This NCLEX review will discuss abruptio placentae vs. placenta previa.
As a nursing student, you must be familiar with these maternity complications along with how to provide care to a patient experiencing one of these conditions.
Don’t forget to take the abruptio placentae vs placenta previa quiz.
You will learn the following from this NCLEX review:
- Definition of each complication
- Pathophysiology
- Signs and Symptoms
- Nursing Interventions
Lecture on Placenta Previa and Abruptio Placentae
Placenta Previa
An ATTACHMENT ISSUE!! It is the abnormal attachment of the placenta in the uterus near or over the cervical opening.
Where should the placenta normally attach?
It should attach either to the top or side of the uterus…. NOT in the lower parts of the uterus, near or over the cervical opening.
Different types of placenta previa:
Total previa: placenta completely covers the cervical opening
Partial previa: placenta partially covers the cervical opening (not fully covered)
Marginal previa: placenta is near the edge of the cervical opening
Cases of placenta previa vary and treatment depends on how far along the women is: Placenta previa can be seen on the 20 week ultrasound. Sometimes if the placenta is found to be low lying (partially or marginal) the placenta will move upward away from the cervix as the uterus grows throughout the rest of the pregnancy. This will be reassessed with an ultrasound at 32 weeks.
So, in some cases the placenta previa will correct itself.
Causes of the placenta attaching abnormally?
- Maternal age >35 years old
- Multiples
- Already had a baby
- Drug use: cocaine or smoking
- Scarring in the uterus from surgery: fibroid removal, c-section etc.
Signs and Symptoms of Placenta Previa
PREVIA
Painless vaginal bright RED bleeding (mild to profuse)
Relaxed soft uterus NON-tender
Episodes of bleeding (not spotting) most likely during 3rd trimester…as the body prepares for the baby with the cervix thinning it causes bleeding from where it is tearing the vessels in the placenta.
Visible bleeding (not concealed as in some cases with abruptio placentae)
Intercourse post bleeding (spontaneous or during labor)
Abnormal fetal position breech (bottom first) or transverse lie (sideways)…baby’s head should normally be down but the placenta is in the way…fetal heart rate normal
Nursing Interventions for Placenta Previa
Pelvic rest: no vaginal exams or sexual intercourse, douching throughout the rest of the pregnancy (don’t want to cause injury to the vulnerable placenta presenting at the cervical opening)
No abdominal manipulation
If woman is experiencing NO bleeding or very light bleeding: bed rest, no strenuous exercise or sexual intercourse for the rest of the pregnancy until baby is ready for delivery
If woman is experiencing bleeding: hospitalized to monitor baby and mom
- Watch bleeding…. at risk for hemorrhage:
- may need blood transfusion (type and cross match, RH negative….need RhoGAM, IV access (pick 18 gauge or bigger) for transfusion of blood products and fluids , monitoring CBC, clotting levels
- external monitor to monitor baby’s heart tones, monitoring mom’s vital signs per protocol every 15 minutes (low blood pressure and increased HR….shock)
- monitoring amounts of blood loss (are a lot of pads and linens soiled with blood?), place mom on left side lying position (increases the amount of blood and nutrients going to the baby via the placenta)
- If bleeding can’t be stopped will need c-section.
Contractions causing bleed: may be ordered to give tocolytics (drugs to stop contractions)
Amniocentesis to assess lung maturity of baby and steroids may be given to help baby’s lung mature.
C-section is usually ordered for a partial or complete previa.
In some cases women with a marginal previa (low lying) may be allowed to have baby vaginally.
Complication: Issues with placenta separating completely from uterus because it has embedded deep within the uterus…condition called placenta accreta ….major risk of hemorrhage…may need hysterectomy.
Abruptio Placentae
A DETACHMENT ISSUE!! There is detachment of the placenta from the uterine wall BEFORE the birth of the baby.
When should the placenta normally detach from the uterine wall?
It detaches itself after the birth of the baby because it is no longer needed. The placenta is usually delivered within 10-20 minutes after the delivery of the baby…..learn more about the stages of labor.
Types of abruptio placentae include partial or total detachment.
What can cause premature detachment of the placenta?
Risk Factors include:
- chronic hypertension
- development of preeclampsia
- previous placental abruption
- trauma to abdomen
- cocaine or smoking
- PROM (premature rupture of the membranes)
- multiples
- many pregnancies in the past
Signs and Symptoms of Abruptio Placentae
“Detached”
Dark red bleeding
Extended fundal height from concealed bleeding
Tender uterus
Abdominal pain/contractions
Concealed bleeding that can stay inside the uterus and back flow into the fallopian tubes. The patient can enter shock without seeing the amount of blood loss.
Hard abdomen
Experiences DIC (disseminated intravascular coagulation): a super event of clotting in the body followed by a depletion of clotting factors that leads to uncontrolled bleeding and possibly death.
- If the placenta is not delivered promptly after detachment, the body can experience DIC.
- WHY? When the placenta becomes damaged and detaches from the uterine wall, large amounts of thromboplastin (which is released from damaged platelets and this substance will convert prothrombin into thrombin) is released into mom’s circulation.
- This is going to lead to abnormal clotting throughout the body (blocking small vessels) and depleting clotting factors.
- The body senses this abnormal clotting so it tries to reverse it by causing fibrinolysis to breakdown the fibrin in the clot, but this will further complicate things and leads to the depletion of clotting factors, which leads to hemorrhage and even death.
- Remember mom is at major risk for hemorrhage but she has an open wound in the uterus from where the placenta detached.
- WHY? When the placenta becomes damaged and detaches from the uterine wall, large amounts of thromboplastin (which is released from damaged platelets and this substance will convert prothrombin into thrombin) is released into mom’s circulation.
Distressed baby (heart rate tone abnormalities)
Nursing Interventions for Abruptio Placentae
Watch for signs and symptoms of DIC:
- low platelets, fibrinogen, and prothrombin levels
- gum bleeding
- oozing type bleeding at injection or IV sites
- petechiae or ecchymosis
- micro-emboli (small clots that have formed in important vessels that supply vital organs): decrease in urinary output, chest pain, difficulty breathing, mental status changes
Assess bleeding: vital signs per protocol every 15 minutes, pad count, may be concealed (monitor and mark fundal height and abdominal girth)
No abdominal manipulation or vaginal exams until placenta previa ruled out with ultrasound
Left side lying position NO SUPINE (due to bleeding)
Monitor baby continuously with external monitoring: fetal heart tone
Type and cross match, CBC, clotting levels, Rh Factor (if Rh negative will need RhoGAM shot)
Needs IV (pick 18 gauge or bigger) for transfusion of blood products may be giving IV fluids and blood products
Prep for delivery of baby: vaginal if baby and mom stable OR c-section if baby or mom are showing signs of distress
References:
- Placenta abruption – definition: MedlinePlus Medical Encyclopedia. Medlineplus.gov. Retrieved 23 January 2018, from https://medlineplus.gov/ency/article/000901.htm
- Placenta previa: MedlinePlus Medical Encyclopedia. Medlineplus.gov. Retrieved 23 January 2018, from https://medlineplus.gov/ency/article/000900.htm
- Pregnancy complications | womenshealth.gov. womenshealth.gov. Retrieved 23 January 2018, from https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/pregnancy-complications