Transcript PLACENTA PREVIA-LRDR - Dr. Ahmad Abanamy Hospital

PLACENTA
PREVIA
PRESENTED BY:
JISHA MARIA
LR/DR DEPARTMENT
DEMOGRAPHIC DATA
NAME: MS. P.A.
AGE:
47/F
CASE NO: 193***
Dx: G9P7A1 29 weeks + 3
days, PTL T/C Placenta
Previa, Previous LCCS
PHYSICAL ASSESSMENT
GENERAL
The patient is 47
FEMALE, weight 74 kg.
She is conscious, coherent
y/o,
With the following Vital Signs:
BP= 120/80 mmHg
PR=72 bpm
RR= 23 /cpm
Temp=36.8⁰C
SKIN
Pallor of skin and
nails
No palpable masses
or lesions
HEAD
Maxillary, frontal,
and ethmoid sinuses
are not tender
No palpable masses or
lesions
No areas of deformity
LOC & ORIENTATION
Awake and alert
Oriented to Persons,
Place, Time
EYES
Pale conjunctivae
and no dryness
Pupils equally round
and reactive to light
EARS
No unusual
discharges noted
NOSE
Pink nasal mucosa
No unusual nasal
discharge
No tenderness in
sinuses
MOUTH
Dry mouth and lips
Free of swelling
and lesions
NECK AND THROAT
No palpable lymph
nodes
No masses and
lesions seen
CHEST AND LUNGS
Symmetrical chest
wall upon movement
Clear breath sounds
Absence of chest
pain
HEART
Regular rhythm
ABDOMEN
Abdomen is soft
With mild to moderate
uterine contraction
With mild
hypogastric pain
ABDOMEN
With active bowel
sounds
No abdominal
tenderness
GENITOURINARY
No discharges or foul smell
With minimal vaginal spotting up
to 2-13 pads per day
Able to void freely
No pain in urination
EXTREMITIES
Pulse full and equal
No lesions noted
PATIENT HISTORY
PAST MEDICAL HISTORY
With history of Abortion
At 3 yr before
With 5 times Surgical
history of LSCS
OBSTETRICAL HISTORY
DATES OF PRIOR
PREGNANCIES
GESTATIONAL AGE
G1
G2
TERM
NSD
TERM
LSCS 1X
G3
G4
TERM
VBAC
TERM
LSCS 2X
G5
G6
G7
G8
TERM
LSCS 3X
TERM
LSCS 4X
ABORTION AT 2 MOS.
(-) D& C
TERM
LSCS 5X
G9
PRESENT PREGNANCY
ROUTE
COMPLICATIONS
WEIGHT
MALPRESENTATION
(TRANSVERSE LIE)
MALPRESENTATION
(BREECH)
2.5 – 3.5 KGS
PRESENT MEDICAL
HISTORY
•
•
•
•
C/O:
Mild Hypogastric Pain
MEDICAL HISTORY: G9P7A1 29 3/7
weeks Age of Gestation
ON EXAMINATION:
BP:
120/80mmHg, PR: 72 bpm, RR: 23 cpm,
Temp. 36.8 ⁰C
LMP: Unknown
PV not done
No allergies to any food or drug
With Hypertensive and Diabetic parents
MEDICATIONS
DRUG
Tab. NIFEDIPINE
Inj.
DEXAMETHASONE
IMAGE
T
DOSE
ACTION
10mg TID x 48
hours PO
•Decreases arterial smooth
muscle contractility and
subsequent
vasoconstriction
6mg every 6
hours for 3
doses IV
•A synthetic glucocorticoid
which decreases
inflammation by inhibiting
the migration of leukocytes
and reversal of increased
capillary permeability
MEDICATIONS
DRUG
IMAGE
DOSE
ACTION
AGIOLAX
2tsp BID PO
•Suitable for bowel
regulation during
pregnancy and post
partum
Tab.
