EcIampsia .ps



EcIampsia

Severe form of Preeclarnpsia with seizure or coma. The occurrence of one or more convulsions not attributable to other cerebral disorders such as epilepsy or cerebral hemorrhage in a patient with Preeclampsia. Convulsions usually preceded by headaches, epigastric pain, hyperfiexia and hernoconcentration. It can occur before labor in 50%, during labor in 25% and early postpartum in 25%.

Incidence 0.2%.

Women in whom eclampsia develops exhibit a wide spectrum of signs and symptoms, ranging from extremely high blood pressure, 4+ proteinuria, generalized edema, and 4+ patellar reflexes to minimal blood pressure elevation, no proteinuria or edema, and

normal reflexes.

Maternal complications of eclampsia include cerebral hemorrhage, aspiration pneumonia, hypoxic encephalopathy, coma, thromboembolic events, and maternal death (incidence 0.4% to 14%) (Poole, 2004b). The perinatal death rate in pregnancies complicated by eclampsia is 9% to 23%.

Protocol for treating Eclampsia: {Management}

1. Turn, the woman on her side to prevent aspiration.

2. Establish airway and administer oxygen.

3. Administer 4-6 g of Magnesium Sulfate IV (over 10-15 minutes) followed by a 2g/hour maintenance dose; adjust dose later based on patellar reflexes, urine output and serum magnesium level.

4. Obtain arterial blood gas measurement and chest X-ray film.

5. If convulsions are controlled and maternal condition is stable, initiate induction or delivery within 3-6 hours.

6. Continue to administer Magnesium Sulfate for at least 24 hours after delivery or last convulsion.

7. Obtain computed tomographic scan or magnetic resonance imaging if seizures are atypical or coma is prolonged.

Nursing Interventions:

During the tonic phase of convulsions:

- Turn the woman to her side to allow saliva to drain from her mouth.

- Inserting a padded tongue blade may prevent injury to the mouth; it can be done without force.

- Side rails should be padded or a pillow placed between them and the woman.

- Call for assistance.

When clonic phase begins:

- Remain nearby and assist as an oral airway is inserted.

- Administer oxygen.

- Monitor maternal vital signs and FHR.

- Magnesium Sulfate, Diazeparn, Lasix and other drugs may be administered as prescribed.

- Keep the woman on her left side {left lateral position}.

- A decision about delivery is made based on maternal condition and fetal maturity.

- Signs and symptoms usually decrease rapidly after delivery; however dangers of seizures don’t pass until 48 hours following delivery.

- Follow up care is necessary.

Bleeding disorders

Any bleeding during pregnancy is abnormal. When bleeding occurs early in pregnancy, the most common causes are abortion, ectopic pregnancy and vesicular mole. When hemorrhage occurs late in pregnancy, the most common causes are placenta previa and abruptio placenta.

Bleeding in Early Pregnancy

Vaginal bleeding occurs in 16% of all pregnant women during the first trimester. The exact etiology of bleeding is not always known but there are identifiable reasons in most instances.

Causes of bleeding in early pregnancy:

1. Abortion.

2. Ectopic pregnancy.

3. Hydatidiform (vesicular) mole.

Abortion

Abortion can be defined as the death or expulsion of the fetus either spontaneously or by induction, before the 20th week of pregnancy, and weight less than 500g.

Abortus: Fetus lost before 20 weeks of gestation, less than 17.5 oz. (500 g), or less than 9.8 inches (25 cm) in size.

Types of abortion

1. Spontaneous abortions “Miscarriage”: occur without planning.

2. Induced abortions: are performed deliberately for medical (therapeutic) or social (elective) reasons.

Spontaneous Abortion (SAB)

Etiology:

The exact etiology is not always known, but there are some identifiable factors.

More than 80% of abortions occur in the first trimester.

Chromosomal abnormalities present in 60°/ of first trimester losses, decrease to 7% at 24th week.

Fetal factors:

• Chromosomal abnormalities (cause of about 60-80% of SAB).

