PLACENTA PREVIA

AND ABRUPTIO
PLACENTA
PRESENTER
EESSAA SHRESTHA
 Placenta previa
•Placenta previa is an abnormal implantation of the placenta
in the lower uterine segment, partially or completely covering
the internal cervical os.

•In placenta previa the placenta is implanted in the lower

uterine segment such that is completely or partially cover the
cervix or is close enough to the cervix to cause the bleeding
when the cervix dilated or the lower uterine segment effaces.
 Incidence
•Placenta previa occur in 1 in 200 live birth.
•0.5 % to 1% in hospital deliveries.
•80% cases found in multiparous.
•Increase incidence beyond 35 years.
•Incidence increase with high birth order and multiple
pregnancy.
 Etiology
Exact cause is unknown.
Theory postulated
- Dropping down theory
- Persistence of chorionic activity
- Defective decidua
- Big surface area of the placenta
 Risk factors
(a)Multiparity
(b)Increased maternal age (> 35 years)
(c)History of previous cesarean section or any other scar in the
uterus
(d)Placental size and abnormality
(e)Smoking
(f) Prior curettage
 Classification
•Low implantation

•Partial placenta previa

•Total placenta previa

 Cont…
•Total placenta previa:
the placenta totally
covers the cervical os.
 Cont…
•Partial placenta
previa: the placenta
partially covers the
cervical os.
 Cont…
•Marginal placenta previa:
the placenta lies within 2 to 3
cm of the internal os, but
does not cover it.
 Cont…
•Low-lying placenta: the exact relationship of the placenta
to the os has yet to be determined, or placenta previa is
suspected before the third trimester.
 Clinical manifestation
Cardinal sign:
- Vaginal bleeding
-sudden in onset, painless
- revealed bleeding
-Unassociated with activity
 Cont…
ABDOMINAL EXAMINATION
 The size of the uterus proportionate to the period of gestation

 The uterus feels relaxed, soft and elastic without any localized

area of tenderness
 Cont…
 Persistence of malpresentation

 Head is floating

 Fetal heart sound

 Stallworthy’s sign
 Cont…
VULVAL INSPECTION

Bright red or dark colored

Amount of blood loss

VAGINAL EXAMINATION MUST NOT BE DONE OUTSIDE THE OT

 Diagnosis
•History Taking

•Physical Examination

•Lab studies:
- Complete Blood Count
- Prothrombin Time
 Cont…
•Imaging studies:
- Transabdominal ultrasound
- Transvaginal ultrasound
- MRI
- Placentography
 Complication
MATERNAL
 DURING PREGNANCY
 Antepartum hemorrhage
 Malpresentation
 Premature labor
 Cont…
 DURING LABOUR
 Early rupture of the membrane
 Cord prolapse
 Slow dilation
 Intrapartum hemorrhage
 Increased incidence of operative interference
 Postpartum hemorrhage
 Cont…
 PUERPERINM
 Sepsis
 Subinvolution
 Embolism
 Cont…
FETAL

 Low birth weight

 Asphyxia

 Intrauterine death

 Birth injuries

 Congenital malformation
Management
 Prevention
 Adequate antenatal care

 Antenatal diagnosis

 Warning haemorrhage should not be ignored

 Colour doppler ultrasound

 Management cont…
 IMMEDIATE ATTENSION

 Amount of the blood loss

 Blood samples are taken

 A large bore IV cannula is sited

 Cont…
Infusion of Normal Saline

Gentle abdominal palpation

 Inspection of vulva
 Cont…
If bleeding is minimal and stops, conservative management
with bed rest and hospitalization until fetus is mature and
term delivery can be accomplished.
If bleeding is heavy, I.V. access should be established
immediately, along with CBC and type and cross-matching
for at least 4 units of blood.
Continuous maternal and fetal monitoring.
Amniocentesis: if possible, to determine fetal lung maturity
for possible delivery.
 Cont…
•Cesarean delivery (CS): if degree of previa is more than 30%
or excessive bleeding. The cesarean delivery may be
performed immediately.

