The Causes and Risk Factors of Placenta Previa - Assignment Example

Obstetric Case Studies “Student’s Name” “Institution Affiliation” Case Study 1 History Patient ID: Mrs. W History and Physical conducted by: N.M Date when History and Physical assessment was conducted: 12th June 2016 Source: Mrs. W narration of her medical history appears to be a reliable source. Chief Complaint: As earlier mentioned, Mrs. W (38 yrs. Old) is having complaints of momentous vaginal blood loss for the past one month. History of present illness: Mrs. W is a relatively young woman with a past medical history, as she had experienced vaginal blood loss for the past one month. Today, Mrs. W is complaining of abdominal pain and she narrates that the pain has worsened over the last few hours. Today, Mrs. W seeks for medical care at our facility because he is covered by the Australian Medicare scheme. According to her, the pain is more severe in the lower part of the abdomen. Additionally, the pain is giving her sleepless nights and she spends most of her time laying down. This has greatly affected her day to day activities, and she is suffering depression as a result. She also states that she has lost more weight in the past few days. However, no incidence of allergies is established. The Patient is not under any medication. Furthermore, Mrs. W does not have any history of surgery Objective data: Pulse rate: 72bpmRespiratory Rate: 22/minute Blood Pressure: 110/60 Temperature: 36.5o C Provisional Diagnosis Provisional Diagnosis: Placenta Previa .Differential Diagnosis includes :Spontaneous Abortion, Uterine Rupture, Umbilical Cord Prolapse, Premature Labor. Epidemiology Placenta Previais reported to occur in 0.5% of all Pregnancies in United States of America. According to data conducted by National hospital surveillance it indicates that the case-fatality rate of 17 deaths per 100000 white women whereas black women 40.7 death per 100000. In countries such as Australia, the prevalence of the placenta Previa among the women is found to be 4.8% of every subsequent birth (World Health Organization, 2012). The case fatality is considerably high on low income settings due to reduction on antenatal screening and absence of quality emergency obstetric care. In the Asian countries the prevalence is higher (12.2 per 1000) and lower among the European countries (3.6 per 1000) (Placenta Previa, 2011). Aetiology The causes and risk factors of Placenta Previa are underlined below. Very low implantation of fertilized egg in the uterus. This cause the placenta to form close to or over the cervical cancer Treatment of Infertility Prior Caesarean section Fibroids in the lining of the uterus ( endometrium) Advanced maternal age i.e. > 30 yrs. Smoking and use of cocaine Placenta formed abnormally Pregnancy conceived through the help of reproductive technology such as vitro fertilization. Premature pregnancies Placenta abruptio Defective decidual vascularization Multiple pregnancies Previous uterine injury or insult , uterine surgery Socio-economic status of low level (World Health Organization, 2012). Pathophysiology The embryonic plate which adheres in lower section of Caudad instigates placental implantation and this is detected using the Ultrasound imaging. This attachment and growth of the Placenta may possibly shield the internal cervical. If Atrophic changes due to defective decidual vascularization persist then the patient may experience placental Previa. The principal causative agent of 3- trimester hemorrhage, Placenta Previa presents as a painless bleeding. Investigations While recording historical background of the Patient, it is vital to enquire from the patient of any renowned risk factors prevalent with placenta Previa such as infertility treatment, previous caesarean section and progressive maternal phase. Since the Placenta Previa mostly occurs when a portion or the entire placenta covers the cervix opening, it is of importance that the Professionals have in mind that this incidence may hinder vaginal delivery of the baby. Thus, urgency of the Patient being diagnosed in a hospital and the necessary action taken could save the life of the patient.This condition is easily detected during prenatal care and if the patient has not been in any prenatal care then the Professional may suspect Placenta Previa if the patient has painless bleeding in her third trimester. The color and the blood amount should be assessed to determine whether there is any associated complication such as shock which should be administered. Unfortunately, if the color of the blood is bright red upon examination then there is unlikelihood of Placentae abruptio given this condition occurs if the blood is clotted and dark in color (Stöppler, 2012). Treatment The treatment of placentaPreviawill be based on following: The baby health The amount of bleeding Position of the baby and the placenta The month of your pregnancy. The following are the recommendation to be followed by any Obstetric Professional. Plan and implementation: The patient should be placed in lateral position in order to evade supine hypotension Caution: Vaginal examination should be avoided since the bleeding may increase causing premature labor. Apply fresh pads to control the bleeding and record the application time for purpose of baseline measurement.In order to maintain the