• Faulty or defective germ plasm (a zone found in the cytoplasm of the egg cell).

• Malformation of the trophoblast.

• Poor implantation of the balstocyst.

Maternal factors:

1. General Conditions:

- Infections such as (e.g., bacteriuria and Chlamydia trachomatis)

- Chronic debilitating diseases such as hypertension or renal diseases.

- Endocrine abnormalities as uncontrolled diabetes and progesterone deficiency.

- Malnutrition.

- ABO and Rh incompatibility.

- Recreational drugs and environmental factors such as (Tobacco smoking, Alcohol drinking, Caffeine consumption, Radiation exposure, Oral contraceptives and environmental toxins)

- Aging gametes: insemination 4 days before or 3 days after ovulation.

- Laparatomy, especially nearer to pelvic organs

- Physical trauma.

- Psychological factors as stress and anxiety.

- Maternal anatomical defects, and immunological and endocrine factors

- Exposure to fetotoxic agents

2. Local disorders of the genital tract:

- Acquired uterine defects such as leiomyomas (a benign smooth muscle neoplasm that is not premalignant), intrauterine adhesions or fibroid

- A retroverted uterus (is a uterus that is tilted backwards instead of forwards)

- Cervical incompetence.

- Chronic debilitating diseases such as hypertension or renal diseases.

• Paternal factors:

Little is known but certainly, chromosomes translocation in sperm can lead to zygote defect that result in abortion.

Assessment: -

- Signs and Symptoms:

1. Vaginal bleeding: the earliest sign of an impending abortion (blood stained discharge, brown spotting or a bright red loss) which may be variable in amount.

2. Pain and cramping: usually felt in a central position, low in the abdomen, intermittent and accompanied by backache.

3. Decreased symptoms of pregnancy

4. Dilation of the cervix: present when abortion becomes inevitable.

5. hCG level will decrease.

[pic]

- A pregnancies test, vaginal examination and other tests are indicated.

Classification:

Abortions are classified according to various criteria:

1. Threatened Abortion: Any intrauterine bleeding before 20 weeks of gestation, without dilation of the cervix or expulsion of any POC (products of conception).

Small to moderate amount of bleeding with a closed cervix.

2. Inevitable Abortion: No expulsion of products, but bleeding and dilation of the cervix such that a pregnancy is unlikely.

Moderate to large amount of bleeding with uterine cramping with pain and cervical dilation.

3. Complete Abortion: passage of all products of conception after which bleeding stops. Cervical os is closed, uterus is small and no tenderness. No other symptoms appear.

4. Incomplete Abortion: partial passage of products of conception. Continued, heavy bleeding with discharge of pieces of tissue, severe uterine cramping and open cervical os. The uterus is smaller than expected.

5. Missed Abortion: Death of the embryo or fetus before 20 weeks of gestation with complete retention of the POC; these often proceed to a complete abortion within 1 to 3 weeks but occasionally they are retained much longer.

No symptoms of abortion, but symptoms of pregnancy regress. Condition may persist for many years as slight irregular bleeding.

5. Septic Abortion : infected conceptus with a soft tender uterus, odorous discharge, persistent bleeding, fever and pain. It can progress to septic shock.

7. Recurrent (Habitual) Abortion:

Is defined as three or more successive spontaneous abortions.

Primary: no previous successful pregnancies.

Secondary: repetitive losses after live birth.

Etiology

- Chrornosomal defects.

- Sub mucous myomas.

- Infections.

- Endocrine imbalance (Luteal phase deficiency) inadequate production or response to progesterone.

- Incompetent cervix: premature cervical dilation in the 2nd trimester.

Painless and gradual with eventual expulsion of previable fetus, (the etiology may be previous cervical trauma or congenital structural defects)

Assessment of patients with Recurrent Miscarriage:

1. History: unusual exposure to environmental toxins, drugs, infections, previous gynecological disorder or surgery including dilation and Curettage (D & C: the cervix

is dilated and a curette is inserted and used to scrape the uterine walls and remove the uterine contents).

