BLEEDING in LATE PREGNANCY

1-Placenta previa

Definition

Condition in which placenta is partially or totally implanted over

the lower uterine segment. Simpson, 2009)

Pathophysiology

The placenta is usually formed along the upper part of the uterus,

allowing enough space for the fetus to grow. In placenta previa, the

placenta starts forming very close to or even over the cervix (the opening

of the uterus that leads to the vagina). This obstruction impairs normal

vaginal delivery of the baby at birth.

Degrees of placenta previa

1- Low-lying placenta previa or placenta previa lateralis:

Occurs when the placenta is implanted in the lower uterine

segment. In this variation, the edge of the placenta is near the internal os

but does not reach it.

2- Marginal placenta previa

Occurs when the part of the placenta is implanted over the lower

uterine segment and its margin reaches the internal os but does not cover

it completely

3- Partial central placenta previa

Occurs when the internal os is partially covered by the placenta.

4-Complete central placenta previa

Occurs when the whole placenta is implanted over the lower

uterine segment, with the internal OS located at the center of the placenta.

Thus the placenta covers the internal OS completely even when it is fully

dilated

The causes and risk factors for placenta previa are:

The lining of the uterus (endometrium) has abnormalities such as

fibroids or scarring (from previous previa, incisions, caesarean

sections or abortions). The placenta formed abnormally.

The pregnancy is multiple (i.e., twins or triplets). The chances of

developing placenta previa are doubled for these pregnancies.

The mother may have had several previous pregnancies. The

chances of developing placenta previa are increased to 1 in 20 for

women who have had 6 or more pregnancies.

The mother smokes or uses cocaine. Smoking and cocaine use can

increase the risk of this condition.

The mother is older. The risk of developing placenta previa is 3

times greater in women over 30 years of age than in women under

20 years of age.

The pregnancy has been conceived with the help of assisted

reproductive technology, such as in-vitro fertilization.

A history of a past placenta previa

Symptoms

Slight and occasional bleeding may occur during the first and

second trimester of pregnancy.

The color of the blood may be bright red and it may start and stop

then restart after several days or weeks.

Sudden and excessive bleeding may occur in the third trimester of

pregnancy

Bleeding is usually not accompanied by pain, although uterine

cramping may occur at the time of bleeding in some women. In 7%

to 30% of women there may be no bleeding at all.

The bleeding occurs because as the pregnancy progresses, the

placenta gets detached from the uterine walls. In the third trimester

the uterine walls become thinner and spread to accommodate the

growing fetus. If placenta previa is present, the placenta is attached

very low on the uterine wall. This thinning makes the placenta

stretch and tear away from the uterine wall, leading to bleeding.

Some women with placenta previa do not have any symptoms.

Complications of placenta previa

1-Risks for the baby include:

Problems for the baby, secondary to acute blood loss

Intrauterine growth restriction (IUGR) due to poor placental

perfusion

Increased incidence of congenital anomalies

2-Risks for the mother include:

Life-threatening hemorrhage

Cesarean delivery

Increased risk of postpartum hemorrhage

Increased risk placenta accreta (Placenta accreta is where the

placenta attaches directly to the uterine muscle.)

A condition called placenta abruptio. This means that the placenta

breaks away from the wall of the uterus before the baby has been

born.

Severe bleeding in the mother before or during delivery. This can

be very dangerous for both the mother and the baby. If the placenta

has attached or grown into the wall of the uterus (known as

placenta accreta, placenta increta, or placenta percreta), the

bleeding can be heavy enough to require a hysterectomy.

Having to deliver the baby too early.

Treatment

The kind of treatment you will have depends on:

How much you are bleeding.

How the problem is affecting your health and your baby’s health.

How close you are to your due date.

Treatment

When the diagnosis of placenta previa confirmed, medical

intervention are based on condition of expectant mother and fetus.

The woman is evaluated to determine amount of hemorrhage, and

electronic fetal monitoring is initiated to evaluate fetus. Fetal gestational

age is third considerations

1. Conservative management

If mother cardiovascular status is stable, and fetus immature and

has reassuring status by ultrasound examination and monitoring.

Delaying birth may increase birth weight and maturity. Administration of

corticosteroid to mother speed maturation of fetal lung (Branch, 2008)

2. Home care

Criteria for home care

No evidence of active bleeding is present

The woman is able to maintain bed rest at home

Home is reasonable distance from hospital

Teaching mother to assess color and amount of vaginal discharge

or bleeding, assessing fetal activity, assessing uterine activity, and

refraining from intercourse to prevent disruption of placenta

3. Inpatient care

Periodic electronic fetal monitoring is necessary to determine

whether there are fetal heart activity changes in association with

fetal compromise.

Delivery is scheduled if fetus older than 36 weeks and lung mature.

