Placenta Previa: Third Trimester Bleeding

• Mother is in labor and progressing well with OB (Obstetric)
• Mother and fetus are stable during the third trimester.

Placenta Previa

• This is the premature separation of an abnormally implanted placenta.
• Placenta Previa is also the most common cause of bleeding in the third trimester.

Risk Factors for Placenta Previa

• Multiparity is the most important factor
• Decreased vascularity in the upper uterine segment
• Scarring and tumor
• Increased age which means above 35 years of age
• Multiple pregnancies

Types/Degree of Placenta Previa

• Low-Lying: Placenta is in the lower third of the uterus, but not covering the internal os.
• Marginal: Placenta lies over the margins of the internal os and is considered a low-lying type.
• Incomplete/Partial: The placenta partly covers the internal os.
• Complete or Total: The placenta totally covers the internal os.

Signs and Symptoms of Placenta Previa

• Painless vaginal bleeding (fresh, bright red, external) in third trimester or seventh month
• Uterus soft/flaccid, with intermittent hardening during labor
• Intermittent pain during labor, secondary to uterine contractions
• Bleeding may be slight or profuse, and may come after activity, coitus, or internal examination

Diagnosis of Placenta Previa

• Ultrasonography (Utz) is 95% accurate, able to detect the site of placenta

Treatment of Placenta Previa

• Watchful waiting is expectant management, if the mother is in labor, the fetus is premature, stable, not in distress, and the bleeding is not severe
• Amniotomy which is the artificial rupture of the bag of water causes the fetal head to descend, creating mechanical pressure at the placental site to control bleeding
• Double Set Up involves preparing IE (Internal Examination) for vaginal delivery and Cesarean section if there is term gestation

Delivery Considerations

• Delivery, if watchful waiting are not absent:
• Vaginal delivery is done if the birth canal is not obstructed
• CS (Cesarean Section) is done if placental placement prevents vaginal birth

Complications can include

• Hemorrhage
• Prematurity

Nursing Implementations for Placenta Previa

• Maintain bed rest in a left lateral recumbent position with a head pillow
• Do not perform IE or vaginal examination
• Assessments includes V/S, bleeding, onset/progress of labor, FHT,
• Prepare for UTZ
• Institute shock measures
• Provide psychological support

Abruptio Placenta details

• Abruptio Placenta is a complication of late pregnancy or labor characterized by premature partial separation of a normally implanted placenta
• Abruptio Placenta is the second leading cause of bleeding in the third trimester

Predisposing Factors for Abruptio Placenta

• Maternal HPN, PIH, and renal disease
• Sudden Uterine decompression as in multiple pregnancies & polyhydramnios
• Advance age
• Multiparity
• Short umbilical cord
• Trauma such as fibrin defects

Types of Abruptio Placenta

• Type I: Concealed, Covert, or Central type which is the classic type. The placenta separates at the center, causing blood to accumulate behind the placenta. External bleeding is not evident. Signs of shock are not proportional to the amount of external bleeding.
• Type II: Marginal, overt, or external bleeding type in which the placenta separates at the margins.
• External bleeding (old blood, dark red) is usually proportional to the amount of internal bleeding.
• May be complete or incomplete depending on the degree of placental detachment.
• Marginal, the placenta is near at the edge of cervix.
• Type III: Mixed, some part of the blood collects inside (concealed) and some part is expelled out (revealed).

Assessment Findings for Abruptio Placenta

• Painful vaginal bleeding in the third trimester
• Rigid, board like, and painful abdomen
• Enlarged uterus due to concealed bleeding; signs of shock not proportional to the degree of external bleeding
• If in labor, tetanic contractions with the absence of alternating contractions

Diagnosis of Abruptio Placenta

• Clinical diagnosis
• UTZ
• Clotting studies

Complications of Abruptio Placenta

• Hemorrhagic shock
• Couvelaire Uterus: Bleeding behind the placenta enters the uterine musculature and causes non contraction of the uterus when placenta is delivered
• DIC (Disseminated Intravascular Coagulation): rare but life-threatening and CVA from DIC

Nursing Interventions for Abruptio Placenta

• Maintain bedrest, LLR (Left Lateral Recumbent)
• Monitoring: V/S, I & O, Oliguria, Anuria, FHT, Uterine Pain, Labor onset/progress & Bleeding

Dessiminated Intravascular Coagulation (DIC)

• DIC is an acquired disorder of blood clotting in which the fibrinogen level falls to below effective limits
• Early symptoms include bruising from a bleeding site

Causes of DIC can include

• premature separation of the placenta
• hypertension of pregnancy
• amniotic fluid embolism
• placental retention
• septic abortion
• retention of dead fetus
• an EMERGENCY case

Further managment of DIC

• Do a D-dimer analysis that is specific for fibrin not fibrinogen, degradation of products and abnormalities can be found in 90% patients with DIC.
• DIC phenomenon must be halted (prevention of underlying factors)
• Administer Heparin to halt clotting cascade
• Antithrombin III factor, fibrinogen, or cryoprecipitate for BT
• Fresh frozen plasma or platelets can also aid in restoring clotting function

Pregnancy Induced Hypertension (PIH) details

• PIH is a disorder by three symptoms: (HYPERTENSION, EDEMA, PROTEINURIA).
• PIH appears after the 20th to 24th week of pregnancy and disappears weeks after delivery
• PIH is also one of the major causes of maternal and fetal/neonatal mortality
• UNKNOWN cause

Etiologic Factors of PIH

• Nulliparity with extremes of age: 17 y/o & below / 35 y/o and above.
• Severe nutritional deficiency: low protein diet, low calories
• Coexisting conditions: DM, Multiple pregnancies, polyhydramnios, chronic HPN, renal dse.