[pic]

2. Physical examinations: abnormalities or pelvic examination, abnormal

cervix.

3. Tests:

- Hysterosalpinography

- Luteal phase endometrial biopsy.

- Chromosome analysis.

- Ultrasound examination at 6 weeks of gestation in the next Pregnancy.

Treatment of Recurrent Miscarriage:

1. Treatment of possible causes.

2. Cervical Cerclage (Shirodkar or McDonald techniques) {placement of ligature to close the cervix}:

- Usually vaginal under regional anesthesia.

- Prophylactic placement at end of the 1st trimester.

- Placement after cervical changes less effective.

- Remove cerclage at time of spontaneous rupture of membranes, labor.

- Elective removal after 37 weeks.

- Success rates 80% to 90%.

3. An unsensitized, Rh-negative woman should be given Rho(D) immune globulin (RhoGAM) to prevent antibody formation.

Interventions: ( Spontaneous Abortion )

The goal of interventions is to prevent damage to the mother and to save the pregnancy.

Threatened Abortion:

- Bed rest with close observation of all vaginal discharge.

- Emotional support.

- Measures to promote relaxation in a quiet comfortable environment.

- Poor outcome predicted by: falling of hCG, progressive bleeding and cramping.

Inevitable and Incomplete Abortion:

- IV. hydration

- Dilation and curettage (D & C) or suction curettage.

- Observe 4-6 hours after procedure.

- Rh negative clients should receive Rh immune globulin.

- Always check pathology to rule out mole.

- Analgesics and emotional support are provided

Complete Abortion:

- Rh negative clients should receive Rh immune globulin.

- Submit POC (Product of Conceptus) to pathology.

Missed Abortion: dilation and evacuation

Septic Abortion:

- Culture and sensitivity.

- Antibiotic therapy.

Therapeutic Abortion

Is the termination of pregnancy before the time of fetal viability for the purpose of safeguarding the health of the mother, Religious and legal considerations are always respected.

Indications.

1. When continuation of the pregnancy may threaten the life of the woman or seriously impair her health.

2. When continuation of the pregnancy is likely to result in the birth of a child with grave physical deformities or mental retardation.

Counseling before Elective Abortion:

- Reasons for the abortion should be identified and discussed.

- Discussion of possible resolutions of these reasons.

- Discussion of alternatives of abortion.

Nursing Diagnoses: (Following abortion)

I. Potential for hemorrhage related to abortion.

2. Potential for infection related to surgical procedure.

3. Pain re1ated to uterine cramping.

4. Grieving related to lost pregnancy.

Dealing with Grieving

Grieving

Is a complex of somatic and psychological symptoms associated with some extreme sorrow or loss specially the death of a loved one.

1. Denial and Isolation.

2. Anger

3. Bargaining.

4. Depression.

5. Acceptance.

Management:

- Determine if this was a planned pregnancy

- Assist the woman to discuss her feelings.

- Allow the woman time and opportunity to grieve.

- Don’t tell the woman she can get pregnant again.

- Contact Immam clergy as desire.

- Ensure that the physician talk with the woman / couple regarding her / their future childbearing potential and any treatment that may be necessary to carry a pregnancy to term.

Ectopic Pregnancy

Is any gestation located outside the uterine cavity. When a fertilized ovum implants any place other than the endometrium of the uterus, the pregnancy is called ectopic or extra uterine. Implantation may occur in the fallopian tube (99%), on the ovary, the cervix, on the outside of the fallopian tube, the abdominal wall, or on the bowel.

Most common causes of maternal death in first half of pregnancy but, mortality is decreasing.

[pic]

Factors responsible for increasing incidence (diagnosis) of Ectopic Pregnancy:

- Improved diagnostics method

- Sensitive and specific hCG assays.

- High-resolution ultrasound.

- Diagnostic labaroscopy.

- Increase awareness.