•Vaginal delivery: occasionally in marginal previa or low-

lying placenta without active bleeding. Be prepared for
cesarean delivery also.
 Nursing management
Assessment
•History taking
•Physical examination
•Determine the amount and type of bleeding
•Inquire as to presence or absence of pain in association with the
bleeding
•Record maternal and fetal heart sound
•Palpate for the presence of uterine contractions
•Evaluate laboratory data on hematocrit and hemoglobin
•Assess fetal status with continuous fetal monitoring
 Nursing Diagnosis
•Ineffective Tissue Perfusion, Placental, related to excessive bleeding
causing fetal compromise

•Deficient Fluid Volume related to excessive bleeding

•Risk for Infection related to excessive blood loss and open vessels near
cervix

•Anxiety related to excessive bleeding, procedures, and possible maternal-

fetal complications
 Nursing Intervention
Ineffective tissue perfusion related to excessive bleeding.
•Frequently monitor mother and fetus for vital sign every 5 to
15 minutes initially and afterward every 30 to 60 minutes.
•Position on her side to promote placental perfusion.
•Administer oxygen by face mask, as indicated.
•Prepare for emergency delivery and neonatal resuscitation, as
needed.
 Cont…
Deficient fluid volume related to excessive bleeding.
• Large-bore I.V. line, draw blood for type and screen/cross for
blood replacement. Repeat every 72 hours
• Draw blood for CBC (complete blood count) , platelets, PT/PTT,
fibrinogen, and type and cross for 4 units packed red blood cells
(PRBCs)
• Assist the patient to a sitting position to allow the weight of
fetus to compress the placenta and decrease bleeding.
• Note character, color, and estimated amount of bleeding every 1
to 2 hours.
 Cont…
• Maintain strict bed rest during any bleeding episode.

• If bleeding is profuse and delivery cannot be delayed,

prepare the woman physically and emotionally for a
cesarean delivery.

• Administer blood or blood products

 Cont…
Risk for infection related to excessive blood loss and open
vessel near cervix.
• Use aseptic technique when providing care.
• Evaluate temperature every 4 hours if membranes are
intact; if ruptured membranes, hypothermia, or
hyperthermia, evaluate temperature every 1 to 2 hours.
• Evaluate white blood cell (WBC) and differential count.
• Teach perineal care and hand-washing techniques.
• Assess odor of all vaginal bleeding or lochia.
 Cont…
Anxiety related to excessive bleeding, procedure and possible
maternal fetal complication.
• Explain all treatments and procedures, and answer all related
questions.
• Encourage verbalization of feelings by patient and family.
• Provide information on a cesarean delivery, and prepare patient
emotionally.
• Inform the woman and her support persons that long-term
hospitalization or prolonged bed rest may be necessary and inform
them of the effects.
Patient education and health
maintenance
Educate the etiology and treatment of placenta previa.

Educate the woman to inform medical personnel about her

diagnosis and not to have vaginal examinations.

Educate to avoid intercourse or anything per vagina, to limit

physical activity, to have an accessible person in the event of an
emergency, and to go to the hospital immediately for repeat
bleeding or more that 6 uterine contractions per hour.
 Evaluation
•Fetal condition stable.

•Absence of shock, stable vital signs, absence of bleeding.

•Does not develop any sign of infection.

•Verbalize concerns and understanding of procedures.

Abruptio placenta
 Introduction
•Abruptio placentae is premature separation of the normally
implanted placenta before the birth of the fetus.
•Abruptio Placentae is the premature separation of the
normally implanted placenta from the uterine wall after the
20th week of gestation until the 2nd stage of labor. 
 Incidence

•Incidence ranging from 1 in 75 to 1 in 225 births

•Abruptio placenta recurs in 5 to 17% of pregnancies after 1
prior episode
•Up to 25% after 2 prior episodes 
•Smoking
•1 to 1.5% risk in all pregnancies.
 Etiology
Exact cause is unknown.
Risk factor:
• History of abdominal trauma.
• Maternal hypertension.
• Umbilical cord anomaly (e.g. short umbilical cord)
• Placental anomaly
• Supine hypotension
 Cont…
• multiple gestation
• preterm premature rupture of membranes (PPROM) at
<34 weeks' gestation
• previous abruptio placenta
• Folic acid deficiency
• Cocaine abuse
• Smoking
 Pathophysiology
Etiological factor

