It is one of the causes of painless bleeding.

Occurs in 1 in 200 pregnancies. Occurs close to the internal cervical os. Will be classified according to how much of the internal os is covered.

Types:

A. Low lying placental or also called marginal. May be able to deliver without problems. Pressure of baby coming down can keep mom from bleeding.

B. Partial will have bleeding and may not be able to deliver vaginally.

C. Total will have to have a C-section.

Causes:

Multipara (80%)

Older

Previous C-section

Uterine incisions previously

If had one before, then 12x more likely to have another one.

With all types there is low vascularity of the uterine lining, which forces the placenta to thin out.

S&S:

External bleeding: S&S plus bleeding should be in relation to each other. In other words, the more bleeding, the more shock.

With each episode of bleeding, the bleeding gets worse.

The uterus will remain soft. It will NOT be tender and FHR can be heard.

Diagnosis:

Ultrasound

Hgb and Hct

Nursing Care:

NO vaginal exams.

If MD does vaginal exam, be ready for double set-up. Which means be ready for vaginal delivery or C-section.

In beginning put on CBR to keep pressure off placenta.

Encourage to lie left lateral.

Administer Oxygen.

Hospitalization depends on degree of bleeding.

2 main postpartum concerns:

1. Hemorrhage because where the placenta was attached is not going to contract effectively. The site is usually larger than normal.

2. Infection: losing a considerable amount of blood decreases resistance. Monitor WBC’s and lochia for odor. Must teach good perineal care because at the os is where the placenta was implanted.

Premature separation. Occurs after 20 thru the 24th week. Typically if it occurs before 20th week, classified as a spontaneous abortion. When she is in labor, this can occur. Occurs in 1 in 500 pregnancies, can be partial or complete separation.

Can have concealed or apparent hemorrhage during partial separation (depending on where the separation has occurred) or complete separation.

In other words, she can have external or internal bleeding which means she can be in shock without you seeing any blood on her pad.

Causes:

Trauma to the abdomen.

PIH.

Diabetes.

Gran Multiparas.

Pit induced labor.

S&S:

C/O abdominal pain.

Uterus gets rigid and board-like and tender.

Shocky.

External bleeding out of proportion to signs of shock.

Complete separation causes absent FHR.

Diagnosis:

Ultrasound unless complete separation.

Treatment:

Will deliver ASAP.

May need blood, get Hgb and Hct.

C-section.

A complication to watch for: DIC or Disseminated intravascular coagulation. This is a clotting defect. With DIC, bleeding and thrombosis are forming. Tiny clots are forming and building up in the capillaries. As a result fibrinogen has been used up. Will have hypofibrinogenanemia and are at risk for hemorrhaging. Clots may go to heart or lungs. They can also cause petichea (pinpoint spots that do not blanche).

Treatment:

Give fibrinogen IV.

Put on Heparin to keep from getting more clots. You body has to lysis the clots already there.

Known formerly as toxemia.

Major signs: called triad after 24 weeks.

Edema

Proteinuria

Hypertension

Must have at least 2 of these signs.

Primarily seen in prima gravida.

Big cause of maternal death (3rd).

High rate of fetal mortality.

Cause: not really known exactly.

Risk Factors:

Family history of HTN.

Weight extremes.

Diabetes.

Multiple pregnancies (more than 1 at a time).

Polyhydramnios.

Hydidaform mole.

Inadequate prenatal care.

History of PIH.

Higher incidence in young primigravida.

Association with poverty.

Not enough protein.

S&S:

Severe narrowing and spasms of blood vessels throughout the body. This causes a general vasoconstriction. Expecially seen in peripheral blood vessels. Vasoconstriction equals increased resistance to vascular flow. Causes BP to increase. As a result of vasoconstriction kidneys cause release of Renin. Renin releases angiotensin which is a powerful vasoconstrictor. Decrease in circulation to kidneys is responsible for protein in urine and edema.

Can take 2 forms:

Pre-eclampsia - have not had a seizure.

Eclampsia - have had a seizure.

Anybody in the high risk category must be monitored closely.

Clinical Manifestations:

A. Sudden development of HTN.

Increase in systolic of 30mmHg.

Increase in diastolic of 15mmHg.

Diagnosis is made with 2 readings at 6 hours apart.