Etiology

Ectopic implantation may be -tortuitous or result of a tubal abnormality, which obstructs or delays the passage of the fertilized ovum as:

• History of sexually transmitted infections or pelvic inflammatory disease

• Prior ectopic pregnancy

• Previous tubal, pelvic, or abdominal surgery

• Endometriosis

• Current use of exogenous hormones (i.e., estrogen, progesterone)

• In vitro fertilization or other method of assisted reproduction

• In utero diethylstilbestrol (DES) exposure with abnormalities of the reproductive organs.

• Use of an intrauterine device

Frequency and Implantation Site:

1. Tubal Pregnancy 97% most frequent location,• 86% in the distal half.

- Ampullary: the most common.

- Isthmus: early rupture.

- Interstitial: rare but very dangerous because it ends in rupture uterus and hemorrhage.

- Infundibula.

2. Abdominal Pregnancy: 9.2/1000 ectopic. Mortality rate much higher.

3. Ovarian Pregnancy: pregnancy attached to uterus by utero ovarian vasculature. Oophorectomy may be indicated.

4. Cervical Pregnancy: implantation within endocervical canal, very rare 1/l000 to 1/9500 pregnancies).

Clinical Manifestations:

Vary with site of implantation and usually occur after tubal rupture.

Early Signs and Symptoms:

- Menstrual irregularities (irregular vaginal bleeding)

- Symptoms of early pregnancy.

- Dull pain on the affected side.

Signs and Symptoms of Tubal rupture:

- Pain: sudden, severe and unilateral, generalized and radiated to the shoulder and neck due to phrenic nerve stimulation.

- Vaginal bleeding dark brown and scanty, about 25% of cases without vaginal bleeding.

- Nausea, vomiting, fainting (signs of internal blood loss).

- Signs of shock.

- Normal or low temperature: Fever is important in distinguishing Ruptured tubal pregnancy from Salpingitis.

- Tenderness over abdomen upon palpation.

- Pelvic mass posterior or lateral to uterus.

- Cervical pain during vaginal examination.

- Distension of the posterior fornix with blood in the Cul-de-sac

Differential Diagnoses:

- Threatened or Incomplete abortion.

- Ruptured corpus luteum.

- Salpingitis.

- Appendicitis.

- Adnexal torsion.

- Perforated peptic ulcer.

Diagnostic Evaluation:

- Medical history. (e.g., unilateral, bilateral or diffuse abdominal pain, missed period)

- Physical examination. (a palpable mass is present on bimanual examination in approximately 50% of women)

- hCG that is low for gestational age (because an ectopic pregnancy has a poorly implanted placenta, the level of a hCG does not double every 48 hours as in normal

implantation)

- WBC: can range from normal to 15,000/mm3.

- Transvaginal ultrasonography should be performed to confirm intrauterine or

tubal pregnancy

Treatment:

- Surgical management: Salpingostomy has replaced Salpingectomy except in case of irreparable tubal rupture, tumor or hemorrhage.

- Medical management: Methotrexate (stops cell production and destroys remaining

trophoblastic tissue).

- Blood transfusion for hemorrhage.

- Fluid correction to treat or prevent shock.

Nursing Diagnoses

1. Inadequate tissue perfusion (Shock XX) related to effects of rupture (pain, blood loss..)

2. Potential fluid volume deficit related to blood loss.

3. Pain related to rupture and outpouring of blood into peritoneal cavity.

4. Anxiety related to uncertainty about condition arid potential loss of

childbearing capacity. -

Nursing Interventions:

• To Reduce Pain:

- Remain with the woman as much as possible and provide psychological support.

- Administer prescribed analgesics as needed.

- Explain procedures that needed to be performed to reduce anticipation of additional discomfort.

• To Prevent/Treat Shock:

- Monitor vital signs, assess indications of impending shock.

- Start I.V. fluids/blood as prescribed.

- Provide constant monitoring, noting any changes in the woman’s condition.

- Inspect for vaginal bleeding.

- Prepare the woman for surgery.

- Postoperative care as any patient who had any abdominal Laparatorny.

