with vitamin C for better absorption). Dietary modifications – Encourage iron-rich foods (green leafy vegetables, legumes, fortified cereals) and vitamin C-rich foods (citrus fruits). Monitor hemoglobin levels every 4 weeks . 3. IV iron: If oral iron is ineffective, poorly tolerated, or if hemoglobin is <8 g/ dL with symptoms. Blood transfusion: If hemoglobin is <7 g/ dL with severe symptoms or in case of imminent delivery with significant anemia.

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