Aetiology of Placenta Previa - Assignment Example

Case study 1, 2, and 3 Name Date History Call to: a 38 years old woman who is 34 weeks pregnant and complaining of significant vaginal bleeding over the past hour. Recent history of significant vaginal bleeding over the past hour Vital signs: SaO2- 98% room air Temperature: 36.50C Respiratory rate: 22/min Blood pressure: 110/60 Pain score: 0/10 Heart Rate: 100bpm Color of the skin: pallor Provision diagnosis Provision diagnosis: placenta previa Differential diagnosis: miscarriage, placental abruption, normal labor, cervicitis, and vaginitis. Epidemiology/Aetiology/Pathophysiology The woman is most likely suffering from placenta previa; she is having vaginal massive bleeding and not feeling any pain, the bleeding is bright red. The bleeding occurs at the second or third trimester of pregnancy. The problem occurs when the child placenta partially covers the opening in the cervix (Paterson & Wilson, 2010). The problem is also characterized by premature contractions and the uterus being larger than it should be according to gestation age. Its causes are well not well known but one factor that is well known could be the cause is advancing maternal age, over 35 years of age. Issues of placenta previa after the age of 35 years are reported at 2 percent (Paterson & Wilson, 2010). The problem affects around 0.5 percent of all pregnancies in Australia. Due to cesarean delivery the problem has increased to 2 percent in the recent past (Paterson & Wilson, 2010). The case is not likely to be placental abruption, the patient is not feeling any pain and in placental abruption bleeding is accompanied by a lot of pain. The contraction is rapid while in PP contraction is gentle and the patient is experiencing gentle contractions, and fetal heart rate abnormalities. The problem also is not miscarriage. Miscarriage is normally common in early pregnancies. Miscarriage is accompanied by crampy abdominal pain as bleeding become severe, from light to heavy. Back pain is felt, there is loss of pregnancy symptoms like vomiting, and passing tissue like material (Ronan et al, 2016). Normal labor is also rules out. Normal labor is characterized by not severe bleeding and the bleeding is darker. Labor progress in a normally way and the fetus is not compromised. The problem is also not cervicities, cervicities is characterized by pale yellow vaginal discharge, abnormal bleeding of vaginal normally during periods or after sex, pain during sex, painful or frequent urination (Rowe, 2014). Investigations In cases of placental abruption vaginal examination is normally used, in placenta previa it is not used because it will trigger heavy bleeding so vaginal examination should be avoided at all cost. There is no medical history for the patient, the investigation that can be used now is feeling the belly of the patient with the hand to establish the position of the baby, and if the baby is sideways it is likely to be a problem of placenta previa. Very gentle speculum examination is carried out to ensure that the bleeding is not originating from cervix or vagina (Rowe, 2014). Treatment Response: take a bed rest, the patient will need to lie in bed most of the time, doing exercise is discouraged. Breathing: oxygen should be titrated to achieve SaO2 of above 95 percent. Examination: examination should be minimized because it might trigger heavy bleeding; examination using the hand on the belly of the patient is conducted to ascertain the position of the baby. Circulation: the pulse rate of the patient should be monitored and in deteriorating condition ECG should be considered. Fluids: can be provided if the condition of the patient becomes worst. Medications: give steroid shots to assist in maturing the baby lungs. Transport Because of significant bleeding, the patient should be transported to the hospital, if the condition gets worst on the way the use of lights and sirens should be used to make transport more effective because deteriorating condition may cause distress followed by worsening condition. Get the people around who can donate blood to the woman be transported with her because she might need blood transfusion. When transporting her to the hospital the head should lie flat, pillow should not be used to raise the head (Murray & Murphy, 2008). The knees are raised and supported with materials such as blankets and billows to be higher than the head. Postpartum hemorrhage History Call to: Twenty four years old woman who has just birthed unexpectedly at home. She is bleeding excessively after giving birth. She has had uneventful pregnancy and was booked to local maternity to give birth. Vital signs: respiratory rate- 24/min Pulse rate- 120bpm SaO2 – 95% room air Pain score- 5/10 Temperature- 36.8 degrees centigrade Blood pressure- 70/50 Provisional Diagnosis Provisional diagnosis: Post-partum hemorrhage (PPH) Differential Diagnosis: Uterine atony, retained tissue products, genital tract trauma, coagulation disorder, Uterine Inversion, precipitous labor, prolonged labor. Epidemiology/Aetiology/Pathophysiology After delivery, the woman is having excessive bleeding from the genital tract, bleeding after birth is always substantial because the entire body organs become very vascular during pregnancy. The problem is most likely to be primary PPH because it is happening 24 hours after delivery. The problem occurs at the third stage of the labor. The placenta has not yet birthed and the fundus is boggy. After the placenta separates from the uterus, the uterus contract and retracts resulting in occlusion of these vessels. Failure of the uterus to contract after birth leads to continuous bleeding, this indicate a problem of uterine atony. Initial examination shows that the placenta is retained. Retained products interfere with uterine contraction. Trauma or injury to the uterus, cervix, and vagina during birth can cause continuous bleeding. The problem cannot be caused by the trauma because upon examination there was no any form of injury on birth canal. Injury to the birth canal can occur even if delivery is monitored well. Uterine Inversion is the fundal implantation of placenta during delivery and it cause excessive bleeding (Mohamed & Dawod, 2015). For a woman who has just given birth and she has a problem of uterine inversion, the inverted uterus appears as a bluish gray mass protruding in birth canal. Upon