• To Establish Fluid Volume:

- Monitor vital sighs.

- IV. fluids/blood.

- Intake and output.

• To Cope with anxiety :

- Listen to the woman’s account of what has happened.

- Ask the woman to explain her understanding of future childbearing potential, correct misinformation and reinforce positive aspects.

• Reinforce physician’s decisions/expectations of future childbearing potential.

[pic]

Hydatidiform ( Vesicular ) Mole

It is a developmental anomaly of the placenta and trophoblast in which the fertilized ovum deteriorates and the chorionic villi convert into a mass of clear grape-like vesicles.

It is one of the most common lesions anteceding choriocarcinoma, a malignant tumor of the trophoblast with a tendency toward rapid and widespread metastasis.

[pic]

Incidence:

- Occurs in about 1 of every 1500-2000 pregnancies.

- Previous molar gestation increases risk of developing a subsequent molar gestation by 4 to 5 times.

- Frequency in woman over 45 years is 10 times higher than in woman aged 20-40 years.

Etiology:

The cause is unknown, but factors contributed are:

- Maternal age: below 20 years old and above 45 years.

- Genetic factors.

- High parity and malnutrition.

Clinical classification:

Vesicular mole is classified into complete and partial moles according to the presence or absence of a fetus or embryo and to its location or dissemination.

• A complete mole is characterized by trophoblastic proliferation and the absence of fetal parts.

• Incomplete moles often appear with a coexistent fetus that has a triploid genotype (69 chromosomes) and multiple anomalies. Most fetuses associated with incomplete moles survive only several weeks in utero before being spontaneously aborted. Incomplete moles are almost always benign and have a much lower malignancy potential than complete moles.

• An invasive mole is similar to a complete mole but has invaded the myometrium layer of the uterus. Invasive moles rarely metastasize.

• Choriocarcinoma is invasive, malignant trophoblastic disease that is usually metastatic and can be fatal

|Complete mole |Partial |Feature |

|absent |present |Embryonic or fetal tissue |

|diffuse |focal |Hydatidiform swelling of villi |

|Diffuse |Focal |Trophoblastic hyperplasia |

|? 20 % |? 5 % |Trophoblastic tumor |

129

Clinical manifestation:

1. Bleeding: the most common sign and vary from spotting to profuse, continuous or intermittent, red or brownish bloody discharge, about the 12th week of gestation, may also pass villi.

2. Enlargement of the uterus is out of proportion to what it normally is at a specific time in pregnancy. Uterine enlargement results from the rapidly proliferating trophoblastic tissue and the large accumulation of clotted blood.

3. Signs of preeclampsia or eclampsia earlier than 20 weeks gestation.

4. Hyperemesis Gravidarum experienced by 30% of women with this condition (due to uterine enlargement).

5. Pallor and dyspnea → anemia.

6. hCG titer is markedly increased beyond the 90th day of gestation when normally expected to drop.

7. Anxiety and tremors → thyroid dysfunction due to high hCG.

8. Uterine discomfort due to over stretching.

9. Absent fetal heart tone.

10. Absent fetal parts (except in partial mole) found on ultrasound or X-ray.

Diagnostic Evaluation:

- Ultrasound is the diagnostic method of choice.

- A patient often presents with vaginal bleeding, uterine enlargement in absence of fetal heart tone.

- CBC, Hb, HCT, and RBCs, are decreased.

- Blood chemistries: renal, liver and thyroid function test.

- Chest X-ray, for ? lung cancer metastasis.

- hCG titers are elevated up to 1 to 2 million IU in 24 hours.

- Notes: normal hCG at 10 weeks ? 400,000 IU.

Management:

1. Suction curettage has low complications rate with uterine size < 16 weeks.

Excessive uterine enlargement may predisposed to pulmonary complication as preeclampsia and fluid overload.

2. Primary Hysterectomy:

- Patients who have completed childbearing and desire sterilization are good candidates.

- Reduce malignant sequelae from 20% to 5%.