blood pressure at conventional range IV line should be opened and volume expanding fluid should be administered(Pantoja et al, 2015). Transport This incidence should be treated as high risk. It is not easy to manage or control the vaginal bleeding at home place. Thus, the patient should be taken to hospital to curb the risk of losing the fetus. Case study 2 History Subjective data: The patient is A 24 yrs. old woman, 41 weeks gestation and has just given birth unexpectedly at home. History of present illness: The woman of G1P0 had an uneventful pregnancy. All blood tests, screening and ultrasounds are up to date and NAD. She has no medical history of the past Medical history: No incidence of allergies is established. The patient is currently taking multivitamins Objective data: Pulse rate: 120bpm Respiratory Rate: 24/minute Blood Pressure: 70/50 Body temperature: 36.8o C Provisional Diagnosis Provisional Diagnosis: Postpartum Hemorrhage Differential Diagnosis: Uterine Rupture, Postpartum Endometritis, Genital Tract Manipulation, Eclampsia/Preeclampsia. Epidemiology Postpartum hemorrhage (PPH) is one of the principal causes of maternal mortality in the world rating 6 percent. Africa has the highest rate of approximately 10.5%. both in Africa and Asiamost maternal death due to PPH amount to 30 percent of all Maternal Deaths. Women carrying pregnancy more than 20 weeks are at high risk of PPH. Data from several sources especially on the research conducted in the industrialized countries indicates a prevalence rate of PPH is about 5 percent for blood loss of more than 500ml while PPH of more than 1000ml is relatively low at 1percent. This pandemic condition is prevalent in the developing countries due to insufficient medications used in active management of the third stage (World Health Organization, 2012). Aetiology Postpartum hemorrhage (PPH) is a major cause for death and pregnancy morbidity. The primary cause of PPH is the Uterine Atony, Trauma incidence inclusive of iatrogenic which increases the prevalence of PPH (Stöppler, 2012). Women who previously had PPH in pregnancy present a higher risk of having fatal PPH in the subsequent gestation. Other risks factors include: Lacerations of the genital tract Instrumental delivery Failure of development during the second stage of labor Placenta retention Hypertensive disorders Labor induction Pathophysiology Postpartum Hemorrhage is defined as loss of blood of 500ml or more within 24 hours after birth. It is evident that PPH is one of the major causes of maternal deaths in less privileged countries. Most of the deaths caused by PPH occur within the 24hours of Postpartum. If usage of prophylactic uterotonics is avoided during labor especially the third stage and having appropriate prehospital management then most of these fatal deaths could be eliminated or rather avoided. In accordance to Proctor, there are 2 stages of PPH which includes the primary and secondary stage which are based on the occurrence time. The primary stage is when the bleeding takes place within the 24 hours of birth while secondary stage is considered as the bleeding after 24 hours up to 12 weeks of delivery. During primary stage, the blood loss ranges between 500 and 1000ml while if the blood loss exceed 1000ml it is considered as secondary stage. (Kosmas et al, 2016). Investigations The woman has been reported as healthy and has fully attended the prenatal care before the delivery. Her first child was delivered immediately on arrival of paramedics and had been undergoing excessive vaginal bleeding. After examination, the placenta was retained and the fundus is found to be boggy.in reference to the causes of PPH which are Tissues, Trauma,Thrombin,Tone. (4T’s) two of them are the major causative agent. Firstly, retained placenta or any other tissue in the uterine is a proof that the placenta had not been birthed. Lastly is the uterine atony with the fundus. She displays shock signs due to excessive bleeding and fluid resuscitation should be administered to prevent any further risk. Treatment Uterine massage should be administered as it assist in contraction of the uterus hence reduce bleeding. Combination of ergomentine and syntocinon should be used as part of Active management of the third stage of labor Intravenous Oxytocin or Ergotamine may also be used. This helps the uterus to quickly contract and last for a longer period of time. The patient should be placed in a position of comfort and the airways should be clear. Oxygen is required to raise the oxygen saturation if the patient is tachypnoeic The only recommended uterotonic drug is the Intravenous oxytocin. If its unavailable use of intravenous ergometrine should be adopted If the PPH persists, consider packing, surgical procedure and blood transfusion products. For the intravenous resuscitation of women with PPH usage if isotonic crystalloids is preferred. If the temperature drops, the patient should be kept warm. If the patient is tachycardic and hypotensive due to the blood loss.In order to raise the blood pressure and avoid shock exacerbations been experienced by the patient then fluid resuscitation is recommended that is2 large bores of IVfluid (World Health Organization, 2012). Transport Since this condition of Postpartum Hemorrhage is fatal and likely to cause death of the mother including the fetus. Then