PLACENTA PREVIA

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PLACENTA PREVIA

• PRESENTED BY
• JISHA MARIA
• LR/DR DEPARTMENT

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DEMOGRAPHIC DATA
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NAME MS. P.A. AGE 47/F
CASE NO 193
Dx G9P7A1 29 weeks 3 days, PTL T/C Placenta
Previa, Previous LCCS
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PHYSICAL ASSESSMENT
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GENERAL

• The patient is 47 y/o, FEMALE, weight 74 kg.
• She is conscious, coherent

• With the following Vital Signs
• BP 120/80 mmHg
• PR72 bpm
• RR 23 /cpm
• Temp36.8C

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SKIN

• Pallor of skin and nails

• No palpable masses or lesions

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HEAD

• Maxillary, frontal, and ethmoid sinuses are not
  tender

• No palpable masses or lesions
• No areas of deformity

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LOC ORIENTATION

• Awake and alert

• Oriented to Persons, Place, Time

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EYES

• Pale conjunctivae and no dryness

• Pupils equally round and reactive to light

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EARS

• No unusual discharges noted

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NOSE

• Pink nasal mucosa

• No unusual nasal discharge

• No tenderness in sinuses

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MOUTH

• Dry mouth and lips

• Free of swelling and lesions

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NECK AND THROAT

• No palpable lymph nodes

• No masses and lesions seen

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CHEST AND LUNGS

• Symmetrical chest wall upon movement

• Clear breath sounds

• Absence of chest pain

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HEART

• Regular rhythm

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ABDOMEN

• Abdomen is soft

• With mild to moderate uterine contraction

• With mild hypogastric pain

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ABDOMEN

• With active bowel sounds

• No abdominal tenderness

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GENITOURINARY

• No discharges or foul smell

• With minimal vaginal spotting up to 2-13 pads per
  day

• Able to void freely

• No pain in urination

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EXTREMITIES

• Pulse full and equal

• No lesions noted

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PATIENT HISTORY
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PAST MEDICAL HISTORY

• With history of Abortion
• At 3 yr before
• With 5 times Surgical history of LSCS

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OBSTETRICAL HISTORY
DATES OF PRIOR PREGNANCIES GESTATIONAL AGE ROUTE COMPLICATIONS WEIGHT
G1 TERM NSD
G2 TERM LSCS 1X MALPRESENTATION (TRANSVERSE LIE)
G3 TERM VBAC
G4 TERM LSCS 2X MALPRESENTATION (BREECH) 2.5 3.5 KGS
G5 TERM LSCS 3X
G6 TERM LSCS 4X
G7 ABORTION AT 2 MOS. (-) D C
G8 TERM LSCS 5X
G9 PRESENT PREGNANCY
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PRESENT MEDICAL HISTORY

• C/O Mild Hypogastric Pain
• MEDICAL HISTORY G9P7A1 29 3/7 weeks Age of
  Gestation
• ON EXAMINATION BP 120/80mmHg, PR 72 bpm, RR
  23 cpm, Temp. 36.8 C
• LMP Unknown
• PV not done
• No allergies to any food or drug
• With Hypertensive and Diabetic parents

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MEDICATIONS
DRUG IMAGE DOSE ACTION
Tab. NIFEDIPINE T 10mg TID x 48 hours PO Decreases arterial smooth muscle contractility and subsequent vasoconstriction
Inj. DEXAMETHASONE 6mg every 6 hours for 3 doses IV A synthetic glucocorticoid which decreases inflammation by inhibiting the migration of leukocytes and reversal of increased capillary permeability
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MEDICATIONS
DRUG IMAGE DOSE ACTION
AGIOLAX 2tsp BID PO Suitable for bowel regulation during pregnancy and post partum
Tab. FERROUS SULFATE I tab OD PO Provides supplemental iron, an essential component in the formation of hemoglobin
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INVESTIGATIONS
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LABORATORY RESULT REFENCE RANGE
CBC HGB HCT PLT 11.8g/dl 35.9 292 11.2-15.7 g/dL 34.1-44.9 182-369/UL
Blood Group O
Rh Type Positive
PT 13.3 sec 10.9 16.3 Seconds
APTT 30.4 sec 27 39 Seconds
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INVESTIGATIONS