Hemorrhage into decidua basalis and hematoma formation

Degeneration and necrosis of decidua basalis with adjacent placenta

 Cont…
Rupture of basal plate forming communication between hematoma and intervillous villi

Fluid and blood perfolate into myometrium upto serous coat

Sometimes serosa split open and blood enter into peritoneal cavity
 Classification
Revealed

Concealed

Mixed
 Cont…
•Revealed types : Blood
expell out through vagina.
Revealed (separation of
placenta with blood visible
outside)
 Cont…
•Concealed: blood collects
behind the separated
placenta. Not visible
outside)
 Cont…
•Mixed: Some are
concealed and some are
revealed.
 Clinical classification
•Grade—0: Clinical features may be absent.
-Diagnosis is made after inspection of placenta
following delivery.
 Cont…
•Grade—1 (40%):(i) vaginal bleeding is slight
(ii) uterus: irritable, tenderness may be
minimal or absent
(iii) maternal BP and fibrinogen levels
unaffected
(iv) Fetal heart sound is good.
 Cont…
•Grade—2 (45%):(i) vaginal bleeding mild to moderate
(ii) uterine tenderness is always present
(iii) maternal pulse ↑, blood pressure is
maintained
(iv) fibrinogen level may be decreased
(v) shock is absent
(vi) fetal distress or even fetal death occurs.
 Cont…
•Grade—3 (15%): (i) bleeding is moderate to severe or may
be concealed
(ii) uterine tenderness is marked
(iii) shock is pronounced
(iv) fetal death is the rule
(v) associated coagulation defect or anuria
may complicate
 Clinical feature
•Sudden onset, intense, localized, uterine pain/tenderness
with (external) or without (occult) vaginal bleeding
•Uterine contractions of low amplitude and high frequency
•Uterine baseline resting tone may be elevated, making
assessment of uterine activity difficult
•Changes in the FHR i.e. tachycardia or bradycardia, or
repetitive late decelerations
 Cont…
•Fetal response depends on the amount of blood loss and
the extent of uteroplacental insufficiency present
•Abdominal pain is commonly present due to increased
uterine activity
•Nausea and vomiting
•Signs and symptoms of rapid labor progress and delivery
 Diagnosis
•Woman's history & physical examination

•Ultrasound

•Laboratory screen for erythrocyte rosette or Kleihauer-

Betke or acid elution tests on mother's blood to check for
fetal cells in the maternal circulation
 Cont…
•Laboratory study :
-clotting time
-Bleeding time.
-Platelet count
-Fibrinogen level.
-Prothrombin and partial prothrombin time
•Renal function test
 Complication
Maternal
•Sepsis
•Disseminated intravascularcoagulopathy
•Postpartum hemorrhage
•Acute respiratory distress syndrome
•Sheehan's syndrome (postpartum pituitary necrosis)
•Oliguria and anuria
 Cont…
Fetal
•Prematurity
•Fetal death
•Hypoxia brain injury
•Neonatal anemia
 Prevention
•Early detection and effective therapy of preeclampsia and
other hypertensive disorders of pregnancy.

•Needle puncture during amniocentesis should be under

ultrasound guidance.

•Avoidance of trauma.
 Cont…
•To avoid sudden decompression of the uterus— in acute or
chronic hydramnios, amniocentesis is preferable to artificial
rupture of the membranes.

•To avoid supine hypotension the patient is advised to lie in

the left lateral position in the later months of pregnancy.

•Routine administration of folic acid from the early pregnancy.

