Abnormal Ob

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BLEEDING DISORDERS OF LATE PREGNANCY
PLACENTA PREVIA
* placenta develops in the lower part of uterus versus the upper part * There are 3 degrees of previa:
* Marginal – reaches within 3cm of cervical opening
* Partial – placenta partially covers the cervical opening * Complete/ Total – completely covers opening
* Observe bleeding during contraction
Manifestations:
* bright red, painless vaginal bleeding
* risk of hemorrhage increases with nearing of labor
* fetus often in abnormal presentation because uterine segment is covered, therefore, there is no descent * fetus may have anemia because of chronic bleeding
* Mother may be more at risk postpartum for infection and hemorrhage * Vaginal organisms can easily reach placenta site
* Lower portion of uterus has fewer muscles resulting to weaker contractions Diagnosis:
* serial monitoring through ULTRASOUND! (Abdominal)
* can confirm diagnosis
* full bladder can create false appearance of anterior previa * presenting part may overshadow posterior previa
* transvaginal scan can locate placental edge and internal os * transvaginal and internal examinations – discouraged because it may lead to early pregnancy bleeding Treatment:
* depends on AOG and amount of bleeding
* Goal is to maintain pregnancy as long as safety possible (at least until 37 weeks AOG) * Mother encouraged to lie on side or with pelvic tilt to avoid supine hypotension * Delivery by C-section if total or partial

* May deliver vaginally if low-lying or marginal double set-up * With no active bleeding
* Expectant management
* No intercourse and digital exams
* With late pregnancy bleeding
* Assess overall status, circulatory stability
* Full dose Rhogam if Rh-
* Consider maternal transfer to tertiary hospital if premature * May need corticosteroids, tocolysis, amniocentesis
* Rhogam – to prevent antibody production
* Tocolysis – promote uterine relaxation; terbutalin drop * Amniocentesis – check lung maturity
Medical Management:
* Mom stable, fetus immature Bed rest, no sex act, report bleeding * Fetus > 36 weeks Amniocentesis to check lung maturity, delivery * S/S of hypovolemia in mother (hemodynamically compromised) Delivery Expectant Management:

* may discharge home if stable after 72 hours of inpatient observation * reduces stay in hospital by average of 14 days
* No increase in:
* Hemorrhage
* Need for transfusion
* Poor maternal and neonatal outcomes
Tocolytics
* to prolong pregnancy and reach term for at least 37 weeks AOG * can add an additional 11 days to pregnancy
* allows for administration of corticosteroids
* no increase in maternal or fetal complications
* birth weight average of 320 grams
Double Set-up Exam
* evaluation of previa by digital exam in operating room set for immediate CS delivery * appropriate only in marginal previa with vertex presentation * carefully palpate placental edge and fetal head

* perform CS delivery for:
* complete previa
* fetal head not engaged
* non-reassuring tracing late decelerations (uteroplacental insufficiency) * brisk/ persistent bleeding
* regional anesthesia is safe, less blood loss
Nursing Care:
* observe for vaginal blood loss pad count
* observe for S/S of shock monitor VS
* NO VAGINAL EXAMS!
* Vital signs q15 mins if actively bleeding and oxygen administered * Continuous fetal monitoring external FM
* Prepare for CS if indicated
* Supportive care

ABRUPTIO PLACENTAE
* premature permanent separation of placenta from implantation site * mother is not yet in labor, placenta already separated
* predisposing factors include
* hypertension PIH vasoconstriction separation!
* Cocaine or alcohol use
* Smoking
* Poor nutrition
* Abdominal trauma
* Prior history of...
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