examination there was no protruding uterus and that rules out the problem of uterus inversion. Uterine rapture also causes profuse bleeding after birth. This rapture normally occurs if the woman has previous classical incisions or uterine surgeries (Mohamed & Dawod, 2015). Furthermore in situation of short intervals between pregnancies or history of many cesarean deliveries especially in women who does not have previous vaginal deliveries. The woman does not have any history of classical incision or uterine rapture, she is giving birth for the first time, this rules out the problem of uterus rapture. In developing countries, 1.2% of woman giving birth encounter PPH problem, when the problem occur statistics shows that 3% of the women affected by PPH die. Globally it is the leading cause of death during gestation, 44,000 to 86,000 women die yearly due to PPH. In United Kingdom 0.4 women per 100,000 succumb to PPH problems after delivery while in Africa the problem is worst because 150 women per 100,000 deliveries die (Weeks, 2015). The rate of PPH is higher in multiple pregnancies as compared to singletons, 32% and 10% respectively. It is also higher in women who are giving birth for the first time 12% as compared to mothers who have already given birth which is 10% (Weeks, 2015). Investigations After receiving the information about the woman medical state, asses the airway, breathing, body temperature and blood circulation. The woman is then placed in lithotomy position and the genital is then examined. Vaginal packs or suctions are used to remove blood for clear visualization. The placenta is examined to find out whether the whole of it is completely removed. Examination will also ascertain whether the uterus is protruding from the vagina. The volume of the blood lost is estimated by looking at the soaked clothes. Treatment Response: Airway patency is maintained by tilting the head of the woman and lifting the chin. The boggy fundus is messaged so as to stimulate it again to become firm or the woman is given pitocin or breastfeeding the child (Anderson & Etches, 2007). Intra-uterine balloon insertion is tried; tamponade effect of the inflated balloon and its warmness might stop the bleeding. Circulation: the pulse rate of the patient should be monitored and in deteriorating condition ECG should be considered. Fluids: can be provided if the condition of the patient becomes worst. Medications: Administer uterotonics drugs to improve contractions of the uterus. Transport The patient should be transported to the hospital first because the problem might worsen. Use of lights and sirens should be applied to make transport more effective because deteriorating condition may cause distress making the condition worst. Breech birth (Frank breech) History Call to: A woman in labour, 41 weeks gestation G3P2, She has been in labour for two hours contractions are 5 minutely and moderate in strength, membranes have ruptured and there is clear liquor draining. PMx: Fibroids and asthma Is taking Multivitamins and Ventolin PRN Blood tests, screening, and ultrasounds are up to date Allergic to penicillin Vital signs: SaO2- 99% room air Temperature - 36.90C Respiratory rate - 20/min Blood pressure - 110/70 Pulse rate - 95bpm Heart Rate - 130bpm Provisional diagnosis Provisional diagnosis: Breech birth (Frank breech) Differential diagnosis: Transverse lie and face birth Epidemiology / Aetiology / Pathophysiology Breech pregnancy is a delivery condition in which the baby is not in the head down. The fetus is positioned with head and legs facing up and buttocks facing down. There are three types of breech pregnancies frank, complete, and footling breech. The problem that is being faced by this patient is frank breech pregnancy, in this condition the buttock of the baby is directed towards birth canal while the legs sticks straight up in front of the body. This problem is caused by prematurity of the fetus, having multiple pregnancies, or uterus fibroids; medical history shows that the woman had uterus fibroids and that could be the cause of the problem. In transverse lie pregnancy the baby lies horizontally across uterus and the shoulders will be the part that is directed towards birth canal. The problem is not transverse lie because when the woman start pushing the part that appears first is bottom and not shoulders. During delivery buttocks and feet of the baby does not provide a good wedge to pass through the woman cervix. This may lead into the prolapse of umbilical cord and the head of the child might get trapped in the course of delivery. Globally, the rate in which breech pregnancy occur is 3 to 4 percent. Investigations Examine the birth canal of the woman. In face presentation the mouth and malar bones forms something like a triangle while in breech presentation trochanter and anus forms a straight line. Exam the baby the way it is coming out from birth canal. Treatment Response: administer IV fluids to the patient, the mother should like down in a position that sh is comfortable with Circulation: the pulse rate of the patient should be monitored and in deteriorating condition ECG should be considered. Transport The woman is transported to the hospital while lying in a position that she is comfortable in. Call and inform the hospital about the condition of the woman and impending arrival. References Paterson, N. D., & Wilson, R. D. (2010). Placenta previa. American Journal of Obstetrics and Gynecology, 202, 6 Murray, A., & Murphy, D. J. (2008). Vasa praevia: diagnosis and management. The Obstetrician & Gynaecologist, 10, 4, 217-223 Rowe, T. (2014). Placenta previa. Journal of Obstetrics and Gynaecology Canada : Jogc = Journal D'obstétrique Et Gynécologie Du Canada : Jogc, 36, 8, 667-8. Ronan B et al. (2016). Placenta Previa. Medscape. Available at http://emedicine.medscape.com/article/262063-overview#a2 Weeks, A. (2015). The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next?. BJOG: an international journal of obstetrics and gynaecology. 122 (2): 202–10. Anderson JM, & Etches D (2007). Prevention and management of postpartum hemorrhage. American Family Physician. 75 (6): 875–82 Mohamed, N. A. R., & Dawod, K. G. A. (2015). Management Of Primary Postpartum Hemorrhage: Risk Factors, Preventive Measures, and nursing responsibility for women anticipating primary postpartum hemorrhage. Saarbrücken LAP LAMBERT Academic Publishing Read More