INTRODUCTIONINTRODUCTION

ABRUPTIO PLACENTA is separation of the placenta (the organ that nourishes the fetus) from the site of uterine implantation before delivery of the fetus.

Also referred to as premature separation of placenta, accidental hemorrhage, ablatio placenta, placental abruption.

Placenta affects about 9 in 1,000 pregnancies.

It usually occurs in the third trimester of pregnancy, but it can occur any time after the 20th – 24th weeks and before the birth of the baby.and before the birth of the baby.

Up to 15% of abruptions aren't obvious until labor is in progress or after delivery.

Fetal distress appears early in the condition in Fetal distress appears early in the condition in approximately 40-50% of cases. The infants who approximately 40-50% of cases. The infants who live have a 40-50% chance of complications.live have a 40-50% chance of complications.

After 1 placenta abruptio, a woman has a After 1 placenta abruptio, a woman has a 4% to 17% chance of having another in a 4% to 17% chance of having another in a later pregnancy. After two pregnancies later pregnancy. After two pregnancies complicated by placenta abruptio, a woman complicated by placenta abruptio, a woman has a 25% chance of having another.has a 25% chance of having another.

Risk FactorsRisk Factors 1.Multiparity1.Multiparity 2.Hypertension2.Hypertension 3.Blunt external abdominal trauma/direct3.Blunt external abdominal trauma/direct 4.Smoking4.Smoking 5.Poor nutrition5.Poor nutrition 6.Age older than 35 yrs old6.Age older than 35 yrs old 7.Short umbilical cord7.Short umbilical cord 8.Coccaine8.Coccaine 9.Previous third trimester bleeding 9.Previous third trimester bleeding 10. Alcohol use10. Alcohol use

Signs and symptomsSigns and symptoms

1. Sharp abdominal pain/ back 1. Sharp abdominal pain/ back painpain

Due to myometrium rupture because Due to myometrium rupture because retroplacental blood penetrated through retroplacental blood penetrated through the uterine wall into the peritoneal the uterine wall into the peritoneal cavity cavity

2. Uterine tenderness2. Uterine tenderness

The blood is concealed between the The blood is concealed between the placenta and the deciduas while placenta and the deciduas while pressure builds up, forcing blood pressure builds up, forcing blood through the fetal membranes into the through the fetal membranes into the amniotic sac. amniotic sac.

The build up of blood cause uterine The build up of blood cause uterine tenderness.tenderness.

3. Vaginal bleeding3. Vaginal bleeding

Due to decidual necrosis, blood Due to decidual necrosis, blood vessels rupture. Bleeding occurs vessels rupture. Bleeding occurs due to distended uterus. It cannot due to distended uterus. It cannot close the opened blood vessels.close the opened blood vessels.

4. Signs of maternal shock4. Signs of maternal shock

-When blood accumulates between the -When blood accumulates between the separated placenta and the uterine wall, separated placenta and the uterine wall, and there is bleeding into the myometrium and there is bleeding into the myometrium resulting in tissue damage, increased resulting in tissue damage, increased tonicity and inability of the uterus to relax tonicity and inability of the uterus to relax between contractionsbetween contractions

5. Fetal distress5. Fetal distress

Abruption interferes with fetal Abruption interferes with fetal circulation. Decreased uterine circulation. Decreased uterine perfusion, maternal hypovolemia, and perfusion, maternal hypovolemia, and uterine hypertonus disrupt the maternal uterine hypertonus disrupt the maternal and fetal (uteroplacental) blood and fetal (uteroplacental) blood exchange thus if a significant amount exchange thus if a significant amount of blood is lost, fetal distress occurs.of blood is lost, fetal distress occurs.

Painful (sharp stabbing) Painful (sharp stabbing) vaginal bleedingvaginal bleeding

Keep woman in lateral (not Keep woman in lateral (not supine) positionsupine) position

Abdomen is tender, painful, Abdomen is tender, painful, and tense (board-like)and tense (board-like)

Oxygenation to limit fetal anoxiaOxygenation to limit fetal anoxia

Fetal distress (altered FHR)Fetal distress (altered FHR) FHT monitoring; VS monitorngFHT monitoring; VS monitorng

May lead to couvelaire May lead to couvelaire uterus (blood infiltrating the uterus (blood infiltrating the uterine musculature) uterine musculature) forming a hard, board-like forming a hard, board-like uterus without apparent uterus without apparent bleedingbleeding

