6.1 - Placental Complications - exam

Question 1

Antepartum Haemorrhage

Answer 1

• defined as bleeding from the genital tract after 20 weeks gestation
• before onset of labour
• may occur intrapartum bleeding

Question 2

Placenta previa (first)

Answer 2

• Placenta implants in the lower uterus
  covers the internal cervical os

Question 3

Cause of placental previa

Answer 3

• cause is unclear
• ? upper uterus endometrium is not well vascularized
• Damage from:
  
  • Previous cesarean
  • Abortion (induced or spontaneous)
  • Uterine surgery
  • Multioparity

Question 4

Risk Factors

Answer 4

• Having multiple placentas
• multiple fetus
• placenta larger than normal surface area
  
  • caused by having twins or triplet
• Maternal risk factors
  
  • Maternal age >35
  • Intrauterine fibroids
  • maternal smoking, cocaine
  • scaring from the previous surgery - csection

Question 5

Types of placenta previa

Answer 5

• complete - completing covering the cervical OS
• Partial - covering part of the cervical OS
• Marginal within 2 cm of the cervical OS

Question 6

Antenatal bleeding

Answer 6

• Lower uterine segment increases in size
• disrupts placental vessels
• causes painless bright red bleeding (after 20 weeks gestation)
• Intermittent or continuous bleeding

Question 7

complications of placenta previa

Answer 7

• Maternal:
  
  • related to blood loss
  • dilation and contractions can cause bleeding
  • If placenta doesn’t completely separated called Placenta Accreta
    
    • increase hemmorrhage
    • Hysterectomy
• Fetal:
  
  • Hypoxia & preterm delivery

Question 8

Placenta acreta - first layer invades the myomtrium

Answer 8

• Placenta invades the myomtrium
  
  • usually the Decidua
• uterus has 3 layers
  
  • endometrium
  • Myometrium
  • Perimemum
• Endometrium changes for implantation of embryo
  
  • decidualization
  • than called the Decidua
• Trophblasts - implantation into the decidua
  
  • Decidua basalis

Question 9

Placenta increta - well into the myometrium

Answer 9

bedding well in to the myometrium

Question 10

Placental Percreta - most dangerous ICU admission post delivery

Answer 10

• invades the:
  
  • endometrium
  • myometrium
  • perimetumum
  • an can attached to the bladder

Question 11

Why Placenta accreta occur

Answer 11

• Previous c-section
• Curettage
• myomectomy
• transfers a thin emdmetrium
• lower segment of the uterus. (thinner walls)

Question 12

Diagnosis

Answer 12

• Prenatal ultrasound 20 weeks ultrasound
• (sometimes) during labour

Question 13

Treatment & Management

Answer 13

• plan and manage preterm labour
• avoid if possible
• corticosteroids given to enhance fetal lungs development
• minor bleeding
  
  • bed rest
• Major Bleeding
  
  • Blood products
  • Intravenous fluids
  • c-section required
• Severe cases
  
  • immediate c-section preformed

Question 14

Signs of placenta previa

Answer 14

• P - painless bright red bleeding
• R - relaxed soft uterus non-tender
• E - episodes of bleeding:
  
  • (mild profuse) 3rd trimester
  • body prepares for birth
  • thinning of the cervix tears vessels placenta
• V - visible bleeding
• I - intercourse post bleeding (spontaneous or labour)
• A - abnormal fetal position:
  
  • breech
  • transverse lie
    
    • fetal HR normal

Question 15

Midwifery interventions

Answer 15

• Pelvic rest
  
  • no intercourse
  • no vaginal exams
• No abdo manipulation
• No bleeding
  
  • light bed rest
  • no strenuous activities until baby is ready for devlier
• If bleeding
  
  • Hospitalised
  • Haemorrhage risk
  • bloods transfusion may be required
  • IVC
  • Group & hold
  • FBE
  • Rh negative
  • Kleihauer
    
    • Rh negative
    • abdominal trauma
    • abnormal CTG
  • external monitor baby - CTG or FHR
  • monitor and weight blood loss
  • Obs
  • if active bleeding 15 mins obs
  • Left side lying
  • c-section if bleeding doesn’t sto
• Tocolytics
  
  • to stop contractions (contraindication if woman is actively bleeding
• Magnesium sulfate
  
