PLACENTA PREVIA/PLACENTAL ABRUPTION

Allison Krickl

Edgewood College School of Nursing

DEFINITIONS

v  Placenta previa- an abnormal implantation of the placenta in the

lower segment of the uterus near or over the cervical os instead of

attaching to the fundus. •  Complete/total-the cervical os is completely covered by the placental

attachment. •  Incomplete/partial-the cervical os is only partially covered by the

placental attachment. •  Marginal/low-lying-the placenta is attached in the lower uterine

segment but does not reach the cervical os.

•  (Sommer, et al., 2013).

INCIDENCE/ETIOLOGY

v  Placenta previa affects approximately 1 in 200 term pregnancies.

v Risk factors include: •  History of previous placenta previa •  History of previous cesarean birth •  History of prior suction curettage •  Advanced maternal age •  Multifetal gestation, multiparity, or closely spaced pregnancies •  Smoking

•  (Lowdermilk, et al., 2012) & (Sommer, et al., 2013).

CLINICAL MANIFESTATIONS

v  Subjective Data •  Painless, bright red vaginal bleeding during the second or third

trimester.

v Objective Data •  Soft, relaxed, nontender uterus with normal tone. •  Fundal height greater than expected for gestational age. •  Breech, oblique, or transverse position of fetus. •  Reassuring FHR. •  Vital signs within normal limits. •  Decreasing urinary output may be a better indicator of blood loss.

•  (Sommer, et al., 2013).

v Hemorrhage

v Abnormal placental attachment •  Placenta accreta •  Placenta increta •  Placenta percreta

v Hysterectomy

v  Surgery-related trauma

v  (Lowdermilk, et al., 2012)

MATERNAL/FETAL OUTCOMES

v  Preterm birth

v  Stillbirth

v  Malpresentation

v  Fetal anemia

v  Intrauterine growth restriction (IUGR)

v  Increased incidence of fetal anomalies

ABNORMAL PLACENTAL ATTACHMENT

DIAGNOSIS

v Diagnostic Procedures •  Transabdominal or transvaginal ultrasound for placement of the

placenta. •  Fetal monitoring for fetal well-being assessment.

•  (Sommer, et al., 2013).

MANAGEMENT

v  Expectant management (observation and bed rest) •  Laboratory tests •  Assess for bleeding, leakage, or contractions •  Pelvic rest •  Administer IV fluids, blood products, and medications as prescribed •  Home care

v Active Management (immediate cesarean birth) •  Assess maternal and fetal status while preparing woman for surgery •  Emotional support

(Lowdermilk, et al., 2012)

DEFINITIONS

v  Placental abruption-the premature separation of the placenta from

the uterus. •  Grade 1: Mild separation (10%-20%) •  Grade 2: Moderate separation (20%-50%) •  Grade 3: Severe separation (>50%)

•  (Lowdermilk, et al., 2012) & (Sommer, et al., 2013).

INCIDENCE/ETIOLOGY

v  1 in 75 to 1 in 226 pregnancies are complicated by placental abruption.

v  1/3 of all antepartum bleeding is caused by placental abruption.

v Risk Factors •  Maternal hypertension (chronic or gestational) •  Cocaine use •  Blunt external abdominal trauma (motor-vehicle crash, maternal battering) •  Cigarette smoking •  History of abruption in a previous pregnancy

•  Preterm rupture of membranes •  Multifetal pregnancy

•  (Lowdermilk, et al., 2012) & (Sommer, et al., 2013).

CLINICAL MANIFESTATIONS

v  Subjective Data •  Sudden onset of intense localized uterine pain with dark red vaginal

bleeding.

v Objective Data •  Area of uterine tenderness may be localized or diffuse over uterus

and board-like •  Contractions with hypertonicity •  Fetal distress •  Signs of hypovolemic shock

•  (Sommer, et al., 2013).

v Hemorrhage

v Hypovolemic shock

v Hypofibrinogenemia

v Thrombocytopenia

v Renal failure

v  Pituitary necrosis

v Rh Sensitized

v  (Lowdermilk, et al., 2012)

MATERNAL/FETAL OUTCOMES

v  Perinatal morality rate of 20-30%

v  If >50% abruption, fetal death is likely

to occur.

v  Intrauterine growth restriction (IUGR).

v  Preterm birth

v Risk for neurologic defects, cerebral

palsy, and death from SIDS are increased.

DIAGNOSIS

v Diagnostic Procedures •  Ultrasound for fetal well-being and placental assessment •  Biophysical profile to ascertain fetal well-being

•  (Sommer, et al., 2013).