3. Prophylactic chemotherapy:

- May reduce malignant sequelae in high-risk patient.

- Not routinely recommended in cases of uncomplicated mole.

4. Blood transfusion: to correct anemia and to replace blood loss.

130

Follow-up:

Follow-up supervision at least for 1 year includes the following:

1. hCG measurement as:

- Once weekly until titers are negative for 3 consecutive weeks, then:

- Once monthly for 6 month then.

- Every 2 months for 6 months and,

- Every 6 months.

2. Chest X-ray: to exclude and detect metastases are done every month until hCG titers are negative, then every 2 months for 1 years.

3. Start contraception during surveillance (for 1 year).

Oral contraceptive are the best choice.

Prognosis:

- Favorable if hCG titers doesn't persist at elevated levels.

- Unfavorable if a malignant mole is discovered and untreated.

Nursing diagnosis:

1. Fluid volume deficit…

2. Knowledge deficit regarding this condition.

3. Grieving related to fetal loss.

4. Potential for infection..

5. Altered nutrition status related to nausea and vomiting.

6. Anxiety related to prognosis of the condition.

Nursing Intervention:

* preoperative and postoperative care:

- Replace blood as prescribed.

- Prepare the woman for surgery, suction curettage or hysterectomy.

- Administer antimetabolite drugs as prescribed.

- Observe for complication e.g. hemorrhage or rupture uterus.

- Advice the woman for the one year follow-up care.

- Counsel the woman to avoid attempting pregnancy for 1 year to allow hCG to be monitored carefully.

Promoting a healthy self concept:

- Encourage the woman to discuss her feelings regarding the condition.

- Determine the woman's understanding of what causes the abnormal development, correct misinformation and reinforce the correct one.

- Help the woman to understand that the abnormal development was a "quirk of nature" and not caused by her partner actions or genetic make up.

131

Bleeding in late pregnancy

Bleeding during 2nd half of pregnancy occurs in 3% to 4% of woman.

The most common causes are placenta previa and placental abruption. It is potentially fatal to both mother and fetus.

Placenta previa

Is the development of the placenta in the lower uterine segment, partially or completely covering the internal cervical os.

Incidence:

- One of the major causes of bleeding during the last trimester.

- Occurs once in every 200 deliveries (1/200 births).

- It accounts for 20% of all antepartal hemorrhages.

- More common in parous woman (1/20 in grand multiparity).

Classification:

Traditionally categorized in to 3 types:

1. Complete, total or central previa: internal os entirely covered. It is associated

with the greatest amount of blood loss.

2. Partial placenta previa: internal os partially covered.

3. Marginal placenta previa: placenta reaches edge of the internal os.

Note: the term low-lying Implantation is used when the placenta situated in the lower uterine segment but away from the os.

[pic]

Etiology:

▪ Placenta previa may be associated with conditions that cause scarring of the uterus such as a prior cesarean section, multiparity, or increased maternal age.

▪ large placental mass as seen in multiple gestations.

▪ Smoking, cocaine use.

▪ Prior history of placenta previa

▪ Closely spaced pregnancies

▪ Maternal age greater than 35 years

Clinical Manifestation:

- Usually presents as painless vaginal bleeding in the 3rd trimester, but can occur as early as 20 weeks of gestation. Bleeding occurs without warning in the absence of trauma.

- Blood loss from the first bleeding is rarely fatal; in each subsequent episode bleeding is heavier.

- Placenta previa may not cause bleeding until labor begins, or complete dilation has occurred.

- Bleeding occurs earlier and is more profuse with total placenta previa.

Notes:

• There is a relationship between the site and size of the placenta because low uterine segment is less favorable than that of the fundus, so placenta needs to cover larger area for adequate efficiency.

• The site of placenta is close to the cervical os more accessible to ascending infection from the vagina. Hemorrhage and anemia increase the risk of antenatal infection (placentitis) and purpraul sepsis.

