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!