 Management
•Depends on the maternal and fetal status and degree of bleeding

•Admitted immediately

•If fetal compromise, severe hemorrhage, coagulopathy, poor

labor progress, or increasing uterine resting tone: emergency
cesarean delivery done
 Cont…
•If the mother is hemodynamically stable and the fetus is stable
(reassuring FHR tracing) or has already died in utero (intrauterine
fetal demise): vaginal delivery is recommended
•If mother is not hemodynamically stable, stabilize with
I.V./blood/blood products replacement to maintain urine output at
30 to 60 mL/hour and hematocrit at least 30%.
•With rapid infusion of fluids, monitor woman for signs/symptoms of
pulmonary edema.
•A neonatal specialty team: due to prematurity and neonatal
complications.
 Nursing management
Assessment
•History taking
•Physical examination
•Determine the amount and type of bleeding
•Inquire as to presence or absence of pain in association with the
bleeding
•Record maternal and fetal heart sound
•Palpate for the presence of uterine contractions
•Evaluate laboratory data on hematocrit and hemoglobin.
•Assess fetal status with continuous fetal monitoring.
 Nursing diagnosis
•Ineffective Tissue Perfusion: Placental related to excessive
bleeding, hypotension, and decreased cardiac output, causing
fetal compromise

•Deficient Fluid Volume related to excessive bleeding

•Fear related to excessive bleeding, procedures, and unknown

outcome
 Nursing intervention
Ineffective Tissue Perfusion: Placental related to
excessive bleeding, hypotension, and decreased
cardiac output, causing fetal compromise
• Evaluate amount of bleeding weighing all pads;
monitor CBC results and vital signs
• Position in left lateral side with the head elevated to
enhance placental perfusion
• Administer oxygen 8 to 12 L/minute; maintain oxygen
saturation >90%
 Cont…
• Evaluate continuous fetal status
• Encourage relaxation techniques
• Prepare for possible cesarean delivery if necessary
 Cont…
Deficient Fluid Volume related to excessive bleeding.
• Establish and maintain large-bore I.V. line for fluids and blood
products as prescribed.

• Evaluate coagulation studies bleeding time, clotting time,

prothrombin time.

• Monitor maternal vital signs and contractions.

• Monitor vaginal bleeding

 Cont…
Fear related to excessive bleeding, procedures, and unknown outcome
• Inform the woman and her family about the status of herself and the
fetus.

• Explain all procedures in advance when possible or as they are

performed.

• Answer questions in a calm manner, using simple terms.

• Encourage the presence of a support person.

 Patient education and health
maintenance
•Provide information to her and family about etiology and
treatment for abruptio placentae.
•Encourage neonatal team regarding education related to
fetal/neonatal outcome.
•Teach high-risk women the sign and symptom of placental
abruption and increased uterine activity.
•Instruct woman to report immediately if excessive bleeding or
pain occur at home.
•Instruct for emergency plan for transport to medical facility
expediently.
 Reference
•Tuitui ,R.(2010). Manual of midwifery I(Eds). Bhotahity, Kathmandu: Vidyarthi pustakh bhandar.
•Dutta, DC.(2013). DC Dutta’s Textbook of obstetrics(7th edition). New Delhi, India: Jaypee Brothers Medical
Publishers.
•Goodwin, T. Murphy. Montoro, Martin. N. Muderspach, Laila. I. Paulson, Richard. J. Roy Subir. (2010).Management
of problem in obstetrics and gynecology(fifth edition). Southern gate, Chiserter, West Sussex, Uk: John Wiley and
Son Publishers.
•https://www.semanticscholar.org/paper/Safety-and-Efficacy-of-Aortic-Vs-Internal-Iliac-for-Tokue-Tokue/db1906c1e
f7d5842490e9b5e454af1f41f6f28ad
•https://www.whattoexpect.com/pregnancy/placenta-previa/
•https://www.msdmanuals.com/de/heim/gesundheitsprobleme-von-frauen/schwangerschaftskomplikationen/plaze
ntaabl%C3%B6sung
•https://www.legeforeningen.no/foreningsledd/fagmed/norsk-gynekologisk-forening/veiledere/veileder-i-
fodselshjelp/invasiv-placenta-placenta-previa-og-vasa-
previa/https://www.legeforeningen.no/foreningsledd/fagmed/norsk-gynekologisk-forening/veiledere/veileder-i-
fodselshjelp/invasiv-placenta-placenta-previa-og-vasa-previa/
Thank you