PLACENTA PREVIA
– low implantation of the placenta
– 3rd trimester bleeding
– measured in percentage
4 degrees:
- Low-lying placenta – implantation in the lower portion of the uterus
- Marginal implantation – placental edge approaches the cervical os
- Partial Placenta previa – implantation the occludes a portion of the cervival os
- Complete Placenta Previa – total obstruction of the cervical os
Risk factors:
- increased parity
- advanced maternal age
- past CS or D & C
- multiple gestation
Assessment:
- abrupt, painless, bright red vaginal bleeding
- duration of pregnancy
- time the bleeding began
- woman’s estimation of the amount of blood
- pain
- color of blood: redder blood indicates that the bleeding is fresher/continuing
- prior episodes of bleeding/cervical surgery
Management:
- Avoid coitus
- bed rest
- WOF: bleeding – occurs when the lower uterine segment begins to differentiate from the upper segment late in pregnancy; results from placenta’s inability to stretch to accommodate the differing shape of the lower uterine segment/cervix
when bleeding: Risk for Hemorrhage – compromised fetal oxygen supply
- position: side-lying position when in bed rest
- no pelvic or rectal exam! –massive hemorrhage
- IV fluids
- Betamethasone – steroid that hastens lung maturity (≤34 weeks AOG)
- Vaginal birth for 30% previa; CS for previa of more than 30%
- Placenta Previa women: more prone to post partal hemorrhage because the placental site is in the lower uterine segment, which does not contract as efficiently as the upper segment.
ABRUPTIO PLACENTA
– premature separation of the placenta.
– correct implantation but suddenly separates and bleeding results.
Predisposing Factors:
- increased parity
- short umbilical cord
- chronic hypertensive disease
- hypertension in pregnancy
- direct trauma
- vasoconstriction from cocaine use
- cigarette smoking
Assessment:
- sharp, stabbing pain as the initial separation occurs
- labor + separation = pain
- if no pain is felt, there is tenderness upon uterine palpation
- Bleeding:
- external bleeding – placenta separates 1st at the egde & blood escapes freely from the cervix.
- internal bleeding – center separates first; pooling of blood under the placenta
– COUVELAIRE UTERUS (uteroplacental apoplexy) = hard, board-like abdomen with no apparent or minimally apparent bleeding present
- signs of shock: uterus – tense & rigid to touch
Management:
- IV fluids
- oxygen by mask to limit fetal anoxia
- V/S q 5-15 minutes
- side lying position
- no pelvic or rectal exams
- no enema
- WOF: post partal infection
PRE-ECLAMPSIA
a.k.a. Pregnancy-Induced Hypertension
Toxemia of Pregnancy
After 20 weeks AOG:
- Hypertension
- Edema
- Proteinuria
- + convulsions = eclampsia
Management:
- ↑ OFI (water and juice); no carbonated drinks and no high sodium fluids
- position: left side-lying
- Non-stress test to determine fetal status
- Report: headache, visual changes, dizziness, epigastric pain
- ↑ protein intake – ↓processed foods 7 table salt
- weigh daily – edema/nutritional status
- hematocrit
DOC: Magnesium sulfate (MgSO4) –
Before giving this drug, check for:
- Urine output – ≥30cc/hour
- BP – systolic BP not below 90mmHg
- RR – not below 12 bpm
- Patellar tendon reflex – should be (+)
- IM, 4 doses in alternate buttocks
Antidote for MgSO4 toxicity: Calcium Gluconate
Premature Rupture of Membranes (PROM)
Premature rupture of membranes (PROM) is a rupture (breaking open) of the membranes (amniotic sac) before labor begins. If PROM occurs before 37 weeks of pregnancy, it is called preterm premature rupture of membranes (PPROM).
Causes
- Rupture of the membranes near the end of pregnancy (term) may be caused by a natural weakening of the membranes or from the force of contractions. Before term, PPROM is often due to an infection in the uterus. low socioeconomic conditions (as women in lower socioeconomic conditions are less likely to receive proper prenatal care)
- sexually transmitted infections such as chlamydia and gonorrhea
- previous preterm birth
- vaginal bleeding
- cigarette smoking during pregnancy
- unknown causes
Why is premature rupture of membranes a concern?
PROM is a complicating factor in as many as one third of premature births. A significant risk of PPROM is that the baby is very likely to be born within one week of the membrane rupture. Another major risk of PROM is development of a serious infection of the placental tissues called chorioamnionitis, which can be very dangerous for mother and baby. Other complications that may occur with PROM include placental abruption (early detachment of the placenta from the uterus), compression of the umbilical cord, cesarean birth, and postpartum (after delivery) infection.
Symptoms:
- leaking or a gush of watery fluid from the vagina
- constant wetness in panties
Diagnosis:
In addition to a complete medical history and physical examination, PROM may be diagnosed in several ways, including the following:
- an examination of the cervix (may show fluid leaking from the cervical opening)
- testing of the pH (acid or alkaline) of the fluid
- looking at the dried fluid under a microscope (may show a characteristic fern-like pattern)
- ultrasound
Treatment
- hospitalization
- expectant management (in some cases of PPROM, the membranes may seal over and the fluid may stop leaking without treatment)
- monitoring for signs of infection such as fever, pain, increased fetal heart rate, and/or laboratory tests
- giving the mother medications called corticosteroids that may help mature the lungs of the fetus (lung immaturity is a major problem of premature babies). However, corticosteroids may mask an infection in the uterus.
- antibiotics (to prevent or treat infections)
- tocolytics – medications used to stop preterm labor.
- delivery (if PROM endangers the well-being of the mother or fetus, then an early delivery may be necessary to prevent further complications)
OXYTOCIN
Antepartum: Oxytocin is indicated for the initiation or improvement of uterine contractions, where this is desirable and considered suitable for reasons of fetal or maternal concern, in order to achieve vaginal delivery.
Indications:
1) induction of labor in patients with a medical indication for the initiation of labor, such as Rh problems, maternal diabetes, preeclampsia at or near term, when delivery is in the best interests of mother and fetus or when membranes are prematurely ruptured and delivery is indicated;
(2) stimulation or reinforcement of labor, as in selected cases of uterine inertia;
(3) as adjunctive therapy in the management of incomplete or inevitable abortion. In the first trimester, curettage is generally considered primary therapy. In second trimester abortion, oxytocin infusion will often be successful in emptying the uterus. Other means of therapy, however, may be required in such cases.
Postpartum: Oxytocin is indicated to produce uterine contractions during the third stage of labor and to control postpartum bleeding or hemorrhage.
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