1. 8/2/2015 1 Mrs. Mahdia Samaha Kony

2. 8/2/2015 2 Mrs. Mahdia Samaha Kony

3.  Placenta previa occurs when any part of the placenta implants in the lower uterine segment in advance of the fetal presenting part.  Bleeding condition that occurs during the last two trimesters of preg. 8/2/2015 3 Mrs. Mahdia Samaha Kony

4.  Occurs in approximately 1 in 200 pregnancies.  More than 90% of placenta previas diagnosed in the second trimester resolve as pregnancy advances, secondary to differential growth of the placental trophoblastic cells toward the fundus. 8/2/2015 4 Mrs. Mahdia Samaha Kony

5.  Total (complete) placenta previa occurs when the entire internal cervical os is covered by placenta.  Partial (incomplete) placenta previa occurs when part of the internal cervical os is covered by placenta.  Marginal placenta previa occurs when the placental edge extends to within 2 cm of the internal cervical os.  Low-lying pp: occurs when the placenta is implanted in the lower uterine segment and is near the internal os but doesn’t reach it. 8/2/2015 5 Mrs. Mahdia Samaha Kony

6. 8/2/2015 6 Mrs. Mahdia Samaha Kony

7.  The cause of placenta previa is unknown  Endometrial damage from previous pregnancies and defective decidual vascularization have been postulated as possible mechanisms. 8/2/2015 7 Mrs. Mahdia Samaha Kony

8.  Maternal age. Placenta previa is three times more common at age 35 than at age 25.  Increasing parity.  Previous uterine scar.  Prior placenta previa.  Tobacco and cocaine use.  Multiple gestation.  Previous myomectomy to remove fibroid 8/2/2015 8 Mrs. Mahdia Samaha Kony

9.  Sudden onset of painless vaginal bleeding in the second or third trimester.  Bleeding and uterine contractions without uterine tetany.  Malpresentation.  Coagulation disorders are rare in cases of placenta previa. 8/2/2015 9 Mrs. Mahdia Samaha Kony

10.  Immediate delivery 1. In a pregnancy of 36 weeks or greater with documented fetal lung maturity, the neonate should be delivered by cesarean delivery. 2. In the case of marginal placenta previa, with documented fetal lung maturity, double-setup examination should be performed to determine whether the patient is a candidate for a trial of vaginal delivery. 3. Low vertical uterine incision is probably safer in patients with an anterior placenta previa. 4. Cesarean delivery may be performed regardless of gestational age if hemorrhage is severe and jeopardizes the mother or fetus. 8/2/2015 10 Mrs. Mahdia Samaha Kony

11.  Monitor amount of blood loss, pain level, and uterine contractility.  Assess maternal vital signs  Monitor the lab results.  Emotional support  Bed rest  Kick count  Prevent vaginal examination  FHS monitoring  Administer Rh immunoglobulin if the client Rh negative at 28 weeks  Prepare for CS  Monitor tocolytic agents 8/2/2015 11 Mrs. Mahdia Samaha Kony

12.  Occurs when a normally implanted placenta completely or partially separates from the decidua basalis after the 20th week of gestation and before the third stage of labor 8/2/2015 12 Mrs. Mahdia Samaha Kony

13. 8/2/2015 13 Mrs. Mahdia Samaha Kony

14.  Placental abruption occurs in approximately 1 in 100 deliveries  Accounts for 15% of perinatal mortality 8/2/2015 14 Mrs. Mahdia Samaha Kony

15.  Grade 1, mild (10- 20% marginal seperation): 1. Vaginal bleeding is slight or absent (<500 ml). 2. Uterine tenderness. 3. No fetal heart rate abnormalities are present. 4. There is no evidence of shock or coagulopathy. 8/2/2015 15 Mrs. Mahdia Samaha Kony

16.  Grade 2, moderate (20-50%): 1. External bleeding may be absent to moderate (1000-1500 ml). 2. Uterine tone may be increased. Tetanic uterine contractions and uterine tenderness may be present. 3. Fetal heart tones may be absent and, when present, often show evidence of fetal distress. 4. Maternal tachycardia, narrowed pulse pressure, and orthostatic hypotension may be present. 5. Early evidence of coagulopathy 8/2/2015 16 Mrs. Mahdia Samaha Kony

