INTRODUCTION

Placenta previa Placenta previa is an obstetric complication that occurs in the second and third trimesters of pregnancy. It may cause serious morbidity and mortality to both the fetus and the mother. It is one of the leading causes of vaginal bleeding in the second and third trimesters. Normally, the placenta is attached to the uterus in an area remote from the cervix. Sometimes, the placenta is located in such a way that it covers the cervix. This is called a placenta previa. Clinically, these patients present after 20 weeks with painless vaginal bleeding, usually mild. This is in contrast to patients with placental abruption, who usually experience significant pain and contractions. An old rule of thumb is that the first bleed from a placenta previa is not very heavy. For this reason, the first bleed is sometimes called a "sentinel bleed." Later episodes of bleeding can be very substantial and very dangerous. This can lead to hypovolemic shock and maternal death. Because a pelvic exam may provoke further bleeding it is important to avoid a vaginal or rectal examination in pregnant women during the second half of their pregnancy unless you are certain there is no placenta previa. There are degrees of placenta previa. The first type is total placenta previa and it occurs when the internal cervical os is completely covered by the placenta. Second type is partial placenta previa occurs when the internal os is partially covered by the placenta. Third type is marginal placenta previa occurs when the placenta is at the margin of the internal os. And lastly lowlying placenta previa occurs when the placenta is implanted in the lower uterine segment. In this variation, the edge of the placenta is near the internal os but does not reach it.

Risk Factors: Risks for the mother include: 1. Life-threatening hemorrhage 2. Cesarean delivery 3. Increased risk of postpartum hemorrhage 4. Increased risk placenta accreta (Placenta accreta is where the placenta attaches directly to the uterine muscle.) Risk factors for placenta previa that can be controlled include:
1. 2.

Smoking during pregnancy. Using cocaine during pregnancy.

Risk factors that can't be controlled include:

1.

2. 3. 4. 5.

Past surgeries or tests that affected the lining of the uterus, such as uterine surgery, dilation and curettage (D&C), or myomectomy. Past cesarean delivery (C-section). A history of five or more past pregnancies. Being 35 or older. A history of a past placenta previa.

6. 7.

Women with large placentae erythroblastosisare at higher risk. Increased risk in blacks and Asians.

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Clinical Manifestations Symptoms Vaginal bleeding after the 20th week of gestation is the primary symptom of placenta previa. Although the bleeding is typically painless, in some cases it can be associated with uterine contractions and abdominal pain. Bleeding occurs in 70% to 80% of women with placenta previa. Bleeding may range in severity from light to severe. Complications Placenta previa can be associated with other complications of pregnancy including placenta accreta occurs when the placental tissues grows too deeply into the womb, attaching to the muscle layer, resulting in difficulty separating from the wall of the uterus at delivery. This complication can cause life-threatening bleeding and commonly requires hysterectomy at the time of Cesarean delivery. Placenta accrete occurs in 5% to 10% of women with placenta previa. Then preterm premature rupture of the membranes (PPROM) can result from the bleeding of placenta previa. Also other abnormalities of the placenta or umbilical cord can be associated with placenta previa there can be also breech or abnormal presentation of the fetus can be associated with placenta previa due to the presence of the placenta in the lower part of the uterus. Some studies also have shown a reduction in fetal growth associated with placenta previa. Finally, placenta previa, like other complications of pregnancy, can have a significant emotional impact on the mother after it has been diagnosed. Some complications for the baby include intrauterine growth restriction (IUGR) due to poor placental perfusion, increased incidence of congenital anomalies and problems for the baby, secondary to acute blood loss

Diagnostic examinations: A. Imaging Studies 1. Transabdominal ultrasonography - A simple, precise, and safe method to visualize the placenta, this ultrasonography has an accuracy of 93-98%. There is a false-positive results can occur secondary to focal uterine contractions or bladder distention. 2. Transvaginal ultrasonography- Recent studies have shown that the transvaginal method is safer and more accurate than the transabdominal method. Transvaginal ultrasonography is also considered more accurate than transabdominal ultrasonography. The angle between the transvaginal probe and the cervical canal is such that the probe does not enter the cervical canal. Some advocate insertion of the probe no more than 3 cm for visualization of the placenta. 3. Transperineal ultrasonography Transperineal ultrasonography has been suggested as an alternate method, especially when instrumentation of the vaginal canal with a probe is a concern. A recent study suggests that transperineal ultrasonography may compliment transabdominal ultrasonography and help eliminate false-positive results using the transabdominal method alone. 4. MRI - MRI has been suggested as a safe and alternate method and may be useful in determining the presence of placenta accreta. A large trial determining the efficacy and safety of the use of MRI during pregnancy has not been performed, and further investigation is required. 5. Ultrasound - Most cases of placenta previa are found during the second trimester when a woman has a routine ultrasound. Or it may be found when a pregnant woman has vaginal bleeding and gets an ultrasound to find out what is causing it. Some women find out that they have placenta previa only when they have bleeding at the start of labor.