Baseline fibrinogen( if bleeding Baseline fibrinogen( if bleeding is extensive, fibrinogen reserve is extensive, fibrinogen reserve may be used up in the body’s may be used up in the body’s attempt to accomplish effective attempt to accomplish effective clot formationclot formation

NO IE or rectal examination, no NO IE or rectal examination, no enemaenema

Keep IV open for possible blood Keep IV open for possible blood transfusiontransfusion

MEDICAL MANAGEMENTMEDICAL MANAGEMENT The woman is hospitalized and monitored The woman is hospitalized and monitored

carefully for signs of increasing separation. carefully for signs of increasing separation. Ultrasound is necessary to differentiate Ultrasound is necessary to differentiate

abruptio placenta from placenta previa. abruptio placenta from placenta previa. Monitor fetal heart rate. Monitor fetal heart rate. Monitor vital signs.Monitor vital signs. Check urine output, hematocrit, platelet Check urine output, hematocrit, platelet

counts and fibrinogen concentration counts and fibrinogen concentration determination. determination.

Cesarean birth delivery.Cesarean birth delivery. Blood replacement. Blood replacement.

SURGICAL MANAGEMENTSURGICAL MANAGEMENT

Classical CSClassical CS Classic uterine incisionClassic uterine incision – the uterus is – the uterus is

incised vertically above the attachment of incised vertically above the attachment of the bladder. The bladder is not dissected of the bladder. The bladder is not dissected of the lower uterine segment. This approach is the lower uterine segment. This approach is rarely used but may be necessary for a rarely used but may be necessary for a fetus in transverse presentation or for fetus in transverse presentation or for multiple fetuses. It may be indicated for a multiple fetuses. It may be indicated for a low anterior placenta, varicosities of the low anterior placenta, varicosities of the lower uterine segment, or cervical cancer. A lower uterine segment, or cervical cancer. A major disadvantage is the high incidence of major disadvantage is the high incidence of rupture with subsequent pregnancy.rupture with subsequent pregnancy.

PREVENTIONPREVENTION 1 .Avoid drinking, smoking or using other 1 .Avoid drinking, smoking or using other

drugs during pregnancy.drugs during pregnancy.

2. Keep a regular schedule of prenatal 2. Keep a regular schedule of prenatal checks throughout your pregnancy.checks throughout your pregnancy.

3. If you have high blood pressure, carefully 3. If you have high blood pressure, carefully follow your health professionals treatment follow your health professionals treatment recommendations.recommendations.

4. Take prenatal vitamins with folate [ 400ug 4. Take prenatal vitamins with folate [ 400ug ( 0.4 mg ) ], since low folate has a possible ( 0.4 mg ) ], since low folate has a possible link to placental problems & abruption.link to placental problems & abruption.

ECTOPIC PREGNANCYECTOPIC PREGNANCY

ECTOPIC PREGNANCYECTOPIC PREGNANCY

A. Pregnancy in which implantation occur A. Pregnancy in which implantation occur outside of the uterus, mostly in the Fallopian outside of the uterus, mostly in the Fallopian tubetube

B. May be diagnosed by ultrasonographyB. May be diagnosed by ultrasonography

C. Pattern in tubal pregnancy: C. Pattern in tubal pregnancy: -spotting after one or two missed menstrual -spotting after one or two missed menstrual

periodsperiods--    sudden, sharp, knife-like lower sudden, sharp, knife-like lower

abdominal pain radiating to the shoulderabdominal pain radiating to the shoulder--  concealed bleeding from site of rupture leads concealed bleeding from site of rupture leads

to sudden shockto sudden shock

A.A. Therapeutic InterventionsTherapeutic Interventions1.1. Diagnosis confirmed by Diagnosis confirmed by

ultrasound examination, ultrasound examination, laparoscopy, culdocentesislaparoscopy, culdocentesis

2.2. Immediate blood replacement if Immediate blood replacement if blood loss is severeblood loss is severe

3.3. Surgical repair or removal of Surgical repair or removal of ruptured fallopian tuberuptured fallopian tube

Amenorrhea with (+) PTAmenorrhea with (+) PT Prepare for surgeryPrepare for surgery

Unilateral LQ (abdominal or Unilateral LQ (abdominal or pelvic painpelvic pain

Shock monitoring and Shock monitoring and management before and after management before and after surgerysurgery

Rigid, tender abdomen on Rigid, tender abdomen on palpationpalpation

Provide emotional support for Provide emotional support for the grieving process the grieving process

