1. A Case Presentation on: PLACENTA PREVIA Grace Ruth gladdy mae g. pagaduan ob-gyne department February 2013

2. DEMOGRAPHIC DATA  Name: Mrs. X  Age: 47  Gender: Female  Case Number: 193***  Diagnosis: G9P7A1 29 weeks + 3 days, PTL T/C Placenta Previa, Previous LCCS

3. PHYSICAL ASSESSMENT General Appearance:  Well-groomed  Cooperative  Weak-looking

4. Vital Signs:  Blood Pressure: 120/80  Pulse Rate: 72  Respiratory Rate: 23  Temperature: 36.8 PHYSICAL ASSESSMENT

5. Head and Neck:  Facial symmetry  Absence of scalp tenderness  Absence of lesions nor masses noted  Iris are black, pupils are equally round and reactive to light accommodation  With white and clear sclera  Pinna is of same color with the facial skin, smooth and aligned with eye level  Able to hear sound clearly as claimed PHYSICAL ASSESSMENT

6. Head and Neck:  Absence of pain, inflammation or drainages  With patent and clear nostrils  Absence of nasal flaring, congestion or drainages  Tongue and uvula are centrally positioned  Lingual tonsils at the posterior portion of the tongue  Has good oral hygiene, no halitosis  Jugular vein not distended  No swollen lymph nodes as palpated

7. Thorax:  Symmetrical chest wall upon movement and breathing on room air  Breath sounds are clear Cardiovascular:  Absence of chest pain  Normal peripheral pulse PHYSICAL ASSESSMENT

8. Genitourinary:  Minimal vaginal spotting up to 2-3pads per day  No discharges nor foul smell  Able to void freely  Urine is clear  No pain in urination Gastrointestinal:  Mild hypogastric pain  Abdomen is soft  With mild to moderate uterine contraction  With active bowel sounds  No abdominal tenderness PHYSICAL ASSESSMENT

9. Musculoskeletal:  No physical deformities nor paralysis  With active ROM  Joints can move freely without any resistance or pain Neurologic:  Awake, alert and oriented to time, person and place  Understands written and spoken language and responds accurately  Able to follow commands PHYSICAL ASSESSMENT

10. PATIENT HISTORY I.PAST MEDICAL HISTORY  With history of Abortion.  Surgical history of LSCS 5x.

11. Obstetrical History

12. PATIENT HISTORY II. PRESENT MEDICAL HISTORY  Patient 193*** is a referral from another hospital with chief complaint of vaginal spotting at 10:30 AM associated with mild hypogastric pain.  G9P7A1 29 3/7 weeks Age of Gestation  LMP: Unknown  PV not done  No allergies to any food or drug  With Hypertensive and Diabetic parents

13. MEDICATIONS:

14. Ferrous dexamethasone

15. INVESTIGATIONS:

16. Ultrasonographic Result PU 31weeks + 5days AOG by fetal biometry Live Singleton in cephalic presentation, Male fetus Good Cardiac and somatic activity Left Lateral Placenta, Grade II, Previa Totalis Adequate fluid volume BPP= 8/8

17. Actual Ultrasound Result bladder Uterus

18. INVESTIGATIONS: MRI Result: Pelvis shows gravid uterus with single fetus and the placenta is in left lateral position and in lower uterine segment completely covering the internal os and shows heterogenous sigal intensity with bulging of lower uterine segment and irregular thick intraplacental T2 dark bands and loss of thin subplacental myometrial zone and tenting of the urinary bladder seen along its ntero-superior margin, most probably suggestive of placenta previa.

19. PATHOPHYSIOLOGY

20. TOPIC PRESENTATION INTRODUCTION: The term placenta previa refers to a placenta that overlies or is proximate to the internal os of the cervix. The placenta normally implants in the upper uterine segment. In placenta previa, the placenta either totally or partially lies within the lower uterine segment. Traditionally, placenta previa has been categorized into 4 types: Complete placenta previa, where the placenta completely covers the internal os. Partial placenta previa, where the placenta partially covers the internal os. Thus, this scenario happens only when the internal os is dilated to some degree. Marginal placenta previa, which just reaches the internal os, but does not cover it. Low lying placenta, which extends into the lower uterine segment but does not reach the internal os.

21. ANATOMY AND PHYSIOLOGY

26. ETIOLOGY  Increased maternal age  Uterine factors: Previous CS Instrumentation of the uterine cavity (D and C for miscarriages or Induced Abortions)  Placental factors: Multiparity Cigarette smoking Living at high altitude

27. SIGNS AND SYMPTOMS  Vaginal bleeding  Painless but can be associated with uterine contractions and abdominal pain  Bleeding may range from light to severe  Gross hematuria

28. INTERVENTION  Bed rest in lateral position to maximize venous return and placental perfusion  Women in the third trimester are advised to avoid sexual intercourse and exercise and to reduce their activity level

29. TREATMENT Depends upon the extent and severity of bleeding, the gestational age and condition of the fetus, position of the placenta and fetus and whether the bleeding has stopped.  Caesarean section – as soon as he baby can be safely delivered (typically after 36weeks gestation). Although emergency CS at any earlier gestational age may be necessary for heavy bleeding that cannot be stopped.  Hysterectomy

30.  Conservative Management, bed rest

31.  Continuous maternal and fetal monitoring

32.  Blood transfusion and IVF for heavy bleeding  CBC, blood typing and cross matching of at least 4 units of blood

33.  Tocolytics (Nifedipine 10mg TID)  Corticosteroids (Dexamethasone 6mg IM q6 for 24hours)

34. COMPLICATIONS Maternal:  Increased risk of PROM leading to premature labor  Immediate hemorrhage with possible shock and maternal death  Postpartum hemorrhage  Placenta Accreta  Accreta Vera – a term used to denote a placenta with villi that adhere to the superficial myometrium  Increta – when the villi adheres to the body of the myometrium, but not through its full thickness  Percreta – when the villi penetrate the full thickness of the myometrium and may invade neighboring organs such as the bladder or the rectum

36. Fetal:  Abnormal fetal presentation (breech)  Reduced fetal growth  Prematurity

37. PRIORITIZATION OF NURSING PROBLEMS  Impaired fetal gas exchange related to altered blood flow and decreased surface area of gas exchange at site of placental detachment  Ineffective Tissue Perfusion related to excessive bleeding causing fetal compromise  Deficient Fluid Volume related to excessive bleeding  Anxiety related to excessive bleeding, procedures, and possible fetal-maternal complications

38. NCP: IMPAIRED FETAL GAS EXCHANGE

39. NCP: DEFICIENT FLUID VOLUME

40. CONCLUSION Placenta previa is a medical emergency that needs immediate management because it can lead to serious maternal and fetal complications, even death of one or both of them. Once diagnosed, close observation must be done to monitor the status of both the mother and the baby. Any untoward symptom must be urgently referred to the attending physician. Complications can be diminished if the diagnosis and management are done at an early stage.

41. THANK YOU!