CHAPTER 21 1 Define the hemorrhagic complications of placenta previa, abruptio placentae, disseminated intravascular coagulation (DIC), and gestational trophoblastic disease. 2 Identify the classical signs and symptoms of placenta previa, abruptio placentae, DIC, and trophoblastic disease. 3 List the appropriate nursing interventions for care of the perinatal patient with a hemorrhagic disorder. 4 Correlate patient response with desired response to treatment to anticipate subsequent care. 5 Assemble the appropriate health care provider team and coordinate the health care team as long as is necessary. A Hemorrhagic disorders are obstetric emergencies. They are the leading cause of perinatal patient admissions to intensive care units. Maternal morbidity and mortality are significantly affected (Fuller & Bucklin, 2007; Martin, Hamilton, Ventura, Menacker, & Park, 2002; Ventura, Martin, Curtin, Menacker, & Hamilton, 2001). Between 17% and 25% of all pregnancy-related deaths can be directly attributed to hemorrhage (Chang, Elam-Evans, & Berg, 2003). 1. Bleeding complicates one in five pregnancies 2. Incidence and type of bleeding varies by trimester. B The maternal mortality rate for 2006 was 13.3 deaths per 100,000 live births. African American women have a substantially higher risk of maternal death than white women with a maternal mortality rate of 32.7, roughly 3.4 times the rate for white deaths per 100,000 live births. The maternal mortality rate for Hispanic women was 10.2 deaths per 100,000 live births (National Vital Statistics Report, 2009). 1. The ranked order causes of death after a live birth are uterine atony, complications from DIC, and abruptio placentae. 2. The ranked order causes of death after stillbirth are abruptio placentae and uterine rupture. 3. 68% of maternal deaths secondary to hemorrhage occur within 48 hours after the pregnancy ends. C Obstetric hemorrhage is defined as a 10% decrease in hematocrit, total blood loss of more than 1000 mL, or need for transfusion therapy (Benedetti, 2002). Class 2 hemorrhage is characterized by a 1200- to 1500-mL blood loss and early compensatory changes of tachypnea and tachycardia (Francois & Foley, 2007). A Placenta previa is an implantation of the placenta in the lower uterine segment, near or over the internal cervical os. The underlying cause of placenta previa is unknown. 1. Reported incidence affects approximately 0.5% to 1% (1 in 200) of births; among grand multiparous women it is increased 2% (Clark, 2004; Hull & Resnik, 2009). 2. Recurrence risk following one pregnancy complicated by a previa ranges from 4% to 8% (Konje & Taylor, 1999). 3. There is a direct relationship between the number of previous cesarean births and risk of placenta previa, probably due to uterine scarring (Benedetti, 2002; Clark, 2004; Gilbert, 2007; Hull & Resnik, 2009; Konje & Taylor, 1999). B Classifications for placenta previa 1. Classifications for placenta previa are based on the degree to which the internal cervical os is covered by the placenta. The four types of placenta previa identified are: a. Low-lying placenta: reserved for those situations in which the exact relationship of placenta to the cervical os has not been determined b. Marginal previa: edge of the placenta is within 2 to 3 cm of the internal cervical os but does not cover it c. Partial (incomplete) previa: partial or an incomplete placental coverage of the cervical os d. Complete placenta previa: placenta covers part or all of the internal cervical os in the third trimester 2. Advanced ultrasound technology has allowed more accurate assessments of placental location in relation to the cervical os. The more contemporary ultrasound classification used is that the os is covered or marginal. C The degree of occlusion of the internal cervical os may depend on the degree of cervical dilation, so what may appear to be low-lying or marginal on ultrasound examination prior to the onset of labor can become more serious as labor progresses. A The classical sign of placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. a. Presents with confirmed placenta previa or vaginal bleeding (1) Previously diagnosed by ultrasonogram (a) About 12% to 25% of women might be diagnosed with placenta previa or low-lying placenta before 30 weeks’ gestation. (b) Low-lying and placenta previa before 30 weeks usually resolves (up to 75%) or migrates. (c) If the placental edge is 15 mm or more over the internal os at 12 to 16 weeks’ gestation, the incidence of third-trimester previa becomes 5.1% (Taipale, Hiilesmaa, & Ylostalo, 1997). (2) Documentation on antepartal record (3) History of one or more previous pelvic bleeding episodes (4) Increased risk for incidence (Hull & Resnik, 2009): (a) Previous placenta previa; 83 times the increased risk (b) Advanced maternal age greater than 40; 93 times the increased risk (Ananth, Demissie, Smulian, & Vintzileos, 2003) (c) Previous cesarean birth: 