Vaginal spotting or bleeding Vaginal spotting or bleeding may be presentmay be present

Administration of RHOGAM Administration of RHOGAM to Rh negative mothersto Rh negative mothers

Presence of bloody fluidPresence of bloody fluid

Visualization of pelvic Visualization of pelvic organs through culdoscopyorgans through culdoscopy

Gestational sac in tube in Gestational sac in tube in UTZUTZ

Nursing CareNursing Care1.1.Assess continuously for signs of Assess continuously for signs of

shockshock

2.2.Administer analgesics as orderedAdminister analgesics as ordered

3.3.Provide emotional supportProvide emotional support

4.4.Administer Rhogam to Rh-negative Administer Rhogam to Rh-negative clientclient

TROPHOBLASTIC DISEASETROPHOBLASTIC DISEASE

A. DefinitionA. Definition 1.1.            A group of disorders in which there A group of disorders in which there

is is an abnormal proliferation of an abnormal proliferation of tissues and tissues and high HCG levelshigh HCG levels

2.2.          Includes Hydatidiform mole, Includes Hydatidiform mole, invasive invasive mole, and Choriocarcinomamole, and Choriocarcinoma

B. Clinical Findings:B. Clinical Findings: 1.1.            Types include;Types include;

– a.a. Molar pregnancy – no fetus or Molar pregnancy – no fetus or amnionamnion

a.a. Partial Molar Pregnancy – a fetus or amnion sac Partial Molar Pregnancy – a fetus or amnion sac is presentis present

b.b.          Invasive mole – locally invasive to surrounding Invasive mole – locally invasive to surrounding tissuestissues

c.c. Choriocarcinoma – may occur years after an H-Choriocarcinoma – may occur years after an H-molemole

1.1.            Uterus is generally larger for a period of Uterus is generally larger for a period of gestation and fetal parts are not palpablegestation and fetal parts are not palpable

2.2.          Symptoms of PIH and hyperemesis are Symptoms of PIH and hyperemesis are commoncommon

3.3.          Potential for uterine perforation and Potential for uterine perforation and hemorrhagehemorrhage 4.4.          Confirmed by UTZConfirmed by UTZ   

Nursing CareNursing Care

1.1.The same as The same as with clients with clients who have who have undergone undergone abortionabortion

2.2.Teach about Teach about the the importance of importance of follow up carefollow up care

Hydatidiform MoleHydatidiform Mole

Definition: Developmental (degenerative) Definition: Developmental (degenerative) anomaly of the placenta converting the anomaly of the placenta converting the chorionic villi into mass of clear visiclechorionic villi into mass of clear visicle

Uterus large for Uterus large for gestational agegestational age

Monitoring and management of shock by Monitoring and management of shock by blood transfusion or IV therapyblood transfusion or IV therapy

Persistent bleeding (dark Persistent bleeding (dark red/ brown vaginal fluid red/ brown vaginal fluid with passage of grapelike with passage of grapelike clustersclusters

Mole is removed by vacuum aspiration or Mole is removed by vacuum aspiration or curettagecurettage

UTZ findings (no fetus)UTZ findings (no fetus) Educate on avoiding pregnancy for at least 1 Educate on avoiding pregnancy for at least 1 yearyear

Elevated HCG levelsElevated HCG levels Educate on the need to monitor HCG for 1 Educate on the need to monitor HCG for 1 year (biweekly until low then monthly fr six year (biweekly until low then monthly fr six months, then every two months for the next months, then every two months for the next six months) six months)

No FHTNo FHT If there is no rise in HCG, further treatment If there is no rise in HCG, further treatment (hysterectomy or chemotherapy) is required.(hysterectomy or chemotherapy) is required.

Increased nausea and Increased nausea and vomitingvomiting

INCOMPETENT CERVIXINCOMPETENT CERVIX

A. DefinitionA. Definition1.1.Cervical dilatation and effacement after Cervical dilatation and effacement after

the second trimester the second trimester 2.2.Usually results from previous forceful Usually results from previous forceful

dilation and curettage, difficult birth or dilation and curettage, difficult birth or congenitally short cervixcongenitally short cervix

B. Clinical findingsB. Clinical findings 1.1.            Painless contraction in midtrimesterPainless contraction in midtrimester 2.2.          Birth of dead or nonviable fetusBirth of dead or nonviable fetus

PLACENTA PREVIAPLACENTA PREVIA

Definition: abnormal implantation of the placenta Definition: abnormal implantation of the placenta in the lower uterine segment, partially or in the lower uterine segment, partially or completely covering the internal cervical oscompletely covering the internal cervical os

Spotting (during first and second trimester)Spotting (during first and second trimester) Bleeding that is sudden, profuse and Bleeding that is sudden, profuse and

PAINLESS (during end of second trimester, PAINLESS (during end of second trimester, or during third trimester)or during third trimester)

Note: Bleeding may occur until onset of Note: Bleeding may occur until onset of cervical dilatation causing the placenta to cervical dilatation causing the placenta to loosened from the uterus. Total placenta loosened from the uterus. Total placenta has earlier more profuse bleeding.has earlier more profuse bleeding.