Diastolic reading is most important.

Roll over test: between 26-32 week, may put woman on her left side for 15 minutes, then take BP, then lay on back and take BP again (normally BP falls). An increase in BP (by 20mmHg) could be a warning sign of pre-eclampsia.

B. Sudden weight gain.

Edema in non-dependent areas even after resting.

Will see the edema in hands and feet.

C. Proteinuria.

May do 24 hour urine for protein along with the dipstick test.

This is a serious sign that happens later.

Treatment:

Mild: Bed rest if BP is only slightly elevated. Lay on Left side. High protein, increased CHO, decreased FAT, regular salt diet. Regular salt because completely eliminating will activate Renin/angiotensin system that will cause more edema. Teach to weigh daily. Possibly could be on HTN med especially with a pre-existing HTN.

Severe: hospitalized. Most effective treatment is the delivery of the baby. Problem is the fetus may be immature. Want to keep 36 weeks if possible. They may start labor with pitocin or schedule a C-section.

Severe and not 36 weeks: hospitalized with CBR. Should be in a private room, keep lights dim, keep environment quiet. Patient should not be moved around such as during AM care. The nervous system is irriatable.

Nursing Care:

I&O, Foley may be inserted.

Vitals q 2h.

Monitor FHR.

Protein checks in urine daily or q shift by dip stick or 24 hour urine.

Seizure precautions, which are side rails, up, airway at bedside (oropharyngeal) and suction at bedside. Always document that you did this or made sure it was done.

The seizures are tonic clonic that iwll start at the head and go down the body. It will put a woman into labor. Always document what goes on during a seizure. Where did it start? Was she incontinent?

An aura is something that always happens just before a seizure that the patient recognizes as a sign one is about to come on (of course if they have had one before). It may be bright lights, a headache or some other feeling. Always ask if the client has an aura.

Question headaches, changes in vision, n/v and epigastric pain (this is a big clue). A PIH headache cannot be releived with Tylenol.

If a woman comes in already in labor with PIH, we do all these interventions and also will administer MagSulfate as MD orders. MgSo4 is the DOC for pre-eclampsia. Usually given IV. IM MgSo4 is painful and can cause abcesses at injection site. Give Z-track method.

Will be given a loading dose of 3-4g and then put on an hourly drip of 1-2g/hr.

MOA:

1. CNS depressant. Decreases the neuromuscualr irritability.

2. Peripheral vasodilator. Causes a decrese in your smooth muscle. Will bring down the BP.

3. Osmotic diuretic. Will change the osmolarity of the blood. Has pulling force that will cause increase in urinary ouptut. Pulls water off the brain (that can cause a seizure) and keeps her from getting cerebral edema.

**Anybody on MgSo4 has to be monitored continuously and closely because the CNS is depressed. Can get too much and resps will be depressed.

Respirations should be 16 before giving MgSo4.

Will feel flushed and have a warm feeling come over them.

Assess deep tendon reflexes (DTR) to see if nervous system is getting more irritable.

0 = no response. Hypotonia. Too much Mag.

1+ = okay if on Mag.

2+ = normal.

3+ or 4+ = call MD, clue to start Mag if not already on it. If already on it, then it’s not enough.

Always do a DTR when Mag is started.

May have a Foley and should be on I&O. Must have adequate output. Mag is primarily excreted in the urine.

Antidote for Mag is 10% Calcium gluconate. Should be on hand to give IV push.

If woman is not 36 weeks, and must deliver, she is given betamethasone. It is given to increase lung maturity of fetus. Given 1 12mg shot, then in 24 hours given another 12 mg shot. Will boost surfactant production in the fetus.

If the woman delivers, they still have to be monitored 48-72 hours after. If severe, they will still have all intervetnions done for 24 hours after delivery.

Severe complication that develops from PIH is the HELP syndrome.

H: Hemolysys of RBC.

E: Elevated liver enzymes. Secondary to decreased

blood flow to the liver.

L: Low

P: Platelets.

This indicates worsening PIH.

N/V, RUQ abdominal pain, and later hematuria, jaundice, generalized abdominal discomfort.

At risk for hemorrhage.

Will deliver at any gestational age because maternal death rate is high with HELP.

Review Rh and ABO incompatibilities.