1.5 to 15 times the increased risk (Clark, 2004; Silver, Landon, & Rouse, 2006). (d) Short interval between pregnancies and multiparity (Cunningham et al, 2005) (e) Previous abortions with curettage; risk increased 1.3 times (f) Smoking, amount dependent, with a 1.4- to 3-fold increased risk (g) Race; Asian women have a 1.9 times greater risk (h) Large placenta related to multiple gestation, diabetes, or erythroblastosis fetalis a. Vaginal bleeding, which is typically bright red and painless (1) Vaginal bleeding, with or without uterine contractions, due to placental separation from cervical os or lower uterine segment and the inability of the uterus to contract at the vessel sites; the initial bleed is rarely profuse and usually stops spontaneously; bleeding recurs later. (2) Presence of clots usually indicates normal coagulation process. (3) Absence of clots might indicate evolving coagulopathy, either hypofibrinogenemia or thrombocytopenia. (4) Painful bleeding can occur when the placenta abrupts away from the uterine tissue, even with a placenta previa. (5) Vaginal examination with speculum is postponed until ultrasound confirmation of diagnosis. (6) Monitor amount, color, and frequency of vaginal bleeding. (1) Abdominal palpation should indicate a soft, relaxed nontender uterus with normal tone. (2) Abdominal tone can be tense with the laboring patient. (3) Transabdominal ultrasound confirms diagnosis in 93% to 97% of cases. Difficulty with interpretation in the obese patient, with a posteriorly implanted placenta and with an engaged cephalic presentation. c. Hemodynamic changes; risk associated with blood loss (1) Vital signs may initially remain normal; due to pregnancy blood volume changes can accommodate up to 40% blood loss before showing signs of a hypovolemic state and shock (Francois & Foley, 2007). (2) Maternal blood loss can occur rapidly; approximately 700 to 1000 mL/min (10% to 15% of maternal cardiac output) of blood flow is directed to the uterine vasculature and placenta during pregnancy (Sosa, 2001). (3) Maternal blood loss results in decreased oxygen-carrying capacity, which directly affects oxygen delivery to maternal organ systems and indirectly affects oxygen delivery to the fetus. (a) Placental blood flow is directly proportional to uterine perfusion pressures; uterine perfusion pressures are proportional to maternal systemic blood pressure. (b) Maternal hemorrhage, if not identified and corrected, leads to a hypovolemic state, decreasing maternal cardiac output and systemic perfusion pressures (Benedetti, 2002). (c) Decreased maternal systemic blood pressure leads to decreased uterine perfusion pressures and fetal compromise. (d) Decreased oxygenation and hypoperfusion can set up cascade of events predisposing to multiorgan dysfunction syndrome (MODS) (Benedetti, 2002). (4) Fetal oxygenation decreases proportionally to changes in maternal cardiac output generation and systemic perfusion pressures (Blackburn, 2007; Feinstein & Atterbury, 2003). (a) Fetal risks from maternal hemorrhage include blood loss, anemia, hypoxemia, hypoxia, anoxia, and preterm birth. (b) Fetal blood loss is always significant because of the small fetal blood volume (80 to 100 mL/kg). (c) Disruption of uteroplacental blood flow can result in a progressive deterioration of fetal status; the degree of fetal compromise is directly related to the total volume of blood loss and duration of the bleeding episode (Sosa, 2001). d. Shock as a result of significant blood loss (1) Rising pulse rate: initially is full and easily palpable; as bleeding continues, pulse becomes weak and thready (2) Increase in respiratory rate; desaturation of hemoglobin as measured by lowered pulse oximetry is a later finding and might overestimate value if vasoconstriction is present in the extremity in which measurement is taken (3) Skin changes to pallor, cold and clammy with mottling as a result of systemic vasoconstriction to shunt perfusion to essential organs (4) Falling blood pressure; hypotension is a late finding (5) Decreasing urinary output secondary to acute left ventricular dysfunction and renal hypoperfusion (6) Decreasing level of consciousness with increasing anxiety, apprehension, and restlessness (7) Changes in laboratory findings consistent with acute blood loss e. Fetal heart rate (FHR) response to maternal bleeding or shock (1) Loss of variability and accelerations (2) Abnormal FHR and loss of variability (a) Initial compensatory tachycardia (b) Subsequent bradycardia; fetal cardiac output is rate dependent, and therefore when baseline rate decreases by 50%, fetal cardiac output decreases by 50%. (c) Sinusoidal pattern, indicating fetal anemia, hypoxia, and acidemia (d) Persistent late decelerations indicating impaired uteroplacental perfusion (3) If maternal status remains unstable, and bleeding is allowed to continue, intrauterine demise is possible. f. Complications associated