• Ultrasonographic Result
• PU 31weeks 5days AOG by fetal biometry
• Live Singleton in cephalic presentation, Male
  fetus
• Good Cardiac and somatic activity
• Left Lateral Placenta, Grade II, Previa Totalis
• Adequate fluid volume
• BPP 8/8

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Actual Ultrasound Result
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INVESTIGATIONS

• MRI Result
• Pelvis shows gravid uterus with single fetus and
  the placenta is in left lateral position and in
  lower uterine segment completely covering the
  internal os and shows heterogenous sigal
  intensity with bulging of lower uterine segment
  and irregular thick intraplacental T2 dark bands
  and loss of thin subplacental myometrial zone and
  tenting of the urinary bladder seen along its
  ntero-superior margin, most probably suggestive
  of placenta previa.

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INTRODUCTION

• The term placenta previa refers to a placenta
  that overlies or is proximate to the internal os
  of the cervix. The placenta normally implants in
  the upper uterine segment. In placenta previa,
  the placenta either totally or partially lies
  within the lower uterine segment. Traditionally,
  placenta previa has been categorized into 4
  types
• Complete placenta previa
• where the placenta completely covers the internal
  os.
• Partial placenta previa
• where the placenta partially covers the internal
  os. Thus, this scenario happens only when the
  internal os is dilated to some degree.
• Marginal placenta previa
• which just reaches the internal os, but does not
  cover it.
• Low lying placenta
• which extends into the lower uterine segment but
  does not reach the internal os.

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ANATOMY AND PHYSIOLOGY
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• The placenta signifies the "second" or
  "embryonic" period of pregnancy (after the
  implantation period) and describes the
  establishment of a fully functional placenta. The
  placenta is an apposition of foetal and parental
  tissue for the purposes of physiological
  exchange. There is little mixing of maternal and
  foetal blood, and for most purposes the two can
  be considered as separate.
• The placenta can be thought of as a "symbiotic
  parasite", unique to mammalia. The placenta
  provides an interface for the exchange of gases,
  food and waste. It also facilitates the de novo
  production of fuel substrates and hormones and
  filters potentially toxic substances.
• The placenta has two distinct seperate
  compartments the fetal side consisting of the
  trophoblast and chorionic villi and the maternal
  side consisting of the decidua basalis.

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• The placenta consists of a foetal portion formed
  by the chorion and a maternal portion formed by
  the decidua basalis. The uteroplacental
  circulatory system begins to develop from
  approximately day 9 via the formation of vascular
  spaces called "trophoblastic lacunae".
• Maternal sinusoids develop from capillaries of
  the maternal side which anastamose with these
  trophoblastic lacunae. The differential pressure
  between the arterial and venous channels that
  communicate with the lacunae establishes
  directional flow from the arteries into the veins
  resulting in a uteroplacental circulation.

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Placental Blood Supply

• Maternal blood carrying oxygen and nutrient
  substrate to the placenta must be transferred to
  the fetal compartment and this rate of transfer
  is the rate limiting step in the process.
  Therefore the placenta has a significant blood to
  facilitate improved exchange.
• Fetal blood enters the placenta via a pair of
  umbilical arteries which have numerous branches
  resulting in fetal chorionic villi within the
  placenta, terminating at the chorionic plate. The
  fetal chorionic villi are then surrounded by
  maternal tissues. This physiology is referred to
  as "invasive decidualisation" as the fetal
  chorionic villi effectively invade the maternal
  tissues. Invasive decidualisation is not present
  in pigs or sheep.

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Placental Blood Supply

• Oxygen and nutrient rich blood returns to the
  fetus via the umbilical vein. Maternal blood is
  supplied to the placenta via 80-100 spiral
  endometrial arteries which allow the blood to
  flow into intervillous spaces facilitating
  exchnage. The blood pressure within the spiral
  arteries is much higher than that found in the
  intervillous spaces resulting in more efficient
  nutrient exchange within the placenta.

