PLACENTA PREVIA

Definition
Placenta previa is a bleeding condition that occurs during the last two trimesters of pregnancy. In
placenta previa, the placenta implants over the cervical os. It may cause serious morbidity and
mortality to the fetus and mother. The risk of placenta previa in a first pregnancy is 1 in 400, but
it rises to 1 in 160 after one cesarean section; 1 in 60 after two; 1 in 30 after three; and 1 in 10
after four cesarean sections and is associated with potentially serious consequences from
hemorrhage, abruption (separation) of the placenta, or emergency cesarean birth. With the rising
incidence of cesarean section operations combined with increasing maternal age and more
infertility treatments, the number of cases of placenta previa is increasing dramatically.
Placenta previa is generally classified according to the degree of coverage or proximity to the
internal os, as follows:
 Total placenta previa: the internal cervical os is completely covered by the placenta.
 Partial placenta previa: the internal os is partially covered by the placenta.
 Marginal placenta previa: the placenta is at the margin or edge of the internal os.
 Low-lying placenta previa: the placenta is implanted in the lower uterine segment and is
near the internal os but does not reach it.
Assessment
Nursing assessment involves a thorough history, including possible risk factors, and physical
examination. Evaluate the client closely for risk factors such as advancing maternal age (more
than 35 years), previous cesarean birth, multiparity, uterine insult or injury, cocaine use, prior
placenta previa, infertility treatment, asian ethnic background, multiple gestations, previous
induced surgical abortion, smoking, previous myomectomy to remove fibroids, short interval
between pregnancies, and hypertension or diabetes. Ask the client if she has any problems
associated with bleeding, now or in the recent past. The classical clinical presentation is painless,
bright-red vaginal bleeding occurring during the second or third trimester. The initial bleeding
usually is not profuse and it ceases spontaneously, only to recur again. The first episode of
bleeding occurs (on average) at 27 to 32 weeks’ gestation.
Management
Therapeutic management depends on the extent of bleeding, the amount of placenta over the
cervical os, whether the fetus is developed enough to survive outside the uterus, the position of
the fetus, the mother’s parity, and the presence or absence of labor. With the rising rate of
previous cesarean sections, the frequency of placenta previa has increased. Most women
continue to present in emergency departments, therefore the associated morbidity due to
hemorrhage remains high. Efforts should be made to avoid primary cesarean section where
possible. In addition, antenatal care and timely diagnosis of placenta pre via on ultrasound can
decrease the associated morbidity. If the mother and fetus are both stable, therapeutic
management may involve expectant care. This care can be carried out at home or on an
antepartal unit in the health care facility. If there is no active bleeding and the client has ready
access to reliable transportation, can maintain bed rest at home, and can comprehend
instructions, expectant care at home is appropriate. However, if the client requires continuous
care and monitoring and cannot meet the home care requirements, the antepartal unit is the best
environment.
ABRUPTION PLACENTA
Definition
Abruptio placentae is the separation of a normally located placenta after the 20th week of
gestation and prior to birth that leads to hemorrhage. It is a significant cause of second-trimester
bleeding, with a high mortality rate. It occurs in about 1% of all pregnancies throughout the
world, or 1 in 100 pregnancies. There is a 10 to 20 times greater risk of reoccurrence in a
subsequent pregnancy. Maternal risks include obstetric hemorrhage, need for blood transfusions,
emergency hysterectomy, disseminated intravascular coagulopathy and renal failure. Maternal
death is rare but seven times higher than the overall maternal mortality rate. Perinatal
consequences include low birth weight, preterm delivery, asphyxia, stillbirth, and perinatal death.
In developed countries, approximately 10% of all preterm births and 10% to 20% of all perinatal
deaths are caused by placental abruption. The overall fetal mortality rate for placental abruption
is 20% to 40%, depending on the extent of the abruption. Maternal mortality is approximately
6% in abruptio placentae and is related to cesarean birth and hemorrhage or coagulopathy
Assessment
Abruptio placentae is a medical emergency. The nurse plays a critical role in assessing the
pregnant woman presenting with abdominal pain and experiencing vaginal bleeding, especially
in a concealed hemorrhage, in which the extent of bleeding is not recognized. Rapid assessment
is essential to ensure prompt, effective interventions to prevent maternal and fetal morbidity and
mortality. Abruptio placentae produces a wide range of clinical effects, depending on the extent
of placental separation and the amount of maternal blood loss. Begin the health history by
assessing the woman for risk factors that may predispose her to abruptio placentae, such as
advanced maternal age (over 35 years old), poor nutrition, multiple gestation, excessive
intrauterine pressure caused by hydramnios, chronic hypertension, cigarette smoking, severe
trauma, cocaine or methamphetamine abuse, thrombophilia, alcohol ingestion, and multiparity.