with placenta previa (1) Coagulopathy is rare (Wing, Paul, & Millar, 1996). (2) Abnormal implantation of placenta invading uterine wall (a) Placenta accreta is an abnormality of invasion of the trophoblast beyond normal boundary of the Nitabuch’s fibrinoid layer. Placenta accreta occurs in 5% to 10% of pregnancies with a previa (Lockwood & Funai, 1999). [i] Prevalence of accreta is increasing and is closely correlated with number of cesarean births a woman has undergone (Benedetti, 2002; Gilbert, 2007). [ii] One prior cesarean: risk of accreta is 10% to 25%; risk is greater than 50% with two or more cesarean births [iii] Presence of accreta significantly increases risk of severe hemorrhage and peripartal hysterectomy (Flamm, 2001). (b) Placenta increta: Invasion of trophoblast extends into the myometrium. (c) Placenta percreta: Invasion of trophoblast extends beyond the serosa. (3) Postpartum hemorrhage due to placental implantation in the less muscular, lower uterine segment, which contracts poorly and lacerates easily during delivery and manual removal of placenta. (5) Abnormal placental development and abnormal cord insertion are rare but significant causes of fetal bleeding (see Chapter 11 for complete discussion of placental variations). (a) Vasa previa: Fetal vessels cross the placental membranes in the lower uterine segment and cover the cervical os. (b) Velamentous cord insertion: Fetal vessels run across chorion and amnion without protective Wharton’s jelly before entering the placental surface. (c) Succenturiate placenta: one or more small accessory lobes of placental vascular tissue in membranes that are attached to main placenta by fetal vessels (d) Classic presentation of vasa previa, velamentous cord insertion, or succenturiate placenta is vaginal bleeding with rupture of membranes, followed quickly by abrupt change in fetal heart rate and fetal death. (e) Increased fetal mortality rate (f) Greater risk of compression, rupture, or both, when velamentous vessels are close to cervix g. Fetal malpresentation in third trimester (Neilson, 2001) a. Ultrasonography accuracy 93% to 98% by combination of abdominal, transperineal, and transvaginal techniques (1) Need more than one view to locate placenta, including lateral uterine walls, for diagnosis of placenta previa. (2) Differentiate placenta previa from abruptio placentae or other causes of bleeding. (3) Determine if placenta previa and abruptio placentae coexist. (4) Approximately 7% to 10% of women are asymptomatic when placenta previa is found on routine ultrasonogram. (5) Magnetic resonance imaging (MRI) is occasionally used to diagnose placenta previa; especially diagnostic for posterior uterine wall placenta (6) Doppler color flow aids diagnosis of placental vessel abnormalities associated with placenta previa, such as velamentous insertion of cord. b. Avoid speculum and digital vaginal examinations to diagnose placenta previa. (1) Speculum examination might be performed after placenta previa has been ruled out by ultrasonography. (2) Digital examination risks perforation or abruption of placenta previa. (3) If speculum examination is absolutely necessary, should be performed with double set-up procedure in room equipped for an emergency cesarean section if profound bleeding occurs. c. If there is significant blood loss, clotting problems develop; therefore, evaluate baseline clotting values. d. Clotting studies (e.g., prothrombin time [PT], partial thromboplastin time [PTT], platelets, D-dimer, complete blood count [CBC], fibrinogen, fibrin split products [FSPs], or fibrin degradation products or clotting screen such as CBC, platelets, and D-dimer. e. Test for presence of fetal RBCs in maternal blood sampling or vaginal blood using rapid tests (4 to 7 minutes): Ogita (most sensitive at 20% fetal blood), APT (sensitive at 60%), Loendersloot (sensitive at 60%), or more lengthy tests (1 hour): Kleihauer-Betke stain or hemoglobin electrophoresis. (1) Avoid vaginal examinations. (2) Monitor maternal pulse and blood pressure. (a) Assess trends in vital signs: hemodynamic status is stable or further fluid resuscitation is needed. (b) Use electrocardiogram (ECG) monitor or maternal rate mode on electronic fetal monitor (EFM), as needed. (c) Monitor central venous pressure (CVP) or pulmonary pressures with Swan-Ganz catheter if bleeding progresses. (3) Establish intravenous (IV) line with large-bore intracatheter (16 gauge preferable, or 18 gauge). (a) Rapidly administer nondextrose crystalloids, such as Ringer’s lactate or normal saline to stabilize and increase blood volume. (a) Type and crossmatch for initial two units of packed cells. (b) Clotting studies as ordered (c) CBC and chemistry profile as ordered (6) Administer oxygen at 8 L per mask (10 to 12 L if rebreather bag used). (7) Measure or estimate blood loss. Weighing pads is a method of accurate assessment of blood loss, but not frequently practiced. b. Anticipated