PLACENTA PREVIA the placenta is

implanted in the lower uterine segment near or over the internal cervical os. > The patient is not in la or > Re!uires immediate evaluation ecause o" the massive lood loss with resulting h#povolemic shoc$ can occur i" leeding resumes > %uring the second trimester& the placenta ma# appear to cover the cervical os' however& at term& it does not cover the os > (ccurs in ).*+ o" irths > ,aternal mor idit# rate is a out *+ > ,aternal mortalit# rate is -.+ > In"ants who are /0A or have intrauterine growth restriction have een associated with placental previa ecause o" poor placental e1change or h#povolemia resulting "rom maternal lood loss and maternal anemia > I" preterm gestation& it ma# e an indication "or admission to a tertiar# perinatal center ecause man# communit# hospitals are not a le to per"orm emergenc# C/ irth 2345 or provide neonatal intensive care 6V7AC4V%AC8 Vaginal irth4deliver# a"ter cesarean 6T#pes o" Placenta Previa8 .. Complete4Total4Central8 I" the internal os is entirel# covered # the placenta when the cervi1 is "ull# dilated 2. Partial4Incomplete8 Incomplete coverage o" the internal os ecause it is partiall# covered

9. ,arginal8 (nl# an edge o" the placenta e1tends to the internal os& ut it ma# e1tend onto the os during dilation o" the cervi1 during la or. The distance o" the placenta is 2 to 9 cm "rom the internal os and does not cover it 3. Low:l#ing8 ;hen the placenta is implanted in the lower uterine segment& ut does not reach the os. The internal os is still open. ;hen the e1act relationship o" the os to the placenta has not een determined or in cases o" apparent placenta previa in the second trimester. 6Important ris$ "actors8 .. Previous placenta previa 2. Previous cesarean irth 9. suction curettage "or miscarriage4induced a ortion <endometrial scarring= 3. ,ultiple gestation <larger placenta area= *. Closel# spaced pregnancies >. ,aternal age > 9* #ears 5. A"rican4Asian ethnicit# ?. ,ale "etal gender @. /mo$ing .). Cocaine use

6Clinical ,ani"estations : A out 5)+ o" women have painless uterine leeding : 2)+ o" women have vaginal leeding associated with uterine activit# : It should e suspected whenever vaginal leeding occurs a"ter 2) w$s A(0 : Associated with the stretching and thinning o" the lower uterine segment <9rd trimester=

: Placental attachment is graduall# disrupted8 7leeding occurs when the uterus is not a le to contract ade!uatel# and stop lood "low "orm open vessels : Initial leeding is usuall# a small amound and stops as clots "orm& ut it can recur at an# time : 7right red lood : Vital signs ma# e normal : /o"t& rela1ed& non:tender uterus with a normal tone : The "undal height is usuall# greater than e1pected "or gestational age ecause the low placenta hinders descent o" the presenting "etal part <I" "etus is in l#ing longitudinall#= : Commonl# in an o li!ue& reech or transverse position 6Associated complications8 .. PR(, 2. Preterm la or4 irth 9. /urger#:related trauma to structures adAacent to he uterus 3. Anesthesia complications *. 7lood trans"usion reactions >. (ver:in"usion o" "luids 5. A normal placental attachments ?. Postpartum hemorrhage @. Anemia .). ... Throm ophle itis In"ection

.. Patient Bistor# : 0PTPAL,& E%C& general status& leeding <!uantit#& precipitating event& associated pain= 2. La orator# studies : C7C& lood t#ping& Rh "actor& coagulation pro"ile& t#pe4crossmatch 9. 7leeding : chec$ing4weighing the amount o" leeding on perineal pads& ed pans& linens <.gC.ml o" lood= 6%iagnosis8 .. Transa dominal ultrasound e1amination > @9:@5+ accurate > Also is used "or placental location 2. /peculum E1amination > E.g. cervisitis& pol#ps& carcinoma o" the cervi1 9. Coagulation Pro"ile > To rule out other causes o" leeding 6Nursing %iagnosis8 .. %ecreased cardiac output related to e1cessive lood loss secondar# to placenta previa 2. %e"icient "luid volume related to e1cessive lood loss secondar# to placenta previa 9. Ine""ective peripheral per"usion related to h#povolemia and shunting o" lood to central circulation 3. An1iet#4"ear related to maternal condition and pregnanc# outcome *. Anticipator# grieving related to actual4perceived threat to sel"& pregnanc#& or in"ant

6Assessment8 6,anagement8

: %epends on the gestational age& condition o" the "etus& and amount o" lood present : %ou le set:up procedure <IE8 I" needed e"ore 93 wee$s& women is ta$en to %R4(R set up "or C/ ecause o" pro"ound hemorrhage can occur= : I" at term and in la or4 leeding& immediate C/ <Nurse will assess maternal4"etal status while preparing "or surger#= : Assess maternal V/ <dec. 7P& inc. PR& changes in levels o" consciousness and oliguria= : Detal assessment # continuous electronic "etal monitoring <signs o" h#po1ia= : Postpartum hemorrhage ma# occur even i" the "undus is contracted "irml# : Eltrasound e1amination <ever# 2:9 wee$s= : Detal surveillance <N/T& 7PPFs .:2 wee$l#= : No se1ual contact until involution ta$es place 6Nursing Interventions8 .. Emotional support 2. Patient education : All procedures should e e1plained 9. /upport person should e present 3. Control4stop leeding to save pregnanc# *. 7ed rest and o servation when "etus is not mature >. ,a# give anterpartum steroids < etamethasone= to promote "etal lung maturit# i" -93 w$s A(0 5. No vaginal4rectal e1aminations