UTZ showing the location and degree of UTZ showing the location and degree of obstructionobstruction

Four degrees of Placenta PreviaFour degrees of Placenta Previa

1.1. Low lying (lower rather than upper Low lying (lower rather than upper implantation)implantation)

2.2. Marginal (placenta edge approaches Marginal (placenta edge approaches cervical os)cervical os)

3.3. Partial (implantation occludes a portion of Partial (implantation occludes a portion of the cervical os)the cervical os)

4.4. Total – implantation totally obstruct Total – implantation totally obstruct cervical os)cervical os)

Bleeding is an Emergency (Fetal oxygen supply may be Bleeding is an Emergency (Fetal oxygen supply may be compromised and premature labor may begin)compromised and premature labor may begin)

Assessment (amount of blood loss in layman’s estimate Assessment (amount of blood loss in layman’s estimate term; duration, accompanying pain if any.term; duration, accompanying pain if any.

Bedrest with oxygen as prescribed.Bedrest with oxygen as prescribed. Positioning: Sidelying or trendelenburg 72 hours. (Sitting Positioning: Sidelying or trendelenburg 72 hours. (Sitting

position for fetus to compress the placenta- Lippincott)position for fetus to compress the placenta- Lippincott) No IE or Rectal exam, as it may initiate massive No IE or Rectal exam, as it may initiate massive

hemorrhage! (If necessary must be done in OR with double hemorrhage! (If necessary must be done in OR with double set up).set up).

Monitor fetal status (FHT and movement)Monitor fetal status (FHT and movement) Determine fetal lung maturity (amniocentesis)Determine fetal lung maturity (amniocentesis) Keep IV line and make blood available (Blood typed and Keep IV line and make blood available (Blood typed and

crossmatched)crossmatched)Note: Has a greater risk for post partum hemorrhage, as Note: Has a greater risk for post partum hemorrhage, as

lower uterine segment does not contract as efficiently as lower uterine segment does not contract as efficiently as the upper segment. Endometritis is also common as the upper segment. Endometritis is also common as placental site is close to cervix (portal of entry)placental site is close to cervix (portal of entry)

C. Therapeutic interventionsC. Therapeutic interventions 1.1. At the end of pregnancy, CS birth or cutting At the end of pregnancy, CS birth or cutting

of suture for vaginal birthof suture for vaginal birth 2.2.  Bed restBed rest   Nursing CareNursing Care1.1.Maintain on bed rest for 24 hour after cerclageMaintain on bed rest for 24 hour after cerclage2.2.Monitor for rupture of membranes or bleeding Monitor for rupture of membranes or bleeding 3.3.Monitor FHRMonitor FHR    

A.A. Clinical Clinical manifestationsmanifestations

1.1.            Painless, Painless, bright red bright red bleeding, bleeding, hemorrhage in hemorrhage in the third the third trimestertrimester

2.2.          Soft uterus in Soft uterus in the latter part the latter part of pregnancyof pregnancy

Signs of infection Signs of infection may be presentmay be present

Therapeutic InterventionsTherapeutic Interventions

1.1. Ultrasonography to confirm the Ultrasonography to confirm the presence of placenta previapresence of placenta previa

2.2. Control bleedingControl bleeding3.3. Replace blood loss if necessaryReplace blood loss if necessary4.4. CS if necessaryCS if necessary5.5. Bethamethasone is indicated to Bethamethasone is indicated to

increase fetal lung maturityincrease fetal lung maturity   

Nursing CareNursing Care

1.1. No admission vaginal examinationNo admission vaginal examination2.2. Maintain on bed rest in semi-Fowler’s Maintain on bed rest in semi-Fowler’s

positionposition3.3. Monitor fetal heart rate and maternal vital Monitor fetal heart rate and maternal vital

signs continuouslysigns continuously4.4. Assess perineal pads to determine blood Assess perineal pads to determine blood

lossloss5.5. Administer IV therapy or blood Administer IV therapy or blood

replacementreplacement   

TORCHS TORCHS

T – Toxoplasmosis ( Toxoplasma gondii): can be T – Toxoplasmosis ( Toxoplasma gondii): can be acquired by eating raw or undercooked meat acquired by eating raw or undercooked meat or by contact with the feces of infected or by contact with the feces of infected animals; organism crosses the placenta; animals; organism crosses the placenta;