17.  Grade 3, severe (>50%): 1. External bleeding may be moderate or excessive (>1500 ml) but may be concealed. 2. The uterus is tetanic and tender to palpation. 3. Fetal death is common. 4. Maternal shock is usually present. 5. Coagulopathy is frequently present. 8/2/2015 17 Mrs. Mahdia Samaha Kony

18.  Pre-eclampsia and hypertensive disorders  History of placental abruption (recurrence rate approximately 10%)  High multiparity  Extremes of age ( 35 years old  Trauma  Cigarette smoking  Cocaine use  Excessive alcohol consumption  Preterm, premature rupture of the membranes  Rapid uterine decompression after delivery of the first fetus in a twin gestation, or rupture of membranes with polyhydramnios 8/2/2015 18 Mrs. Mahdia Samaha Kony

19.  Vaginal bleeding is present in 80% of patients and concealed in 20%.  Pain is present in most cases of placental abruption and is usually of sudden onset, constant, and localized to the uterus and lower back.  Localized or generalized uterine tenderness and increased uterine tone.  The uterus may increase in size with placental abruption when the bleeding is concealed. 8/2/2015 19 Mrs. Mahdia Samaha Kony

20.  Amniotic fluid may be bloody.  Shock is variably present.  Fetal compromise is variably present.  Placental abruption may cause preterm labor. 8/2/2015 20 Mrs. Mahdia Samaha Kony

21.  Proteinuria  Consumptive coagulopathy  Placental separation precedes the onset of the consumptive coagulopathy, which in turn progresses until the uterus is evacuated.  Coagulation occurs retroplacentally as well as intravascularly, with secondary fibrinolysis.  Levels of fibrinogen, prothrombin, and platelets are decreased.  Fibrin split products are elevated, adding an anticoagulant effect.  Hypofibrinogenemia occurs within 8 hours of the initial separation. 8/2/2015 21 Mrs. Mahdia Samaha Kony

22.  Ultra sound: visualize concealed or active Hge, aid in identifying retro placental hematoma.  NST 8/2/2015 22 Mrs. Mahdia Samaha Kony

23. Mild placental abruption  close observation  fetal monitoring  Maternal hematologic parameters should be monitored and abnormalities corrected  tocolytics may be carefully undertaken with consideration of an immature fetus.  Magnesium sulfate is the tocolytic of choice 8/2/2015 23 Mrs. Mahdia Samaha Kony

24.  Careful maternal and fetal monitoring to minimize long-term complications.  Vigorous management of shock  Fresh whole blood should be used to replace blood loss.  Clotting factors may be replaced using cryoprecipitate or fresh-frozen plasma. 8/2/2015 24 Mrs. Mahdia Samaha Kony

25.  Hourly I&O.  V/S  Observe bleeding( dark or bright red)  IV line  Avoid VE  Pain medication  Evaluate fundal height  Observe signs of DIC  Observe fetal distress  Assess oxygen sat. by pulse oxymetry 8/2/2015 25 Mrs. Mahdia Samaha Kony

26.  Delivery should be expedited in all but the mildest cases once the mother has stabilized.  As long as maternal and fetal surveillance is reassuring, with adequate progress of labor and appropriate volume replacement, the time interval to delivery is less crucial.  Amniotomy should be performed because it may facilitate delivery and decrease thromboplastin release into the circulation.  Oxytocin augmentation may be used.  Vaginal delivery is preferred.  Cesarean section is indicated in the following cases: › Fetal distress without impending vaginal delivery › Severe abruption, threatening the life of the mother › Failed trial of labor. 8/2/2015 26 Mrs. Mahdia Samaha Kony

27.  Hemolysis, abnormal liver function tests, and thrombocytopenia have long been recognized as complications of preeclampsia and eclampsia. 8/2/2015 27 Mrs. Mahdia Samaha Kony