Immediate delivery may be necessary regardless of fetal

immaturity if bleeding is excessive, or signs of fetal compromise

are present

2-Abruption placenta

Definition

Separation of normally situated placenta before fetus is born

(Berman2009)

Risk Factors:

Uterine anomalies

Multiparity

Previous cesarean delivery

Abnormally large placenta

Short umbilical cord

Woman over the age of 35

Are pregnant with twins or triplets

Have had a previous placental abruption

Experience trauma to the abdomen

Hypertension/Pre-eclampsia - 44% of all cases

Smoking – 40% increase for each year smoked

Cocaine – hypertension/catecholamine release

Types of Abruption placenta:

Concealed hemorrhage the placenta separation centrally, and a

large amount of blood is accumulated under the placenta.

External (revealed) hemorrhage the separation is along the

placental margin, and blood flows under the membranes and

through cervix.

Combined: Some blood is retained inside the uterus and some is

expelled through the cervix.

Types of abruptio placenta

Signs and symptoms:

These depend on the type of hemorrhage present.

Revealed accidental hemorrhage:

Vaginal bleeding.

Signs of blood loss are present (pale, irritable, air hunger, increased

pulse) Blood pressure is usually not affected.

Laxed uterus between contractions.

Fetal parts are easily felt.

Fetal head may be fixed or engaged in the pelvis.

FHS are heard if less than half of the placenta is separated.

Back pain

Concealed accidental hemorrhage:

Sudden severe abdominal pain followed by fainting and vomiting.

Shock is always present.

Patient becomes pale and irritable.

Systolic pressure decreases while diastolic remain increased.

The uterus is very hard and larger than expected.

If severe shock, no uterine contractions are felt.

Some scanty dark bleeding.

Edema of lower limbs

Restlessness, confusion, or feelings of fear or anxiety.

Shallow, rapid breathing.

Moist, cool skin or possibly profuse sweating.

Weakness.

Thirst, nausea, or vomiting.

Combined accidental hemorrhage:

The blood is partially revealed and partly concealed.

Signs and symptoms depend on the amount of blood loss and

whether it is more revealed or concealed.

Abruption Placenta – Complications

Maternal

Hemorrhagic /Hypovolemic SHOCK

Coagulopathy DIC/Hypofibrinogenaemia

Uterine rupture

Renal Failure

Ischemic Necrosis distal organs

Fetal

Hypoxia - Fetal distress –

Anemia

Growth Retardation - if treated conservatively and survives

CNS Abnormalities

Intra Uterine Death

Treatment

Treatment depends on the severity of the separation, location of the

separation and the age of the pregnancy. There can be a partial

separation or a complete (also called a total) separation that occurs.

There can also be different degrees of each of these which will

impact the type of treatment recommended.

In the case of a partial separation, bed rest and close monitoring

may be prescribed if the pregnancy has not reached maturity. In

some cases, transfusions and other emergency treatment may be

needed as well.

In a case with a total or complete separation, delivery is often the

safest course of action. If the fetus is stable, vaginal delivery may

be an option. If the fetus is in distress or the mom is experiencing

severe bleeding, then a cesarean delivery would be necessary.

Unfortunately, there is no treatment that can stop the placenta from

detaching and there is no way to reattach it.

Any type of placental abruption can lead to premature birth and

low birth weight. In cases where severe placental abruption

occurs, approximately 15% will end in fetal death.

Nursing Management:

Continuous evaluate maternal and fetal physiologic status,

particularly:

Vital Signs

Bleeding

Electronic fetal and maternal monitoring tracings

Signs of shock – rapid pulse, cold and moist skin, decrease

in blood pressure

Decreasing urine output

Never perform a vaginal or rectal examination or take any

action that would stimulate uterine activity.

Asses the need for immediate delivery. If the client is in active

labor and bleeding cannot be stopped with bed rest, emergency

cesarean delivery may be indicated.

Provide appropriate management.

On admission, place the woman on bed rest in a lateral

position to prevent pressure on the vena cava.

Insert a large gauge intravenous catheter into a large vein for

fluid replacement. Obtain a blood sample for fibrinogen

level.

Monitor the FHR externally and measure maternal vital

signs every 5 to 15 minutes. Administer oxygen to the

mother by mask.

Prepare for cesarean section, which is the method of choice

for the birth

Provide client and family teaching.

Address emotional and psychosocial needs. Outcome for the

mother and fetus depends on the extent of the separation, amount

of fetal hypoxia and amount of bleeding

Prevention

Treat maternal hypertension.

Prevent maternal trauma/domestic violence.

Prevent smoking and substance abuse.

Diagnose placental abruption at an early stage in high-risk groups

(eg, maternal hypertension, maternal trauma, association with domestic

violence, smoking habit, substance abuse, advanced maternal age,

premature ruptured membranes, uterine fibromyomas, and

amniocentesis).