  • contraindication if the woman is actively bleeding
  • Indicated at <30 weeks for neuroprotection
  • if delivery is imminent
  • Regimen of Magnesium sulphate
    
    • loading dose 4 grams iv bolus over 20 minutes
    • maintenance dose 1 gram iv for 24 hours or until birth - whatever is first
• Amniocentesis
  
  • lung maturity
  • Steroids
• Teds

Question 16

Types of APH

Answer 16

• Placenta previa - show - vasa praevia
• placental abruption - cervix - cervicitis, ectropion , carcinoma
• Marginal - sinus rupture
  
  • Trauma
  • Vulvovaginal varicosities
  • genital tract tumours
  • Genital infections
  • haematuria
    *

Question 17

Risks associated with APH

Answer 17

• Fetal growth restriction
• preterm labour
• Oligohydramnios
• preterm pre labour rupture of membranes (PPROM)
• Increased rates of c-section
• Postpartum haemorrhage

Question 18

Describe and differentiate the pathophysiologies of APH presentations

Question 19

Placental abruption

Answer 19

• Concealed abruption
  
  • when the blood is behind the placenta and no vaginal bleeding
• Complete abruption
  
  • vaginal bleeding post 20 weeks (APH)
    
    • placental previa - no pain with bleeding
    • placental abruption - painful bleeding
      
      • uterine contractions trying to control the bleeding to vasoconstriction
      • preterm labour:
        
        • delivery of baby
      • Hypovolemia
  • Fetal
    
    • isn’t receiving O2
    • afixiated - hypoxia
    • non reassuring fetal heart trace
      *

Question 20

Management of placental abruption

Answer 20

• unstable maternal and fetus
  
  • delivery of baby
• Stable
  
  • and if too early for delivery continue monitoring
    *

Question 21

Causes of placental abruption

Answer 21

• trauma
  
  • uterine stay stiff
  • placenta can shear away
  • uterine arteries
• HTN
• Smoking
• Cocaine
  
  • diseased blood vessels

Question 22

menti meter

Question 23

Placental praevia is associated with which symptom

Answer 23

no pain

bright loss

Question 24

Placental abruption is associated with which symptoms

Answer 24

Pain bright loss or dark loss

(concealed or revealed)

Question 25

Placenta praevia bleeding can be

Answer 25

revealed because low lying placenta bottom of OS

Question 26

Placental abruption bleeding can be

Answer 26

concealed or revealed

Question 27

Risk factors for placenta praevia are

Answer 27

Previous caesarean risk of scar tissue induced/spont abortion Multiple pregnancy

Question 28

Risk factors of placental abruption are

Answer 28

Hypertension Smoking Preeclampsia Trauma

Question 29

Other possible causes of APH are:

Answer 29

Cocaine - disruption to cervical polyps cancer of the cervix cervical erosion vaginitis

Question 30

An abdominal palpation oligohydramnios can be determined by:

Answer 30

Fetal parts easily felt AFI \<5

Question 31

On abdominal palpation polyhydramnios can be determined by

Answer 31

Fetal parts difficult to palpate AFI 5 - 25

Question 32

Emergency manangement

Answer 32

* MET call * IV access 2 x 16g * Fluid replacement * O2 8 l * In dwelling catheter if delivery * consult obyg - peaeds * resus equipment * notify NICU/SCN * notify PIPER if less than 34 weeks * corticosteroids * IM 11.4mg betamethasone * usually 24 hours apart but can be administered within =12/24 if warranted * at 30 weeks * consider magnesium sulphate for neuro protection of the fetus

Question 33

Placenta praevia is associated with which symptoms

Answer 33

* No pain * bright loss

Question 34

placental abruption is associated with which symptoms

Answer 34

Pain bright loss dark loss

Question 35

Placenta praevia bleeding can be

Answer 35

revealed

Question 36

Placental abruption bleeding can be

Answer 36

concealed Revealed

Question 37

Risk factor for placenta praevia are

Answer 37

previous caesarean induced/spont abortion multiple pregnany

Question 38

risk factors for placental abruption are

Answer 38

HTN smoking Preeclampsia

Question 39

Other possible causes of APH are

Answer 39

cocaine cervical polyps