5. Placenta praevia
• When the placenta is
implanted partially or
completely over the
lower uterine segment
it is called placenta
praevia.
6. INCIDENCE
• 0.5% among hospital deliveries
• 80%-multiparous
• Increased beyond the age of 35
• Multiple pregnancy
7. 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
11. 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 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
Opening up of uteroplacental vessels
Bleeding
16. SPONTANEOUS CONTROL OF
BLEEDING
Thrombosis of the open sinuses.
Mechanical pressure by the presenting part.
Placental infarction.
17. CLINICAL FEATURES
Symptoms
Vaginal bleeding(sudden
onset,painless,causeless,recurrent)
Signs(general condition & anemia are
proportionate to the visible blood loss)
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
18. Signs contd:
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 be done as it can
provoke further separation of placenta with
torrential hemorrhage.
19. 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
20. Differential diagnosis
• Abruptio placenta
• Vasa praevia(unsupported umbilical vessels in
velamentous placenta)
• Local cervical lesions
22. COMPLICATIONS
• During labor
– Early rupture of membranes
– Cord prolapse
– Intrapartum haemorrhage
– Increased operative interferance
– Postpartum haemorrhage
• 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)
23. PUERPERIUM
• Sepsis is increased due to
– Increased operative interference
– Placental site near to vagina
– Anemia & devitalized state of the patient
Subinvolution
embolism
24. fetal
• Low birth weight
• Asphyxia
– Early separation of placenta
– Compression of the placenta
– Compression of cord
• Intrauterine death
– Severe degree of separation of placenta
– Maternal hypovolaemia
– shock
• Birth injuries-increased intraoperative interference
• Congenital malformation
25. 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
26. 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.
27. 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
28. 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
• 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
•
29. 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
• 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.
30. Nursing interventions
• Have oxygen readily available for use should fetal
distress occur, as indicated by bradycardia, tachycardia,
late or available decelerations, pathologic sinusoidal
pattern, unstable baseline, or loss of variability.
• If the patient is Rh-negative and not sensitized,
administer Rh (D) immune globulin (RhoGAM) after
every bleeding episode.
• Administer prescribed IV fluids and blood products.
• Provide information about labor progress and the
condition of the fetus.
• Prepare the patient and her family for a possible
caesarian delivery and the birth of a preterm neonate,
and provide thorough instructions for postpartum care.
31. Nursing interventions
• If the fetus less than 36 weeks gestation expect to administer an
initial dose of betamethasone: explain that additional doses may be
given again in 24 hours and possibly for the next 2 weeks to help
mature the neonates lungs.
• Explain that the fetus survival depends on gestational age and
amount of maternal blood loss. Request consultation with a
neontologist or pediatrician to discuss a treatment plan with the
patient and her family.
• Assure the patient that frequent monitoring and prompt
management greatly reduce the risk of neonatal death.
• Encourage the patient and her family to verbalize their feelings
helps them to develop effective coping strategies, and refer them
for counseling, if necessary.
• Anticipate the need for a referral for home care if the patient
bleeding ceases and she’s to return home in bed rest.
33. DEFINITION
• Bleeding occurs due to premature separation of
placenta.
• Varieties
– Revealed: Following separation of placenta, blood
insinuates downwards between membranes and
decidua.
– Concealed: Blood collects behind separated placenta
or collected in between the membranes and decidua.
– Mixed: some part of the collects inside(concealed) & a
part is expelled out(revealed).
35. ETIOLOGY
High birth order pregnancies.
Advancing age of the mother
Poor-socio-economic condition.
Malnutrition
Smoking
Preeclampsia
Trauma
External cephalic version,RTA,amniocentesis
Sudden uterine decompression
Delivery of 1st baby of twins,sudden escape of liquor amnii in
hydramnios,premature rupture of membranes
Short cord
Supine hypotension syndrome
Sick placenta
Folic acid deficiency
Torsion of the uterus
Cocaine abuse
thrombophilias
36. PATHOGENESIS
Hemorrhage into the decidua basalis
Decidual hematoma
Rupture of the basal plate
Communication of the haematoma with intervillous space
Lack of contraction of the uterus and compression of the torn
bleeding points as it is distended by conceptus
37. pathogenesis
• Blood so accumulated will find the direction in
following ways:
– Complete accumulation behind the placenta.
– Blood may dissect down wards in between the
membranes & the uterine wall & ultimately
escapes out through the cervix or may be kept
concealed by the pressure of the fetal head on the
lower uterine segment.
– Blood may gain access to amniotic cavity after
rupturing through the membranes.
38. Couvelaire uterus
• Severe form of concealed abruptioplacenta.
• Massive intravasation of blood into the
uterine musculature upto the serous coat.
• Condition can be diagnosed only by
laparotomy.
39. Naked eye features
• Uterus is dark port wine colour which may be
patchy or diffuse.
• Occurs intially on cornua before spreading to
other areas more specially over the placental
site
40. Changes in other organs
• Fibrin knots in hepatic sinusoids
• Kidneys –acute cortical necrosis or acute
tubular necrosis.(intra-renal vasospasm
because of massive haemorrhage)
• Shock proteinuria (renal anoxia)
41. Blood coagulopathy
• Excess consumption of plasma fibrinogen due
to DIC & retroplacental bleeding.
• Hypofibrinogenemia
• Elevated fibrin degradation products
• D-dimer
42. Clinical classification
• Grade0:clinical feature may be absent. Diagnosis made
after inspection of placenta following delivery.
• Grade1:
– External bleeding is slight.
– Uterus-irritable,tenderness may or may not be present,
shock is absent,FHS is good
• Grade2:
– External bleeding mild to moderate, uterine tenderness is
always present, shock is absent, fetal distress or even fetal
death occurs.
• Grade3:
– Bleeding is moderate to severe or may be concealed,
uterine tenderness is marked, shock is pronounced,fetal
death,coagulation defect,anuria
43. investigations
• Hb%(low value proportionate to the blood
loss).
• Coagulation profile
– Clotting time increased(>6mt)
– Fibrinogen level low(>150mg/dl)
– Platelet count count low
– Partial thromboplastin time increased
– FDP and D-dimer increased
• Urine for protein
44. Differential diagnosis
• Revealed type
– Placenta praevia
• Mixed or concealed type
– Rupture uterus
– Rectus sheath haematoma
– Appendicular or intestinal perforation
– Twisted ovarian tumor
– Volvulus
– Acute hydramnios
– Tonic uterine contraction
45. Prognosis
• Depends on the clinical type, degree of
placental separation, interval between the
placental separation and delivery of the baby
& efficacy of treatment.
46. MATERNAL
• In revealed type: Maternal risk is proportionate
to the visible blood loss and maternal death.
• In concealed type: The prognosis is very
uncertain.
• Fetal:
• In revealed type the fetal death is to the extent of
25-30%
• In concealed type however the fetal death
appreciably high ranging from 50-100%.The
deaths are due to prematurity and anoxia due to
placental separation.
47. Management
• Prevention and early detection and effective therapy
of preeclampsia and other hypertensive disorders of
pregnancy.
• Needle puncture during amniocentesis should be
under ultrasound guidance.
• Avoidance of trauma-forceful external cephalic version.
• Avoid sudden decompression of uterus, in acute or
chronic hydramnios.
• To avoid supine hypotension the patient is advised to
lie in left lateral position in the later months of
pregnancy.