MANAGEMENT

v Expectant Management •  Woman is monitored closely. •  Assess FHR pattern •  Administer IV fluids, blood products, and medications as prescribed.

v Active Management (Immediate birth) •  Large-bore IV line •  Maternal vital signs are assessed frequently •  Laboratory studies •  Continuous EFM •  Catheter

•  (Lowdermilk, et al., 2012) & (Sommer, et al., 2013).

v  Placenta previa •  Edward Rigsby •  Braxton Hicks •  Lawson Tait •  Charles Macafee

•  (Chamberlain, 2006)

BACKGROUND

REVIEW OF TOPIC

v Management of a patient with placenta previa includes elective

cesarean delivery.

v Collaborative care planning

v Current treatment of obstetric hemorrhage

v  (Bergakker, 2010), (Kim & Cha, 2011), (Rouse & Bardelman, 2009)

EXPERT INTERVIEW

v Dee Dee Krickl, RN-BSN: OB-OR Coordinator at Meriter •  Sees 6 placenta previa or placenta abruption cases a month on

average in the OB-OR •  All are treated as high-bleed risk patients •  20 years in practice-things have changed •  Treatment of hemorrhage •  Collaborative care planning

EXPERT INTERVIEW

v Vasa-previa case •  Went in for a scheduled

cesarean section at 9:45 AM •  Arrived at the ICU at 7:45 PM

v What nurses need to know about

placenta previa/placental abruption •  It is important to be proactive

and 1 step ahead. •  Always anticipate problems

and plan for them for the best patient outcome.

v A nurse is providing care for a client who is diagnosed with a

marginal placental abruption. The nurse is aware that all of the

following findings are risk factors for developing the condition,

EXCEPT?

v A. Maternal hypertension

v B. Blunt abdominal trauma

v C. Cocaine use

v D. Maternal age

v E. Cigarette smoking

v  (Sommer, et al., 2013).

v A nurse is providing care for a client who is at 32 weeks of

gestation and who has a placenta previa. The nurse notes that the

client is actively bleeding. Which of the following types of

medications should the nurse anticipate the provider will prescribe?

v A. Betamethasone (Celestone)

v B. Indomethacin (Indocin)

v C. Nifedipine (Adalat)

v D. Methylergonovine (Methergine)

v  (Sommer, et al., 2013).

v A client is admitted to the labor suite complaining of painless

vaginal bleeding. The nurse assists with the examination of the client

knowing that a routine labor procedure contraindicated with this

client’s situation is:

v A. Leopold maneuvers

v B. External electronic fetal heart rate monitoring

v C. A manual pelvic examination

v D. Hemoglobin and hematocrit evaluation

v  (Silvestri, 2006).

v A nurse is assigned to assist in caring for a client with abruptio

placentae who is experiencing vaginal bleeding. The nurse collects

data from the client knowing that abruptio placentae is accompanied

by which additional finding?

v A. Abdomen soft on palpation

v B. No complaints of abdominal pain

v C. Lack of uterine irritability or tetanic contractions

v D. Uterine tenderness on palpation

v  (Silvestri, 2006).

v A nurse is collecting data on a client diagnosed with placenta

previa. Select all findings that the nurse would expect to note.

v A. Bright red vaginal bleeding

v B. Uterine rigidity

v C. Soft, relaxed nontender uterus

v D. Uterine tenderness

v E. Severe abdominal pain

v  F. Fundal height may be greater than expected for gestational age

v  (Silvestri, 2006).

REFERENCES

v Bergakker, S. A. (2010). Case report: Management of elective cesarean

delivery in the presence of placenta previa and placenta accreta. AANA Journal,

78(5), 380-384.

v Chamberlain, G. (2006). British maternal mortality in the 19th and early 20th

centuries. Journal of the Royal Society of Medicine, 99(11), 559-563.

v Kim, K. J., & Cha, S. J. (2011). Supracervical cerclage with intracavitary

balloon to control bleeding associated with placenta previa. Journal of Perinatal

Medicine, 39, 477-481.

REFERENCES

v Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R.

(2012). Maternity and women’s health care (10th ed.). St. Louis, MO:

Elsevier Mosby.

v Rouse, C. L., & Bardelman, K. (2009). Collaborative care planning.

AORN Journal, 89(6), 1115-1120.

v  Silvestri, L. A. (2006). Comprehensive review for the NCLEX-PN

examination. (3rd ed.). St. Louis, MO: Saunders Elsevier.

REFERENCES

v  Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill,

L. (2013). RN maternal newborn nursing (9.0 ed.). Assessment

Technologies Institute, LLC.

v Todd, N. (2013). Understanding placenta previa—the basics. Retrieved

from http://www.webmd.com/baby/understanding-placenta-previa-

basics