Placental complications

Question 1

Describe the risk factors and pathophysiology associated with placental abruption

Answer 1

Risk factors:
- chronic processes that impact blood vessel formation eg. PE, HT, smoking, stimulant use
- FGR
- trauma
- history of placental abruption
- sudden reduction of over distended uterus eg. polhydramnios ROM, between birth of multiples

Pathophysiology:
maternal arteries tear or rupture, leading to bleeding in the decidua basalis and the formation of a hematoma. the presence of blood between the placenta and myometrium leads to a premature separation of the placenta from the uterine wall. the bleeding can be contained as a retroplacental hematoma, or can dissect through causing marginal separation and bleeding, which trickles behind the membranes, through the cervix and genital tract

Question 2

Describe the risk factors and pathophysiology associated with placenta praaevia

Answer 2

Risk factors:
- uterine scars (CS, fibroids)
- large or multiple placentas
- AMA
- abnormal uterine shape
- multiparty

Pathophysiology:
Placenta implants in the lower uterus, within 2cm of the cervical os (complete, partial, marginal). during uterine expansion, sometimes uterus can migrate higher but in placenta praaevia, remains in the lower uterine segment. Can be a result of the upper endometrium being less vascularised and not suitable for implantation

Question 3

Describe the risk factors and pathophysiology associated with placenta accretia, intreat and percreta - morbid adherence of placentas

Answer 3

Occurs when the endometrium is thin, scarred with poor blood supply, so trophoblastic invasion penetrates deeper to try and achieve this blood supply in placentation

Sometimes trophoblasts just fundamentally aggressive

ACCRETA - adheres to myometrium

INCRETA - infiltrates myometrium

PERCRETA - penetrates myometrium, perimetrium and sometimes bladder wall

can be detected AN with US or in 3rd stage with excessive resistance

If no bleeding and fully adhered, can leave inset to be absorbed over months

OR more likely if bleeding, can be fatal so requires hysterectomy

Question 4

Describe the risk factors and pathophysiology associated with vasa praaevia

Answer 4

Risk factors
- succenturiate or bilobe placenta
- velamentous cord insertion

Question 5

Presenting signs and symptoms: placental abruption vs placenta praaevia

Answer 5

Placental abruption:
- hard woody uterus as uterus attempts to contract and clamp blood vessels
- varied amount of blood loss
- hypovolaemic which is not in proportion with amount of blood loss
- continuous pain
- tender uterus
- signs of fetal distress on CTG
- engaged fetal presenting part

Placenta praevia:
- normal uterine tone
- minimal intermittent blood loss which increasesd as placenta separates further
- hypovolaemic shock in proprtion with amount of blood loss
- painless
- non tender uterus
- typically usual CTG trace unless significant bleeding
- presenting part likely not engaged

Question 6

Midwifery assessment of a woman presenting with an APH

Answer 6

• assessment of PV loss
• gentle abdo palp
• pain assessment
• Obs
• urinalysis
• ## CTG

Question 7

Midwifery management of a woman presenting with an APH

Answer 7

Resuscitation - call code blue or pink
- IV insertion, O2, fluid resus, IDC

Consider CS
- declining maternal or fetal condition
- if required notify nice, pads, obs, anaesthetics
- administer corticosteroids
- TOCOLYSIS AND MAGSULF contraindicated if woman is actively bleeding
- blood products
- anti D if necessary

Inpatient/expectant management
- VTE prophylaxis
- weekly FBE
- treat anaemia
- administer anti D if necessary
- plan for timing of birth
- fetal monitoring daily

Question 8

Risks OF APH

Answer 8

FGR
Peterm labour and birth
oligohydramnios
PPROM
PPH