Assessment Findings for PIH

• Generalized vasospasm and arteriolar vasoconstriction causes increased peripheral resistance, decreases blood flow to tissues
• Kidneys: Proteinuria & edema
• Brain: double vision, blurring, visual disturbances, dimness of vision, convulsion, coma, hyperreflexia & hyperirritability
• Uterus: Decreased placental perfusion, SGA babies which means small for gestational age & Generalized vasoconstriction

Types of PIH

• PREECLAMPSIA which is mild and severe
• ECLAMPSIA

Nursing Interventions for Preeclampsia Patients WITHOUT Severe Features

• Monitor anti-platelet therapy (low-dose aspirin)
• Provide emotional support
• Monitor V/S

Nursing Interventions for Preeclampsia Patients WITH Severe Features

• If pregnancy is >34 weeks, labor should be induced or a cesarean birth performed to end the pregnancy at that point
• Support Bed Rest
• Darken Room and avoid sudden noises to prevent seizures
• Monitor Blood Pressure, Urine output & FHR
• Support Nutrition Intake

Details Magnesium Sulfate

• Anti-Convulsant Drug
• Monitor Intake and Output, Assess deep tendon reflex (DTR)
• Keep Calcium Gluconate at bedside in case of toxicity

Controll of High BP

• Anti-hypertensive drugs used for urgent BP control in pregnancy
• Labetalol
• Hydralazine
• Nifedipine extended release/ immediate release
• Nicardipine (parenteral)

Nursing Interventions for Patient With Eclampsia

• Tonic – Clonic seizures (eclamptic seizure)- maintain patent airway (prevent aspiration)
• Turn them on the side to allow secretions to drain from mouth
• Administer magnesium sulfate/valium
• Assess O2 saturation
• Check vaginal bleeding, placental separation
• Monitor FHR
• BIRTH - delivery is accompanied thru CS

Hemolytic Disease

• About 10% of women are risk for Rh isoimmunization
• 1:1000 births incidence of Rh-related neonatal morbidity

ABO Incompatibility

• Occurs when maternal blood type is O and fetus is: Type A which is most common, Type B which is most serious & Type AB which is rare
• Maternal antibodies attack the fetal RBC and destroy it
• Happens during placental separation

Rh (Rhesus) Incompatibility

• There is also a Rh Factor
• Rh factor is a distinct protein antigen found in the covering of RBC
• 85% Rh positive and 15% Rh negative
• If person has the genes + +, the Rh factor is positive
• If person has the genes + -, the Rh factor is positive
• If person has the gene - - , the Rh factor is negative
• Hydrops fetalis is life-threatening, causing severe swelling in a fetus/newborn
• Stillbirth is fetal death after 20 wks of pregnancy

Rh Sensitization/Isoimmunization

• Exposure of Rh negative blood to an Rh positive blood
• Occurs during placental separation (0.5 ml fetal Rh positive blood can produce massive production of antibodies during the first 72 hours of life)
• Erythroblastosis Fetalis during pregnancy and Hemolytic Disease after delivery: Anemia, Splenomegaly and hepatomegaly & Hyperbilirubinemia

Prevention Steps

• Prenatal screening a. History b. Screening test
• Antibody Titer Test (Coomb’s Test)
• Indirect Coomb’s Test – maternal serum
• Direct Coomb’s Test – fetal cord blood
• Antibody titer is negative:
• Repeat: 16 – 20 weeks and 26 – 27 weeks of pregnancy
• Anti-Rho(D) Gamma Globulin (RhoGRAM) @ 28 weeks and within 72 hours after delivery
• Rho(D) Gamma Globulin be given to all Rh(-) women who: Delivered Rh positive fetus, Untypeable pregnancies, Received ABO compatible Rh positive blood & Have invasive diagnostic procedure (Amniocentesis)

Symptoms

• No signs and symptoms unless the baby dies in the utero and is not born right away

Management details

1. Fetal surveillance (mother’s antibody titer test (+) >1:16 )
2. Intrauterine Blood Fetal Transfusion (IUFT) blood transfusion to the fetus either intraperitoneal or intravascular
3. Labor and deliver

• Do not remove placenta manually to avoid squeezing fetal cells
• Clamp cord immediately after birth
• Kleihauer – Betke Blood Test