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DEFINITION
It is one form of ante partum hemorrhage where bleeding occurs due to premature separation (partial or complete) of normally situated placenta.
Incidence
Varieties
PREDISPOSING FACTORS High birth order Advancing age of mother Poor socioeconomic condition Malnutrition Smoking Recurrence
ETIOLOGY
Hypertension in pregnancy Trauma Sudden uterine decompression Short cord Supine hypotension syndrome Sick placenta Folic acid deficiency Thrombophilias inherited / acquired
PATHOGENESIS
Premature placental separation initiates by hemorrhage into the decidua basalis
Degeneration and necrosis of the decidua basalis and the placenta + rupture of basal plate
Retroplacental haematoma
Accumulated blood finds its way in: complete accumulation behind placenta, blood dissects downwards, blood gains access.
Grade 1- external bleeding is slight uterus irritable, tenderness may or may not be present Shock is absent, FHS good
Grade 2 external bleeding mild to moderate Uterine tenderness is always present Shock is absent fetal distress / death Grade 3-bleeding is moderate to severe or may be concealed ,marked uterine tenderness ,shock present fetal death occurs Associated coagulation defects or anuria
CLINICAL FEATURES
Symptoms Character of bleeding Revealed Abdominal discomfort or pain followed by vaginal bleeding Concealed /mixed Acute intense pain abdomen followed by slight vaginal bleeding ,pain becomes continuous Continuous ,dark color blood stained serous discharge Shock is pronounced which is out of proportion to the visible blood loss Pallor is severe and out of proportion to the visible blood loss
General condition
Pallor
CLINICAL FEATURES
Symptoms Feature of preeclampsia Uterine height Uterine feel Revealed May be absent Proportionate to the period of gestation Normal feel with localized tenderness contractions frequent and local amplitude Can be identified easily Usually present Normal Concealed/ mixed Frequent association either pre existing or appear May be disproportionately enlarged and globular Uterus is tense tender and rigid
INVESTIGATIONS
Revealed Concealed / mixed
Blood Hb%
Low value; Markedly lower; out proportionate to of proportionate to the blood loss the blood loss
Coagulation Profile
Unchanged
Variable changes: Clotting time > 6 min Fibrinogen level < 150 mg Platelet count low Partial thromboplastin time
Absent
Present
DIFFERENTIAL DIAGNOSIS
Revealed type: Placenta previa
Not relevant
Contd;;
Abdominal examination
Height of uterus Proportionate height May be disproportinately enlarged in in concealed type May be tense,tender and rigid Unrelated ,head is engaged
Feel of uterus
Malpresentation
FHS
Present
Cond..
Placentography Placenta in lower segment
Placenta is feel on the lower segment
Vaginal examination
Management
PREVENTIVE AIMS
Elimination of known factors Correction of anemia during antenatal period Prompt detection and institution of therapy to minimize the complications likeShock Blood coagulation disorders Renal failure
Revealed Resuscitation
concealed
ARM+oxytocin Bleeding stops expectant treatment continue preg upto 37 weeks Bleeding continue ARM+oxxytocin
Concealed
Blood transfusion periodic coagulation urine out put
fetal monitoring
ARM+oxytocin No response falling fibrinogen level oliguria fetal distress C.S
NURSING MANAGEMENT
1.Assess the patients extent of bleeding and monitor fundal heighteight Continuously evaluate maternal and fetal physiologic status Avoid per vaginal / rectal examination
CONTINUED..
On admission place woman on lateral position Fluid replacement by I.V. fluids Administer oxygen by mask if needed Provide client and family teaching Meet the emotional and psychosocial needs
NURSING DIAGNOSES
Pain related to bleeding Impaired fetal gas exchange related to insufficient oxygen Fear related to perceived threat and excessive bleeding Risk for anaemia related to excessive loss of blood
TREATMENT
Revealed type: Assessment of case If patient is in labour- it is accelerated by LROM + oxytocin drip If patient is not in labor <37 wks- LROM + oxytocin drip >37 wks- LROM with/ without oxytocin drip
CONTINUED..
Concealed / mixed type: Sedation with morphine Send blood for blood + urine investigation Correct hypovolemia by NS/ Haemaccel infusion and blood transfusion Initiate uterine contractions Observe blood coagulation profile at 2 hourly interval Closely monitor maternal + fetal condition