FERROUS
SULFATE
I tab OD PO
•Provides supplemental
iron, an essential
component in the
formation of hemoglobin
INVESTIGATIONS
LABORATORY
CBC
HGB
HCT
PLT
RESULT
REFENCE RANGE
11.8g/dl
35.9 %
292
Blood Group
O
Rh Type
Positive
PT
13.3 sec
10.9 – 16.3 Seconds
APTT
30.4 sec
27 – 39 Seconds
11.2-15.7 g/dL
34.1-44.9%
182-369/UL
INVESTIGATIONS:
Ultrasonographic Result
– PU 31weeks + 5days AOG by fetal
biometry
– Live Singleton in cephalic presentation,
Male fetus
– Good Cardiac and somatic activity
– Left Lateral Placenta, Grade II, Previa
Totalis
– Adequate fluid volume
BPP= 8/8
Actual Ultrasound Result
INVESTIGATIONS:
• MRI Result:
Pelvis shows gravid uterus with single fetus and
the placenta is in left lateral position and in lower
uterine segment completely covering the internal
os and shows heterogenous sigal intensity with
bulging of lower uterine segment and irregular
thick intraplacental T2 dark bands and loss of thin
subplacental myometrial zone and tenting of the
urinary bladder seen along its ntero-superior
margin, most probably suggestive of placenta
previa.
INTRODUCTION
1.
2.
3.
4.
 The term placenta previa refers to a placenta that overlies or is
proximate to the internal os of the cervix. The placenta normally
implants in the upper uterine segment. In placenta previa, the
placenta either totally or partially lies within the lower uterine
segment. Traditionally, placenta previa has been categorized
into 4 types:
Complete placenta previa
o where the placenta completely covers the internal os.
Partial placenta previa
o where the placenta partially covers the internal os. Thus, this
scenario happens only when the internal os is dilated to some
degree.
Marginal placenta previa
o which just reaches the internal os, but does not cover it.
Low lying placenta
o which extends into the lower uterine segment but does not
reach the internal os.
ANATOMY AND
PHYSIOLOGY
The placenta signifies the "second" or "embryonic" period
of pregnancy (after the implantation period) and
describes the establishment of a fully functional placenta.
The placenta is an apposition of foetal and parental tissue
for the purposes of physiological exchange. There is little
mixing of maternal and foetal blood, and for most
purposes the two can be considered as separate.
The placenta can be thought of as a "symbiotic parasite",
unique to mammalia. The placenta provides an interface
for the exchange of gases, food and waste. It also
facilitates the de novo production of fuel substrates and
hormones and filters potentially toxic substances.
The placenta has two distinct seperate compartments; the
fetal side consisting of the trophoblast and chorionic villi
and the maternal side consisting of the decidua basalis.
The placenta consists of a foetal portion formed by
the chorion and a maternal portion formed by the
decidua basalis. The uteroplacental circulatory
system begins to develop from approximately day 9
via the formation of vascular spaces called
"trophoblastic lacunae".
Maternal sinusoids develop from capillaries of the
maternal side which anastamose with these
trophoblastic lacunae. The differential pressure
between the arterial and venous channels that
communicate with the lacunae establishes
directional flow from the arteries into the veins
resulting in a uteroplacental circulation.
Placental Blood Supply
Maternal blood carrying oxygen and nutrient substrate to
the placenta must be transferred to the fetal compartment
and this rate of transfer is the rate limiting step in the
process. Therefore the placenta has a significant blood to
facilitate improved exchange.
Fetal blood enters the placenta via a pair of umbilical
arteries which have numerous branches resulting in fetal
chorionic villi within the placenta, terminating at the
chorionic plate. The fetal chorionic villi are then surrounded
by maternal tissues. This physiology is referred to as
"invasive decidualisation" as the fetal chorionic villi
effectively invade the maternal tissues. Invasive
decidualisation is not present in pigs or sheep.
Placental Blood Supply
Oxygen and nutrient rich blood returns to the
fetus via the umbilical vein. Maternal blood is
supplied to the placenta via 80-100 spiral
endometrial arteries which allow the blood
to flow into intervillous spaces facilitating
exchnage. The blood pressure within the
spiral arteries is much higher than that found
in the intervillous spaces resulting in more
efficient nutrient exchange within the
placenta.