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ETIOLOGY

• Increased maternal age
• Uterine factors
• Previous CS
• Instrumentation of the uterine cavity (D and C
  for miscarriages or Induced Abortions)
• Placental factors
• Multiparity
• Cigarette smoking
• Living at high altitude

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SIGNS AND SYMPTOMS

1. Vaginal bleeding
2. Painless but can be associated with uterine
   contractions and abdominal pain
3. Bleeding may range from light to severe
4. Gross hematuria

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INTERVENTION

• Bed rest in lateral position to maximize venous
  return and placental perfusion
• Women in the third trimester are advised to avoid
  sexual intercourse and exercise and to reduce
  their activity level

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TREATMENT

• Depends upon the extent and severity of
  bleeding, the gestational age and condition of
  the fetus, position of the placenta and fetus and
  whether the bleeding has stopped.
• Caesarean section as soon as he baby can be
  safely delivered (typically after 36weeks
  gestation). Although emergency CS at any earlier
  gestational age may be necessary for heavy
  bleeding that cannot be stopped.
• Hysterectomy

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COMPLICATIONS

• Maternal
• Increased risk of PROM leading to premature labor
• Immediate hemorrhage with possible shock and
  maternal death
• Postpartum hemorrhage
• Placenta Accreta
• Accreta Vera a term used to denote a placenta
  with villi that adhere to the superficial
  myometrium
• Increta when the villi adheres to the body of
  the myometrium, but not through its full
  thickness
• Percreta when the villi penetrate the full
  thickness of the myometrium and may invade
  neighboring organs such as the bladder or the
  rectum

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• Fetal
• Abnormal fetal presentation (breech)
• Reduced fetal growth
• Prematurity

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PRIORITIZATION OF NURSING PROBLEMS

1. Impaired fetal gas exchange related to altered
   blood flow and decreased surface area of gas
   exchange at site of placental detachment
2. Ineffective Tissue Perfusion related to excessive
   bleeding causing fetal compromise
3. Deficient Fluid Volume related to excessive
   bleeding
4. Anxiety related to excessive bleeding,
   procedures, and possible fetal-maternal
   complications

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ASSESSMENT NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE I am having too much bleeding in my vagina- as verbalized by the patient OBJECTIVE 1.Restlessness 2.Confusion 3.Irritability 4.Manifest Body Weakness 5.Capillary refill more than 3 sec 6.Oliguria V/S taken as follows BP90/60mm of Hg PR110bpm RR20/mt Temp36.5 C Ineffective tissue perfusion related to decreased HgB concentration in blood hypovolemia secondary to Placenta previa. Short Term After 12hrs of nursing Intervention the pt Will demonstrate Behaviors to improve Circulation. Long term After 4 days of nursing Intervention the pt will demonstrate increased perfusion as individually appropriate 1.Establish Rapport 2.Monitor vital signs 3.Assess patient condition 4.Note customary baseline Data (usual BP, weight,lab values) 5.Determine presence of dysrhthmias 6.Perform blanch test 7.Check for Homans Sign 8.Encourage quiet restful enviornment 9.Elevate head of bed 10. Encourage use of relaxationm teqniques 1.To gain patients trust 2.To obtain baseline data 3.To assess contributing factors 4. For comparison with current findings 5.To identify alterations from normal 6.To identify/determine adequate perfusion 7.To determine presence of thrombus formation 8.To lessen O2 demand 9.To promote circulation 10.To decrease tension level Short term The pt shall have demonstrated behaviors to improve circulation. Long term The pt shall have an increased perfusion as individually appropriate.
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CONCLUSION

• Presented a case of a 47 y/o Multigravida,
  G9P7A1, with pregnancy 29 wks 3 days with PTL
  t/c PLACENTA PREVIA, Previous LSCS
• The treatment depends upon the extent and
  severity of bleeding, the gestational age and
  condition of the fetus, position of the placenta
  and fetus and whether the bleeding has stopped.
• Placenta Previa is a medical emergency that needs
  immediate management because it can lead to
  serious maternal and fetal complications, even
  death of one or both of them.
• Nurse-led patient education and the provision of
  a supportive environment are essential to the
  optimal management of Placenta Previa
• Individually tailored and compassionate nursing
  care of women with Placenta Previa will serve to
  enhance the wellbeing of mother and baby

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• THANK YOU!