B. Blood studies 1.Beta-human chorionic gonadotropin (beta-hCG) subunitHuman chorionic gonadotropin or Human chorionic gonadotrophin (hCG) is a glycoprotein hormone produced in pregnancy that is made by the developing embryo soon after conception and later by the syncytiotrophoblast (part of the placenta). Its role is to prevent the disintegration of the corpus luteum of the ovary and thereby maintain progesterone production that is critical for a pregnancy in humans. hCG may have additional functions; for instance, it is thought that hCG affects the immune tolerance of the pregnancy. Early pregnancy testing, in general, is based on the detection or measurement of hCG. Because hCG is produced also by some kinds of tumor, hCG is an important tumor marker, but it is not known whether this production is a contributing cause or an effect of tumorigenesis. 2. Rh compatibility- basic test that determines blood type and Rh factor. Rh factor may play a role in the baby's health, so it's important to know this information early in pregnancy. 3. CBC count-A complete blood count (CBC), also known as full blood count (FBC) or full blood exam (FBE) or blood panel, is a test requested by a doctor or other medical professional that gives information about the cells in a patient's blood. A scientist or lab technician performs the requested testing and provides the requesting medical professional with the results of the CBC. 4. Lecithin/sphingomyelin (L/S) ratio for fetal maturity - the lecithin-sphingomyelin ratio is a test for assessing fetal lung maturity. Lungs require surfactant, a soapy sort of substance, to lower the surface pressure of the alveoli in the lungs. This is especially important for premature babies trying to expand their lungs for that critical first breath after birth. Surfactant is a mixture of lipids, proteins, and glycoproteins. Lecithin and sphingomyelin being two of them. Lecithin makes the surfactant mixture more effective.

Other Tests 1.Kleihauer-Betke test, if concerned about fetal-maternal transfusion- the Kleihauer-Betke ("KB") test, Kleihauer-Betke ("KB") stain or Kleihauer test, is a blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother's bloodstream. It is usually performed on Rhesus-negative mothers to determine the required dose of Rho(D) immune globulin (RhIg) to inhibit formation of Rh antibodies in the mother and prevent Rh disease in future Rh-positive children. 2. SGOT (Serum Glutamic-Oxalocetic Transaminase AST) This test measures the amount of an enzyme called glutamicoxaloacetic transaminase (GOT) in the blood. This enzyme is found in the liver, muscles (including the heart), and red blood cells. It is released into the blood when cells that contain it are damaged. Other names for this enzyme are aspartate aminotranskinase, aspartate transaminase, and AST. The SGOT level is measured to check the function of liver, kidney, heart, pancreas, muscles, and red blood cells. It is also measured to monitor medical treatments that may lead to liver inflammation. Nursing Responsibility: Inform the patient avoid taking certain medicines before the test because they might affect the test result. Make sure your healthcare provider knows about any medicines, herbs, or supplements that you are taking. Instruct the patient that a small amount of blood is taken from arm with a needle. The blood is collected in tubes and sent to a lab. Instruct also that having this test will take just a few minutes of the time. There is no risk of getting AIDS, hepatitis, or any other blood-borne disease from this test. 3. SGPT (Serum Glutamic-Pyruvic Transaminase-ALT)-This test measures the amount of an enzyme called glutamate pyruvate transaminase (GPT) in your blood. This enzyme is found in many body tissues in small amounts, but it is very