ETIOLOGY
Increased maternal age
Uterine factors:
• Previous CS
• Instrumentation of the uterine cavity (D and C
for miscarriages or Induced Abortions)
Placental factors:
• Multiparity
• Cigarette smoking
• Living at high altitude
SIGNS AND SYMPTOMS
1. Vaginal bleeding
2. Painless but can be associated with
uterine contractions and abdominal pain
3. Bleeding may range from light to severe
4. Gross hematuria
INTERVENTION
Bed rest in lateral position to maximize
venous return and placental perfusion
Women in the third trimester are advised
to avoid sexual intercourse and exercise
and to reduce their activity level
TREATMENT
Depends upon the extent and severity
of bleeding, the gestational age and
condition of the fetus, position of the
placenta and fetus and whether the
bleeding has stopped.
Caesarean section – as soon as he baby can
be safely delivered (typically after 36weeks
gestation). Although emergency CS at any
earlier gestational age may be necessary for
heavy bleeding that cannot be stopped.
Hysterectomy
COMPLICATIONS
Maternal:
 Increased risk of PROM leading to premature labor
 Immediate hemorrhage with possible shock and maternal
death
 Postpartum hemorrhage
 Placenta Accreta
 Accreta Vera – a term used to denote a placenta with villi
that adhere to the superficial myometrium
 Increta – when the villi adheres to the body of the
myometrium, but not through its full thickness
 Percreta – when the villi penetrate the full thickness of the
myometrium and may invade neighboring organs such as
the bladder or the rectum
Fetal:
Abnormal fetal presentation
(breech)
Reduced fetal growth
Prematurity
PRIORITIZATION OF
NURSING PROBLEMS
1) Impaired fetal gas exchange related to altered
blood flow and decreased surface area of gas
exchange at site of placental detachment
2) Ineffective Tissue Perfusion related to excessive
bleeding causing fetal compromise
3) Deficient Fluid Volume related to excessive
bleeding
4) Anxiety related to excessive bleeding,
procedures, and possible fetal-maternal
complications
ASSESSMENT
SUBJECTIVE:
I am having too
much bleeding
in my vagina- as
verbalized by
the patient
OBJECTIVE
1.Restlessness
2.Confusion
3.Irritability
4.Manifest
Body Weakness
5.Capillary refill
more than 3 sec
6.Oliguria
V/S taken as
follows:
BP:90/60mm of
Hg
PR:110bpm
RR:20/mt
Temp:36.5 C
NURSING
DIAGNOSIS
Ineffective
tissue perfusion
related to
decreased HgB
concentration
in blood &
hypovolemia
secondary to
Placenta previa.
GOALS&
DESIRED
OUTCOME
Short Term:
After 12hrs of
nursing
Intervention the pt
Will demonstrate
Behaviors to
improve
Circulation.
NURSING
INTERVENTION
1.Establish Rapport
2.Monitor vital signs
RATIONALE
1.To gain patients trust
2.To obtain baseline
data
3.To assess contributing
factors
4. For comparison with
current findings
EVALUATION
Short term:
The pt shall
have
demonstrated
behaviors to
improve
circulation.
3.Assess patient
condition
4.Note customary
baseline
Data (usual BP,
weight,lab values)
5.Determine presence of 5.To identify alterations Long term:
dysrhthmias
from normal
Long term:
After 4 days of
6.Perform blanch test
nursing
Intervention the pt 7.Check for Homans Sign
will demonstrate
increased
8.Encourage quiet &
perfusion as
restful
individually
enviornment
appropriate
9.Elevate head of bed
10. Encourage use of
relaxationm
teqniques
The pt shall
6.To identify/determine have an
increased
adequate perfusion
perfusion as
7.To determine
presence of thrombus
individually
formation
appropriate.
8.To lessen O2 demand
9.To promote circulation
10.To decrease tension
level
CONCLUSION
 Presented a case of a 47 y/o Multigravida, G9P7A1, with
pregnancy 29 wks + 3 days with PTL t/c PLACENTA
PREVIA, Previous LSCS
 The treatment depends upon the extent and severity of
bleeding, the gestational age and condition of the fetus,
position of the placenta and fetus and whether the bleeding has
stopped.
 Placenta Previa is a medical emergency that needs immediate
management because it can lead to serious maternal and fetal
complications, even death of one or both of them.
 Nurse-led patient education and the provision of a supportive
environment are essential to the optimal management of
Placenta Previa
 Individually tailored and compassionate nursing care of women
with Placenta Previa will serve to enhance the wellbeing of
mother and baby
THANK
YOU!