- severity of infection related to gestational age; severity of infection related to gestational age; can cause hydrocephalus and intracranial can cause hydrocephalus and intracranial calcification in the infant.calcification in the infant.

- Incidence of abortion, stillbirths, neonatal Incidence of abortion, stillbirths, neonatal deaths, and severe congenital anomaliesdeaths, and severe congenital anomalies

TORCHS TORCHS

O – Others (HIV, gonorrhea, [Neisseria O – Others (HIV, gonorrhea, [Neisseria gonorrhea], human papillomavirus, gonorrhea], human papillomavirus, varicella zoster, group B streptococcus, varicella zoster, group B streptococcus, hepatitis B, measles, mumps)hepatitis B, measles, mumps)

– R – Rubella (rubella virus): greatest risk R – Rubella (rubella virus): greatest risk to the fetus when maternal infection to the fetus when maternal infection occurs in first 12 weeks of gestation; occurs in first 12 weeks of gestation; baby may be born with encephalitis, baby may be born with encephalitis, ocular abnormalities, cardiac ocular abnormalities, cardiac maldevelopment , and other defects; maldevelopment , and other defects; these infants may have active viral these infants may have active viral infection and should be isolated until infection and should be isolated until pharyngeal mucus and urine are free of pharyngeal mucus and urine are free of virus; for mothers who have not rubella virus; for mothers who have not rubella or who are serologically negative, rubella or who are serologically negative, rubella vaccine should be given in the immediate vaccine should be given in the immediate post birth period, not during pregnancy.post birth period, not during pregnancy.

Rubella - first trimester in between 3Rubella - first trimester in between 3rdrd and and 77thth week of pregnancy – death week of pregnancy – death

Early 2Early 2ndnd trimester – permanent hearing trimester – permanent hearing impairmentimpairment

Leukemia in childhood has been noted. Leukemia in childhood has been noted. Thus infected newborns often die in early in Thus infected newborns often die in early in infancy.infancy.

C – Cytomegalic inclusion disease C – Cytomegalic inclusion disease (cytomegalovirus): pregnant women (cytomegalovirus): pregnant women usually asymptomatic; this sexually usually asymptomatic; this sexually transmitted infection may cause transmitted infection may cause hemolytic anemia, hydrocephalus, hemolytic anemia, hydrocephalus, microcephalus, intrauterine growth microcephalus, intrauterine growth retardation, or neonatal deathretardation, or neonatal death

H – Herpes genitalis (herpesvirus): contracted by the H – Herpes genitalis (herpesvirus): contracted by the mother during sexual relations characterized by mother during sexual relations characterized by periods of exacerbations and remissions; first attack periods of exacerbations and remissions; first attack most severe; intercourse must be avoided during last most severe; intercourse must be avoided during last 4 to6 weeks of pregnancy; during active stage the 4 to6 weeks of pregnancy; during active stage the infant must be delivered by cesarean birth; if delivered infant must be delivered by cesarean birth; if delivered vaginally, neonatal infection can be disseminated and vaginally, neonatal infection can be disseminated and result in death; surviving infants suffer CNS result in death; surviving infants suffer CNS involvementinvolvement

- There is 20 – 50% rate of spontaneous abortion if There is 20 – 50% rate of spontaneous abortion if infection occurs during the 1infection occurs during the 1stst trimester. Infection after trimester. Infection after the 20th week AOG leads to incidence of premature the 20th week AOG leads to incidence of premature births but not to teratogenic defects. The neonate can births but not to teratogenic defects. The neonate can acquire the infection.acquire the infection.

- Survivors have permanent visual damage and Survivors have permanent visual damage and impaired psychomotor and intellectual development.impaired psychomotor and intellectual development.

S – SyphilisS – Syphilis

Therapeutic interventions: care is Therapeutic interventions: care is directed toward prevention directed toward prevention and early treatment in the and early treatment in the pregnant woman to eliminate pregnant woman to eliminate or reduce risk to the fetusor reduce risk to the fetus