6.1 - Placental Complications - exam Flashcards
Antepartum Haemorrhage
- defined as bleeding from the genital tract after 20 weeks gestation
- before onset of labour
- may occur intrapartum bleeding
Placenta previa (first)
- Placenta implants in the lower uterus
covers the internal cervical os
Cause of placental previa
- cause is unclear
- ? upper uterus endometrium is not well vascularized
- Damage from:
- Previous cesarean
- Abortion (induced or spontaneous)
- Uterine surgery
- Multioparity
Risk Factors
- 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
Types of placenta previa
- complete - completing covering the cervical OS
- Partial - covering part of the cervical OS
- Marginal within 2 cm of the cervical OS
Antenatal bleeding
- Lower uterine segment increases in size
- disrupts placental vessels
- causes painless bright red bleeding (after 20 weeks gestation)
- Intermittent or continuous bleeding
complications of placenta previa
- 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
Placenta acreta - first layer invades the myomtrium
- 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
Placenta increta - well into the myometrium
bedding well in to the myometrium
Placental Percreta - most dangerous ICU admission post delivery
- invades the:
- endometrium
- myometrium
- perimetumum
- an can attached to the bladder
Why Placenta accreta occur
- Previous c-section
- Curettage
- myomectomy
- transfers a thin emdmetrium
- lower segment of the uterus. (thinner walls)
Diagnosis
- Prenatal ultrasound 20 weeks ultrasound
- (sometimes) during labour
Treatment & Management
- 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
Signs of placenta previa
- 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
Midwifery interventions
- 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
Types of APH
- Placenta previa - show - vasa praevia
- placental abruption - cervix - cervicitis, ectropion , carcinoma
- Marginal - sinus rupture
- Trauma
- Vulvovaginal varicosities
- genital tract tumours
- Genital infections
- haematuria
*
Risks associated with APH
- Fetal growth restriction
- preterm labour
- Oligohydramnios
- preterm pre labour rupture of membranes (PPROM)
- Increased rates of c-section
- Postpartum haemorrhage
Describe and differentiate the pathophysiologies of APH presentations
Placental abruption
-
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
*
- vaginal bleeding post 20 weeks (APH)
Management of placental abruption
- unstable maternal and fetus
- delivery of baby
- Stable
- and if too early for delivery continue monitoring
*
- and if too early for delivery continue monitoring
Causes of placental abruption
- trauma
- uterine stay stiff
- placenta can shear away
- uterine arteries
- HTN
- Smoking
- Cocaine
- diseased blood vessels
menti meter
Placental praevia is associated with which symptom
no pain
bright loss
Placental abruption is associated with which symptoms
Pain bright loss or dark loss
(concealed or revealed)
Placenta praevia bleeding can be
revealed
because low lying placenta bottom of OS
Placental abruption bleeding can be
concealed or revealed
Risk factors for placenta praevia are
Previous caesarean risk of scar tissue
induced/spont abortion
Multiple pregnancy
Risk factors of placental abruption are
Hypertension
Smoking
Preeclampsia
Trauma
Other possible causes of APH are:
Cocaine - disruption to
cervical polyps
cancer of the cervix
cervical erosion
vaginitis
An abdominal palpation oligohydramnios can be determined by:
Fetal parts easily felt
AFI <5
On abdominal palpation polyhydramnios can be determined by
Fetal parts difficult to palpate
AFI 5 - 25
Emergency manangement
- 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
Placenta praevia is associated with which symptoms
- No pain
- bright loss
placental abruption is associated with which symptoms
Pain
bright loss
dark loss
Placenta praevia bleeding can be
revealed
Placental abruption bleeding can be
concealed
Revealed
Risk factor for placenta praevia are
previous caesarean
induced/spont abortion
multiple pregnany
risk factors for placental abruption are
HTN
smoking
Preeclampsia
Other possible causes of APH are
cocaine
cervical polyps