> /eparation occurs in the area o" the decidua asalis a"ter 2) wee$s o" pregnanc# and e"ore irth o" the a # > ,ost li$el# to occur in twin gestations > /igni"icant *:.5+ recurrence ris$ > (ccurs in 9rd stage o" la or > CanFt save pregnanc# > Placenta is normal <upper posterior "undal region' possi le at upper anterior "undal region and corpus luteum& ut never at cervi14isthmus= > Clotting de"ects <%IC= u .@:9)+ i" women <usuall# within ? hours o" hospital admission= > .+ ,ortalit# rate8 leading cause o" maternal death > Perinatal mortalit# rate ranges "rom .*:9)+ > ;omen are usuall# not managed out o" the hospital ecause the placenta can separate at an# time and immediate intervention or irth ma# e necessar# 6T#pes8 .. ,arginal8 %uncanFs mechanism& maternal side out 2. Central8 /chultFs mechanism& "etal side out 6Ris$ "actors8 .. ,aternal h#pertension 2. Cocaine use <associated with the development o" h#pertension= 9. 7lunt e1ternal a dominal trauma <motor vehicle accidents4maternal attering= 3. ,aternal smo$ing *. Pressure # enlarging uterus >. PR(, causing sudden release o" pressure

A7REPTI( PLACENTAE premature

seperation4detachment o" part or all o" the placenta "rom its implantation site

5. Bigh parit# ?. ,alnutrition @. Previous placental apople1# 6Clinical mani"estations8 : %ar$ red lood : /harp& sta ing pain : /eparation ma# e partial& complete or onl# the margin o" the placenta ma# e involved : 7leeding "rom placenal site ma# separte mem ranes "rom the decidua asalis and "low through the vagina <ma# remain concealed : retroplacental hemorrhage or ma# do oth= : Vaginal leeding and a dominal pain : Eterine tenderness and contractions : /ilent a ruption <uterine tenderness and a dominal pain ma# e a sent= : 7leeding ma# result to maternal h#povolemia and coagulopath# : ,ild to severe uterine h#pertonicit# : Pain is mild to severe and localiGed over one region o" the uterus or di""use over the uterus with a oardli$e a domen : E1tensive m#ometrial leeding damages the uterine muscle : Couvelaire uterus4uteroplacental apople1# <i" lood accumulates etween the separated placenta and the uterine wall4retroplacental lood ma# penetrate through the thic$ness o" the wall o" the uterus into the peritoneal cavit#= : Eterus appears purplish and copper colored& ecch#motic& and contractilit# is lost : /hoc$ ma# occur and is out o" proportion to lood loss

: <H= Apt test <"or lood in amniotic "luid= : Bemoglo in4hematocrit levels drop : Coagulation "actor levels drop : Ileihauer:7et$e stain <to determine the presence o" "etal to maternal leeding : transplacental hemorrhage= 6,aternal& Detal& Neonatal outcomes8 .. ,otherFs prognosis depends on the e1tent o" placental detachment& overall lood loss& degree o" %IC& and time etween placental detachment4 irth 2. Complications include hemorrhage& h#povolemic shoc$& h#po"i rinogenemia and throm oc#topenia 9. Couvelaire uterus& %IC& in"ection occurs 3. Renal "ailure and pituitar# necrosis </heenanFs s#ndrome= ma# result "rom ischemia *. Rare cases8 Rh <:= women can ecome sensitiGed i" "etal:to:maternal hemorrhage occurs and "etal lood t#pe is Rh <H= >. %eath occurs "rom "etal h#po1ia& preterm irth& /0A status 5. Increased ris$s "or neurologic de"ects and "etal complications <congenital anomalies= 6Colla orative Care8 : Dundic height ma# e measured due to concealed leeding : >)+ o" "etuses e1hi it non:reassuring signs on the electronic "etal heart monitor <loss o" varia ilit#& late decelerations& uterine h#per stimulation& increased resting tone

: ,an# women demonstrate coagulopath# # a normal clotting studies <"i rinogen& platelet count& prothrom in time& partial throm oplastin time& "i rin split products= : /onographic e1amination8 rule out placenta previa' <:= "indings do not rule out a ruption 6Bospital care8 : Treatment depends on severit# o" lood loss and "etal maturit#4status : ;oman is hospitaliGed and closel# o served "or signs o" leeding4la or : Detal status is monitored with intermittent DBR monitoring and N/T47PP until "etal maturit# is achieved or until the womanFs condition deteriorates and immediate irth is indicated : Corticosteroids to accelerate "etal lung maturit# : Rh <:= women ma# e given Rh<%= immune glo ulin i" "etal:to:maternal hemorrhage occurs and the "etal lood is <H= : Vaginal irth "or hemod#namicall# sta le women : Detal comprise& severe hemorrhage& coagulopath#& poor la or progress& increasing uterine resting tone : C/ deliver# : .> gauge IV line should e started : /erial la orator# studies <hematocrit or hemoglo in determinations and clotting studies= : Continuous "etal monitoring : Indwelling Dole# catheter is inserted "or continuous assessment o" urine output : 7lood and "luid replacement <goals8 maintain E( J 9) ml4hrH and hematocrit J 9)+H= : I" goals not met& hemod#namic monitoring

: Dresh "roGen plasma4cr#oprecipitate given to maintain "i rinogen level at a min. o" .)):.*) mg4dl 6Nursing Interventions8 .. Emotional support 2. Patient education : All procedures should e e1plained 9. ,onitor V/ "re!uentl# !.* 3. 7ed rest and close o servation *. 0ive o1#gen in le"t lateral position >. ,onitor leeding