Placenta and Cord Anomalies

Anomalies of the Placenta and Cord

• This category includes several conditions affecting the placenta and umbilical cord, impacting pregnancy.

Placenta Succenturiata

• One or more accessory lobes connect to the main placenta via blood vessels.
• There aren't any associated fetal abnormalities.
• Small lobes may remain in the uterus after birth, potentially leading to maternal hemorrhage, so recognition is important.

Placenta Circumvallata

• The fetal side the placenta is covered in chorion, varies to some extent among cases.
• The umbilical cord enters at the usual midpoint, and a large vessel spreads out from there.

Battledore Placenta

• The umbilical cord inserts marginally rather than centrally.

Velamentous Insertion of the Cord

• The umbilical cord inserts into the fetal membranes outside the placental margin.
• The umbilical cord travels within the membranes to the placenta, specifically between the amnion and the chorion.
• With this condition, the umbilical cord is abnormally inserted into the placenta.
• The umbilical cord inserts into the amniotic membrane rather than in the placenta.

Risk Factors for Velamentous Cord

• Risk factors include having a two-lobed placenta, uterine anomalies, and the fetus having a single umbilical artery.
• Advanced maternal age is a risk factor.
• Carrying twins increases the risk.
• Pregnancies conceived via assisted reproductive technology, like in vitro fertilization (IVF), are at higher risk.
• A prior abnormal cord insertion also raises the risk.

Complications Related to Velamentous Cord Insertions

• Potential complications include the baby being Small for Gestational Age.
• Preeclampsia and premature birth are risks.

Vasa Previa

• The umbilical vessels of a velamentous cord insertion cross the cervical os, meaning they would deliver before the fetus.
• Cervical dilatation can cause the vessel to tear.

Placenta Accreta

• Classified as a spectrum of abnormal placental implantation and firm adherence.
• Placenta accreta is the depth of invasion into the uterus.
• The placenta attaches too deeply and firmly into the uterus, without intervening decidua.

Placenta Increta

• The placenta attaches even more deeply into the muscle wall of the uterus.
• The placenta extends into the myometrium.

Placenta Percreta

• The placenta attaches itself and grows through the uterus, sometimes reaching nearby organs like the bladder.
• Penetrates the entire myometrial thickness and through the uterine serosa.

Two Vessel Cord

• A condition where the umbilical cord has only one vein and one artery instead of the normal two arteries and one vein.
• Also called a single umbilical artery.
• Affects about 1% of pregnancies.
• Typically diagnosed by ultrasound.
• This condition can result in congenital heart and kidney anomalies, and IUGR.

Unusual Cord Length

• An unusually short cord can result in premature separation of the placenta or an abnormal fetal lie.
• An unusually long cord has tendency to twist or knot.
• Nuchal cord refers to the cord around the fetal neck.
• Nuchal cords don't interfere with fetal circulation.
• An abnormally long umbilical cord can present with marked spiraling and true knots.

Knots of Umbilical Cord: True Knot

• This occurs when the fetus passes through a loop of the cord.
• If pulled tight, fetal asphyxia may result.

Knots of Umbilical Cord: False Knot

• This is a localized collection of Wharton's jelly containing a loop of umbilical vessels.

Primiparas Over 20 Years Old

• This group has an increased risk for pregnancy induced hypertension than women who are 40 years old and above.

Women from Low Socioeconomic Backgrounds

• These women may have a poor diet due to their low socioeconomic background.
• That poor diet could contribute greatly to hypertension.

Underlying Disease

• Underlying illnesses might contribute to the occurrence of pregnancy induced hypertension.
• These include heart diseases, diabetes mellitus, renal involvement, and essential hypertension.

Classical Signs: Hypertension

• An increase in a woman's usual blood pressure is the first sign.

Proteinuria

• Detectable protein in the urine.
• An average is 115-260 mg/day.

Edema

• Results from fluid overload.
• Since protein has already leaked out and it is responsible for containing water inside the vessels, edema starts to occur.
• Occurs before 20 weeks gestation after the other 2 signs are present.