• Blood loss may not cease with the delivery of the infant, blood loss may continue because of the diminished muscle content of the lower uterine segment, therefore, postpartum hemorrhage may occur even the fundus is contracted firmly.

• If uterine bleeding can’t be controlled with ocytocics drugs, ligation of the internal iliac arteries or even hysterectomy may be necessary.

• The major problem related to placenta previa is preterm delivery (about 60% of neonates die).

• Maternal risks associated with placenta previa are shock, the potential for emergency hysterectomy, and death.

Diagnostic evaluation:

• Painless vaginal bleeding is placenta previa until proven otherwise.

• Ultrasound is the diagnostic technique of choice (93% -97% accurate), some difficulties can arise in:

o Obese patients.

o Posterior previa.

o Over distended bladder.

• Transvaginal ultrasound may be preferred to transabdominal for initial resolution.

- Definitive diagnosis by direct palpation of the placenta is not recommended (risk of placental perforation).

- Leopold maneuvers often reveal the fetus to be in a breech or oblique position or transverse lie because of the abnormal location of the placenta.

Management:

1. Hospital admission

- Itravenous access - vital signs.

- Blood typing and screening

2. Remote from term

- Maternal hemodynamic stability obviously a requirement.

- Preterm contractions/labor, Tocolytics have been used (MgSO4 is tocolytic of choice) with no proven efficacy.

- Replace blood loss to keep HCT greater than 30%.

- Steroids have been shown to be beneficial to aid fetal lung maturity.

- Serial ultrasound examinations every 2-3 weeks.

- Home care only under ideal circumstances.

o High motivated patient

o Location near a hospital

o Full understanding of the risk

o Ability to maintain bed rest.

o 24-hours transportation is available.

3. Delivery

• The ideal is a well-planned elective cesarean section at 36-37 weeks.

• Amniocentesis is useful for timing of delivery.

• Vaginal approach considered in rare circumstances.

o Dead fetus.

o Major fetal anomalies.

o Previability.

o Active labor with engagement of fetal head.

Nursing intervention:

• To prevent premature delivery:

o Bed rest

o No vaginal or rectal examination

o Regular assessment of blood loss, uterine contractility, pain, FHR, vital signs, and laboratory tests.

o Intravenous fluid.

o Two units of blood (cross matched) available for immediate transfusion.

Abruptio Placenta

Premature separation of the normally implanted placenta. Separation occurs in the area of deciduas basalis, most often in the third trimester, but can happen any time after 20 weeks.

Incidence:

• Complicates approximately 1% of pregnancies.

• Is a serious disorder, account about 15% of all perinatal mortality "most common cause of intrapartum fetal death".

• Permanent neurologic impairment in 14% of surviving infants.

• Fetal mortality occurs in about 35% of all placental abruptions and can be as high as 50% to 80% when associated with severe placental abruption. Death results from hypoxia that is related to the decreased placental surface area and maternal hemorrhage

Classification:

The 3 types of Abruptio Placenta are:

1. Convert: Placenta separates in the center and bleeding is concealed.

2. Overt: blood passes from under the placenta causing vaginal bleeding.

3. Placental prolapse: total separation of placenta with massive bleeding.

[pic]

Etiology / Risk factors:

• Maternal hypertension.

• PIH.

• Cocaine induced.

• Maternal smoking.

• Short umbilical cord.

• Uterine anomalies.

• Advanced maternal age.

• Physical work.

• Poor nutrition.

• Trauma.

• Amniotomy in patients with polyhydramnios.

Recurrent risk:

• Ten fold increase in second pregnancy over population risk.

• With 2 previous abruptions, 25% chance of third abruption.

Clinical Manifestations:

• Vaginal bleeding (80% of patients), blood remains concealed (20% of patients).

• Other signs include uterine tenderness and abdominal or back pain, a boardlike abdomen and no vaginal bleeding.

• Sudden onset of severe continuous abdominal pain and/ or low back pain.

• Uterine contractions with rigid, tender and irritable uterus.

• Amniotic fluid color may be dark red.