Assess the woman for bleeding. As the placenta separates from the uterus, hemorrhage ensues. It
can be apparent, appearing as vaginal bleeding, or it can be concealed. Monitor the woman’s
level of consciousness, noting any signs or symptoms that may suggest shock. Laboratory and
diagnostic tests may be helpful in diag nosing the condition and guiding management. These
studies may include:
 CBC: determines the current hemodynamic status; however, it is not reliable for
estimating acute blood loss
 Fibrinogen levels: typically are increased in pregnancy (hyperfibrinogenemia); thus, a
moderate dip in fibrinogen levels might suggest coagulopathy (DIC) and, if profuse
bleeding occurs, the clotting cascade might be compromised
 Prothrombin time (PT) and activated partial thromboplastin time (aPTT): determines the
client’s coagulation status, especially if surgery is planned
 Nonstress test: demonstrates findings of fetal jeopardy manifested by late decelerations or
bradycardia
Management
Treatment of abruptio placentae is designed to assess, control, and restore the amount of blood
lost; to provide a positive outcome for both mother and newborn; and to prevent coagulation
disorders, such as DIC. Emergency measures include starting two large-bore IV lines with
normal saline or lactated Ringer’s solution to combat hypovolemia, obtaining blood specimens
for evaluating hemodynamic status values and for typing and cross-matching, and frequently
monitoring fetal and maternal well-being. After the severity of abruption is determined and
appropriate blood and fluid replacement is given, cesarean birth is done immediately if fetal
distress is evident. If the fetus is not in distress, close monitoring continues, with delivery
planned at the earliest signs of fetal distress. Because of the possibility of fetal blood loss
through the placenta, a neonatal intensive care team should be available during the birth process
to assess and treat the newborn immediately for shock, blood loss, and hypoxia. If the woman
develops DIC, treatment focuses on determining the underlying cause of DIC and correcting it.
Replacement therapy of the coagulation factors is achieved by transfusion of fresh-frozen plasma
along with cryoprecipitate to maintain the circulating volume and provide oxygen to the cells of
the body. Anticoagulant therapy (low-molecular-weight heparin), packed red cells, platelet
concentrates, antithrombin concentrates, and nonclotting protein-containing volume expanders,
such as plasma protein fraction or albumin, are also used to combat this serious condition.
Prompt identification and early intervention are essential for a woman with acute DIC associated
with abruptio placentae to treat DIC and possibly save her life.
PLACENTA ACCRETA
Definition
Placenta accreta is a condition in which the placenta attaches itself too deeply into the wall of the
uterus but does not penetrate the uterine muscle. A common risk of placenta accreta during the
birthing process is the possibility of hemorrhaging during manual attempts to detach the
placenta. 1 in 2,500 pregnancies results in this condition. The specific cause of placenta accreta
is unknown, but it can be related to placenta previa, advanced maternal age, smoking, and
previous cesarean births. According to the literature, a cesarean birth increases the possibility of
a future placenta accreta; the more cesarean births that are done, the greater the incidence.
Assessment
Antenatal diagnosis of placenta accreta is typically made by ultrasound. Ultrasound will reveal
placenta previa. Furthermore, it is possible to visualize other abnormalities, including loss of
hypoechoic division between the placenta and myometrium, increased vasculature, myometrial
thinning, and extension of the placenta into serosa or bladder. Color Doppler may reveal lacunae
with turbulent blood flow. Notably, the sensitivity and specificity of ultrasonography appear to be
highly variable. Individual studies of ultrasound diagnosis of accreta report a large range of
sensitivities and specificities. Important factors in the diagnosis are the presence of lacunae and
the loss of hypoechoic retroplacental space.
Management
Placenta accreta is best managed when it has been diagnosed antenatally. Many steps can be
undertaken to minimize risks. The American College of Obstetricians and Gynecologists
(ACOG) has recommended delivery between 34 – 35 6/7 weeks of gestation via cesarean
hysterectomy to optimize neonatal maturity and minimize the risk of maternal bleeding. Before
delivery, there should be a consideration for transfer to a Placenta Accreta Center of Excellence
or a level three or four center for delivery. These center should include perinatologists, pelvic
surgeons, intensivists, general surgeons, urologists, and neonatologists. In patients with bleeding,
consideration should be made for an early transfer to be near an appropriate facility.
Furthermore, the patient’s hemoglobin level should be optimized before delivery, and there
should be coordination with the blood bank to ensure supplies if a massive transfusion should be
needed.
Close monitoring of hemodynamic status and blood loss should be performed. Monitoring blood
loss, hemoglobin, electrolytes, blood gas, and coagulation factors to determine the need for
transfusion objectively. Most often, massive transfusion protocols involve a 1 to 1 to 1 ratio of
packed red blood cells, fresh frozen plasma, and platelets. However, patients may also consider
autologous donation ahead of the procedure. 1g IV tranexamic acid, an antifibrinolytic therapy,
can be considered within the first three hours of delivery. It has been shown to reduce maternal
death due to hemorrhage without an increase in adverse effects