Classifications of PIH: Gestational Hypertension

• An elevated blood pressure of 140/90 mmHg, it is how a woman said to have gestational HPN.
• There is no proteinuria or edema.
• Perinatal mortality is not increased with simple gestational HPN.
• Systolic blood pressure greater than 30 mmHg and diastolic blood pressure greater than 15 mmHg above pregnancy values.
• No edema, no proteinuria and blood pressure returns to normal after birth.

Mild Preeclampsia

• Diagnosable when blood pressure rises to 140/90 mmHg, taken on two occasions at least six hours apart.
• Systolic blood pressure greater than 30 mmHg and diastolic blood pressure greater than 15 mmHg above pregnancy values.
• The woman has proteinuria (1+ or 2+ on a reagent test strip on a random sample).
• A weight gain of more than 2 lbs/week in the second trimester or 1 lb/week in the third trimester usually indicates abnormal tissue fluid retention.

Severe Preeclampsia

• A woman has passed from mild to severe preeclampsia when her blood pressure has risen to 160 mmHg systolic and 110 mmHg diastolic or above on at least two occasions 6 hours apart at bed rest.
• Marked proteinuria is present in the patient.
• Extensive edema is also present.
• The extreme edema will be noticeable as puffiness in a woman’s face and hands.
• It is most readily palpated over bony surfaces. The woman may manifest oliguria.
• The woman may present with oliguria (altered renal function), elevated serum creatinine (more than 1.2 mg/dL); cerebral or visual disturbances (blurred vision).
• Thrombocytopenia and epigastric pain is noted in the patient.
• Oliguria (500ml or less in 24 hours) is noted.
• The altered renal function test shows an elevated creatinine more than 1.2mg/dl.
• Cerebral or visual disturbances may also be present.
• The patient experiences extensive peripheral edema.
• The patient is has upper abdominal pain with or without vomiting.
• Thrombocytopenia, or a the decrease number of platelet, is detected.
• The patient shows and signs of hepatic dysfunction.
• HELLP syndrome is evident in the patient.

LP — Low Platelet Count

• The most common reason for mothers to get ill or die is liver rupture or stroke.
• Cerebral edema or Cerebral hemorrhage may occur.

Eclampsia

• This is the most severe classification of PIH.
• The woman passes into this stage when cerebral edema is so acute that seizure or coma occurs.
• Maternal mortality is high from causes such as cerebral hemorrhage, circulatory collapse or renal failure.
• The fetal prognosis in eclampsia is poor because of hypoxia and consequent fetal acidosis.
• The manifestations are the same accompanied by seizures.

Fetal Effects of PIH

• PIH reduces placental function, resulting in LOW BIRTH WEIGHT.
• PIH can cause prematurity.
• PIH may cause abruptio placenta.
• PIH can cause inta-uterine fetal death (IUFD).

Nursing Management

• Promote bed rest for the patient.
• Implement weight monitoring.
• Regular monitoring of BP is important.
• Monitor fetal and maternal well being.
• Promote good nutrition.
• Provide a daily examination of urine.
• Antihypertensive therapy for the patient.
• Emotional support is crucial.

Post Partum HPN

• This may occur up to 10-14 days after birth.
• Usually occurs in the first 48 hours after birth.

HELLP Syndrome

• A syndrome characterized by hemolysis, elevated liver enzyme levels and a low platelet count.
• HELLP is an obstetric complication that is frequently misdiagnosed at initial presentation.
• Many investigators consider the syndrome to be a variant of preeclampsia, but it may be a separate entity.
• HELLP syndrome is a pregnancy complication, specifically a type of preeclampsia.
• It usually occurs during the third trimester of pregnancy, but it can also develop in the first week after childbirth (postpartum preeclampsia).

HELLP STANDS FOR

• H: Hemolysis, the breaking down of red blood cells.
• EL: Elevated liver enzymes.
• LP: Low platelet count.