• If bleeding is severe, the myometrium may be infiltrated with blood and may fail to contract following delivery (couvelair uterus).

• If bleeding is severe, hypofibrinogenemia may develop (Consumptive coagulopathy).

• Fetal activity may be increased, because of fetal hypoxia. With severe complete abruption fetal heart tones may not be heard (late decelerations, bradycardia and lack of variability on the electronic fetal Monitor).

Complications: "accompany moderate to severe abruption"

1. Hypovolemic shock which may cause Renal failure.

Etiology: is unclear, probably from reduced renal perfusion.

2. Fetal hypoxia or anoxia with possible fetal death.

3. Consumptive Coagulopathy → Hypofibrinogenemia → DIC.

4. Couvelair uterus: bleeding into the myometrium resulting in board-like rigidity of the uterus.

5. Hepatitis post blood or fibrinogen transfusion.

Management:

Goals of therapy:

1. Maternal urine greater than 30ml/hr.

2. HCT greater than 30%.

• Close observation.

• Induction of labor: (48% will deliver vaginally).

o Evidence or concern regarding maternal or fetal compromise.

o Greater than 37 weeks gestation.

o No placenta previa.

o Perform vaginal examination and amniotomy.

o Oxytocin may be useful if labor doesn't progress.

• Cesarean section:

o Continued bleeding.

o Fetal distress.

o May be dangerous in setting of coagulation defect.

-Note: Hypofibrinogenemia is treated with plasma or cryoprecipitate.

• Hemorrhagic shock:

o Wide- bore I.V in place.

o Blood products available.

o Repeat coagulation tests.

o Fetal monitoring: distress develops in 60% of patient with moderate abruption.

Nursing Diagnosis:

1. Potential shock related to hemorrhage.

2. Fluid volume deficit related to hemorrhage.

3. Trauma to fetus related to hypoxia.

4. Anxiety regarding safety of self and fetus.

Nursing Interventions:

A. Fluid Replacement:

1. Administer I.V fluids and whole blood to replace blood loss as prescribed.

2. Monitor fibrinogen level.

3. Monitor vital signs and FHR to detect impending shock and to assess fetal status.

4. Monitor vaginal bleeding and height of the fundus to detect increasing concealed hemorrhage.

B. Ensuring Blood flow and Oxygen:

1. Administer fluids or blood as prescribed.

2. Monitor fetal heart tones continuously to assess fetal well-being.

3. Provide oxygen therapy as prescribed.

4. Maintain the women in a side lying position to keep uterus off vena cava, therapy improving blood flow to intervillous spaces.

5. Prepare the women for immediate delivery (vaginal or cesarean).

C. Reducing Anxiety:

1. Keep the women /couple informed of what is happening and of the plan of care.

2. Reinforce positive aspects of the woman condition without giving false reassurance. Have the couple listen to fetal heart tones.

3. Explain procedure that might be needed.

4. Don't leave the woman alone.

5. Following delivery:

-Provide nursing surveillance during the puerperium for early detection of complications.

- Monitor vital signs and uterine muscle tones to detect uterine atony.

- Be alert for signs of postpartum infections, blood loss and shock greatly reduce resistance to infection.

A comparsion between Abruptio Placenta and Placenta Previa

| |Abruptio Placenta |Placenta Previa |

|Onset |Third trimester |Third trimester |

|Bleeding |May be concealed, external dark hemorrhage or bloody |External, small to profuse in amount, bright red |

| |amniotic fluid | |

|Pain and uterine |Usually present, irritable uterus progress to |Usually absent, uterus soft |

|contraction |broad-like consistency | |

|Fetal heart tone |May be irregular or absent |Usually normal |

|Presenting part |May or may not be engaged |Usually not engaged |

|Shock |Moderate to severe depending on extent of concealed or |Usually not present, unless bleeding is severe |

| |external hemorrhage | |

|Delivery |Immediate delivery usually by cesarean |Delivery may be delayed depending on gestational |

| | |age and amount of bleeding |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download