expectant care management (Gilbert, 2007) (1) Initial hospitalization for evaluation of maternal and fetal status. (2) Activity restriction might be ordered, requiring bedrest with bathroom privileges; as maternal and fetal status allows, the patient may be allowed limited periods of ambulation. (3) Continuous monitoring for active vaginal bleeding. (4) Venous access site maintained during hospitalization (5) Monitor laboratory values of hemoglobin/hematocrit levels and coagulation profile; maternal status determines need to hold blood in blood bank for possible type and cross-match. (6) Continuous EFM initially and during bleeding episodes. (7) Biophysical profile (BPP) or nonstress test (NST) with amniotic fluid index (AFI), followed by a weekly modified BPP. (8) Antenatal corticosteroids to enhance fetal pulmonary maturity between 24 and 34 weeks’ gestation (9) Monitor for signs and symptoms of preterm labor and intrauterine infection; uterine irritability or preterm labor can be treated with tocolytics, such as magnesium sulfate, if patient is otherwise stable (Baron & Hill, 2002). (10) Preparation for emergency cesarean section delivery if necessary. Transfer to a tertiary perinatal center if necessary to manage care effectively. c. Outcomes of improved tissue perfusion: decreased and/or stopped blood loss 2. Maternal blood loss leading to ineffective fetal perfusion and oxygenation (1) Continuously monitor FHR, preferably with EFM, to evaluate variability. (2) Observe for abnormal FHR patterns (see Chapter 12 for further discussion of FHR patterns). (3) Place patient in lateral position or wedge to left. (4) Treat patient for alteration in tissue perfusion as indicated. (5) Anticipate cesarean delivery and maintain close observation for postpartum hemorrhage. b. Outcomes for optimal fetal perfusion (1) Speak calmly to patient and support persons. (2) Explain condition as diagnosed using pictures, images, and resources of health care team. (3) Explain interventions and reason they are being performed. (a) Observation during time frame to allow for fetal growth and organ maturity (b) Administration of tocolysis to treat and prevent premature uterine contractions (c) Immediate responses for profuse bleeding and fetal compromise (d) Reassurances and instructions for home care with patient and support system b. Antepartal home care maintenance (1) Anticipate discharge from health care facility: (a) 72 hours after last bleeding episode (b) If no indicators of preterm labor (c) If evidence of fetal well-being (d) If mechanism in place to return to hospital immediately if active bleeding resumes (2) Focus on accurate assessments and appropriate referral. (3) Criteria for home care management vary with primary perinatal provider and home care agency (Baron & Hill, 2002; Gilbert, 2007; Simpson & Creehan, 2001). (3) Ongoing assessments include assessment of vaginal bleeding; evaluation of fetal well-being and uterine activity; warning signs of preterm labor, including possible home uterine monitoring; daily or at least twice weekly home visits for comprehensive maternal-fetal evaluation; timing of appropriate laboratory assessment; fetal kick counts (after 24 weeks gestation), vaginal bleeding, uterine activity, maternal activity level, and adherence to prescribed nursing care plan (Simpson & Creehan, 2001). c. Outcomes related to maternal anxiety C Health education for placenta previa 1. Education for diagnosis of second-trimester placenta previa a. Assess patient’s readiness for discharge to residential location. (1) Has access to immediate transportation if bleeding recurs (2) Residing at location within reasonable distance of hospital b. Assess patient’s understanding of diagnosis of placenta previa. (1) Use pictures to explain diagnosis. (2) Answer questions as they arise. (3) Involve family members and support team as patient requests. c. Review symptoms that will necessitate a return to hospital. (a) Document amounts in metric or nonmetric units (e.g., 2 cups); pad count. (b) Describe appearance of clots (e.g., dark red, falls apart). (c) Describe feeling of dizziness, difficulty breathing, and pallor. (2) Uterine and abdominal pain d. Review factors that contribute to reducing risk of intrauterine growth restriction. e. Avoid insertion of anything into vagina and coitus until physician approved. f. Explain importance of follow-up. 2. Education for diagnosis of late third-trimester placenta previa a. Explain reasons for hospitalization. (1) Cervical changes occur as delivery approaches. (2) Bleeding increases with cervical changes. (3) Observation of labor status (4) Need for fetal observation and testing (5) Monitor status of fetus at delivery. (6) Provide preparatory educational videotapes and reading materials regarding the following:
Hemorrhagic Disorders
INTRODUCTION
PLACENTA PREVIA
CLINICAL PRACTICE
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