Diagnostic Parameters

• Normal Bilirubin Total: 0 - 1 MG/DL
• Normal Conjugated Bilirubin: 0 - 0.35 MG/DL
• Normal Unconjugated Bilirubin: 0.2 - 0.65 MG/DL
• Normal SGOT: 10 - 40 IU/L
• Normal SGPT: 10 - 40 IU/L
• Normal Alkaline Phosphatase: 40 - 112 U/L
• Normal Total Protein: 6 - 8.5 GM/DL
• Normal Albumin: 3.5 - 5 GM/DL
• Normal Globulin: 2 - 3.5 GM/DL
• Platelets are the smallest component of your blood that control bleeding.
• Platelets function to stop bleeding.
• Platelets are also known as thrombocytes.
• Normal platelet count: Between 150,000 - 400,000 mcl.

Symptoms of HELLP Syndrome

• Abdominal, chest or shoulder pain, especially in the right upper side.
• Nausea, vomiting, or indigestion may be present.
• Headaches that won't go away.
• Pain when breathing deeply may occur.
• Bleeding occurs in the patient.
• Vision Changes may be present.
• Swelling, especially of the face or hands, is a symptom.
• Shortness of breath, difficulty breathing, or gasping for air, happens with the patient.
• Nose bleeds.
• Excess weight gain is also a symptom.

Diabetes During Pregnancy

Pre-Gestational Diabetes

• Diabetes diagnosed before pregnancy.

Diabetes Mellitus

• An endocrine disorder in which the pancreas cannot produce adequate insulin to regulate body glucose level.

Implications of DM During Pregnancy

• The risk of serious injury at birth is doubled.
• The likelihood of Cesarean delivery is tripled.
• The incidence of Neonatal Intensive Care Unit admission is quadrupled.

Gestational Diabetes

• Any degree of glucose intolerance with onset or first recognition during pregnancy.

Screening Vs Diagnostic Testing

• Screening identifies asymptomatic individuals with a high probability of having or developing a specific disease.

Thresholds for Oral Glucose Tolerance Test

• Fasting > 95 mg/ di,
• One hour > 180 mg/di,
• 2 hours > 155 mg/di,
• 3 hours > 140 mg/dl.

Gestational Diabetes Symptoms

• Polyuria
• Polydipsia
• Polyphagia

Risk factors for GDM

• Increasing maternal age and weight is a risk factor.
• A history of previous GDM increases the risk.
• If the patient had a history of previous macrosomic infant, it is a risk factor.
• If the patient's first degree relatives had family history of diabetes among first-degree relatives, it's a risk factor. -A family history of diabetes increases the risk. -A background with a high prevalence of diabetes is a risk factor.

Other Symptoms

• Always tired
• Frequent urination
• Sudden weight loss
• Wounds that don't heal
• Sexual problems
• Always hungry
• Blurry vision
• Numb or tingling hands or feet
• Always thirsty
• Vaginal infections

Notes from the board - Placenta Succenturiata

• Additional lobe noted in the patient.

• No fetal abnormalities

• Can cause hemorrhage if retained"

Notes from the board - Placenta Circumvallata

• additional tissue; excessive

• unknown cause

Notes from the board - Battledore placenta

• Marginally cord rather than center

Notes from the board - Velamentous Insertion Of The Cord

• Not directly attached to the placenta.

• Can cause IUGR

• Fetal hypoxia – decrease oxygen level

Risk Factors To Notes The Board

• One artery one vein

• Too low placenta

• Uterine anomalies

• Advanced maternal age

• Twins

• Pregnancy IVF

• Complication

Medication For Gestational Hypertension

• Methyldopa

• Hydralazine

Corticosteroid

• Enhance Lung Expansion

• Fetal Lung Surfactant

Eclampsia

• Reduce Placental Function.

• Low birth weight.

• Abruptio Placenta.

• Intrauterine Fetal Death.

Other Treatments

• Protamine Sulfate.
• Calcium Gluconate.