concentrated in the liver. It is released into the blood when cells that contain it are damaged. This enzyme is also called alanine transaminase, or ALT. The GPT level is tested to look for and evaluate damage to the liver. It is also measured to check medical treatments that may lead to liver inflammation. Nursing Responsibility: Instruct the patient to avoid taking certain medicines before the test because they might affect the test result. Make sure that the healthcare provider knows about any medicines, herbs, or supplements that the patient taking. Instruct also the patient that a small amount of blood is taken from arm with a needle. The blood is collected in tubes and sent to a lab. Having this test will take just a few minutes of the time. There is no risk of getting AIDS, hepatitis, or any other blood-borne disease from this test. 4. Diagnosis before 20 weeks of pregnancy - its not unusual to detect a low-lying placenta or to see the placenta covering the cervix during a routine midpregnancy ultrasound. Most of these cases resolve on their own before delivery, as the uterus grows and the placenta migrates away from the cervix. It may need additional ultrasounds to track the position of the placenta. The longer placenta previa persists, the more likely it will be present at delivery. 5. Diagnosis after 20 weeks of pregnancy - the health care provider may detect placenta previa later in pregnancy during an ultrasound for an unrelated reason. At this stage of pregnancy, however, vaginal bleeding is usually the tip-off.

Medical Management 1. For little or no bleeding -If marginal placenta previa or another form of placenta previa but little or no bleeding, your health care provider may recommend bed rest at home. Depending on the circumstances, it may need to lie in bed most of the time sitting and standing only when necessary. It needs

to avoid sex and vaginal exams, which can trigger bleeding. Exercise is usually off-limits, too. Discuss the do's and don'ts with your health care provider and be prepared to seek emergency medical care if you begin to bleed. 2. For heavy bleeding - If bleeding, it may need bed rest in the hospital. If the bleeding is severe, it may need a blood transfusion to replace lost blood. It may also benefit from medications to prevent premature labor. 3. For bleeding that wont stop If bleeding can't be controlled or baby is in distress, it may need an emergency C-section even if the baby is premature.

Treatment: 1. IV crystalloid. Up to two liters can effectively treat mild degrees of hemorrhage. In more severe hemorrhage, it can stabilize the patient long enough to get blood transfusions going. Some physicians prefer a colloid solution (and there are arguments both for and against this). Either should be effective in helping expand the intravascular volume. 2. Oxygen. This won't help a lot because the hemoglobin is already nearly 100% saturated with oxygen, but it helps enough that it is worth doing. 3. Blood. The problem with shock is that not enough oxygen is getting to the tissues. Expanding the blood volume with crystalloid won't create any more red blood cells to carry oxygen to the tissues. In cases of moderate to severe shock, blood transfusions are needed. 4. Trendelenberg position. If blood is not immediately available, placing the patient in a head-down position (ie, legs up in the air, or Trendellenberg position) will make available 250 to 500 cc of blood that had been pooled in the lower extremeties.

5. Stop the bleeding. Do whatever needs to be done to stop the bleeding. There is an old medical expression: "All bleeding eventually stops." That's true. 6. Blood transfusion. - The ideal material for use in hemorrhagic shock would be disease-free, body-temperature, fresh, whole blood, with identical blood type and major and minor blood groups. This has excellent oxygen-carrying capacity, platelets, coagulation factors, volume and colloid, and would be totally non-reactive within the victim's bloodstream. Unfortunately, this ideal material does not exist (at least not when quickly needed), so we usually compromise, using various blood products, depending on the needs of the patient.

Medication Women with placenta previa who experience heavy bleeding may require blood transfusions to replace lost blood. Intravenous fluids are usually given. In some cases, tocolytic drugs (medications that slow down or inhibit labor) are given. Magnesium sulfate and terbutaline (Brethine) are examples of tocolytic drugs. A woman with placenta previa may be given corticosteroid medications to speed lung development in the fetus prior to Cesarean delivery (C-section).

Nursing Management: 1. Take and record vital signs, assess bleeding, and maintain a perineal pad count. Weigh saturated perineal pads to assess maternal blood loss. 2. Maintain bedrest and elevate the head of the bed. 3. Provide fluid administration, usually with lactated Ringers solution, through a large-bore IV line to maintain fluid balance. 4. Consider cesarean delivery if the placenta previa is more than 30% or if excessive bleeding occurs.

5. Measure fundal height to assess for rising fundus, which may reveal concealed bleeding. 6. Disallow rectal or vaginal examinations, to minimize the danger of bleeding. 7. Prepare the patient and family emotionally and physically for delivery. 8. Observe for meconium in the amniotic fluid; may indicate fetal distress. 9. Provide emotional support to the patient and family. Surgical Management 1. Caesarean Section - A cesarean section is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby. If the placenta is completely covering the opening of the cervix (placenta previa), delivering the baby through the vagina (birth canal) should not be done. A C-section makes the delivery safer for the mother and the baby. However, if the placenta is covering only part of the opening of the cervix, then in some cases vaginal delivery may be possible.