the patient should be transported to a hospital where obstetrics are available. Case Study 3 History Subjective Data: The age of the woman is undetermined. She is in labor History of present illness: The patient is G3P2, in the 41st week of gestation period. She has experienced an uneventful pregnancy. Ultrasounds, screening and blood tests, objectify normalcy. The laboratory tests are normal and up to date. A review of the past medical history of the patient reveals she has risk for asthma and fibroids. Medical History: The patient has been taking Ventolin PRN and multivitamins. She complains of being allergic to penicillin Objective Data: The patient has a respiratory rate of 20 bpm, Pulse rate reads 95bpm while blood pressure is 110/70. She has a normal temperature of 36.90C Provisional diagnosis The provisional diagnosis reveals Frank Breech deliveries. Differential diagnosis is indicative of breech with fully arched leg, footling is incomplete with one of the thighs extended, while the symptoms the patient presents are suggestive of face and brow presentation. Epidemiology Breech presentation occurs when the fetus moves into delivery position with the buttocks moving closer to the birth canal. In complete breech, the buttocks of the fetus point downwards while the legs of the fetus are folded at the knees and the feet are close to the buttocks. However, in frank breech, the fetus buttocks are facing the birth canal while legs of the fetus are straight up in front of the fetus’ body (Fischbein, 2015). The feet in this presentation in near the head of the fetus. Studies estimates that breech presentation occurs in almost three out of every hundred babies. Nonetheless, the percentage of breech presentations decreases with gestational age before 28 weeks of gestation at 25%. As the gestation period progresses, breech presentation narrows down to 15% in the 32nd week, while at term birth, it further reduces to 3-4%.. Nonetheless, this does not call for alarm, as sometimes, just a matter of chance that the fetus sits and remains in the breech position. However, amount of fluid in the womb, position of placenta, and number of fetuses in the womb may affect the positioning of the fetus. Aetiology As mentioned above, breech presentation is not an isolated case. It occurs under circumstances that the mother or the fetus cannot change. Studies investigating etiology of breech birth suggest that various factor contribute to breech presentation other than being just a matter of chance. Bergenhenegouwen (2015) finds that older gestation age increases the risk for breech presentation; contrary to the earlier findings, that early gestation period has a high risk for breech presentation. In addition, the age of the mother may influence breech presentation, with older mothers more likely to have breech birth compared to younger mothers. Other factors identified in the study include the sex of the fetus, with a female fetus increasing the risk of breech presentation. The size of mother’s pelvic as well as location of the placenta may influence breech presentation, that is, contribute to breech presentation. Mothers who have had a history of breech deliveries are also high likely to experience breech births (Rosman et al, 2014). Other risk factors that contribute to breech presentation include fibroids, which affect the presentation of the fetus in the womb. Pathophysiology Etiology studies suggest that the uterine size and fetus size may influence breech presentation. According to the studies, larger fetuses are forced to assume cephalic presentation during the late stages of the pregnancy mostly because of the space available in the uterus. As such, the size of the fetus combined with size of the uterus may force the fetus to turn into a position or fail to turn from a position that is consider breech presentation. The sex of the fetus as well as multiple pregnancies may indirectly affect the turning of the fetus in the uterus (Bergenhenegouwen, 2015). While breech births are common, they are abnormal because they are not in the presentation that the fetus should come out of the womb. The child’s head in normal birth should come out first. However, in breech presentation, the buttocks of legs of the fetus emerge first during delivery. Investigations Comparing etiology and pathophysiology of the condition and that of the patient, it is apparent that the patient presents with breech presentation. She exhibits normal vital signs but experiences fibroids, a risk factor for breech presentation. Furthermore, examination results reveal frank breech presentation. Treatment The patient does not require any form of treatment until she gives birth when she might consider uterine fibroid embolization to destroy the fibroid condition. Transportation The patient requires midwifery for to help in delivery. The patient will need to push the baby during delivery. References Bergenhenegouwen, L., Vlemmix, F., Ensing, S., Schaaf, J., van der Post, J., Abu-Hanna, A., ...&Kok, M. (2015). Preterm breech presentation: a comparison of intended vaginal and intended cesarean delivery. Obstetrics & Gynecology, 126(6), 1223-1230. Fischbein, S. J. (2015). Delivery of Breech Presentation at Term Gestation in Canada, 2003–2011. Obstetrics & Gynecology, 126(3), 673. Kosmas, I. P., Tatsi, C., Sifakis, S., Tzabari, A., Kiortsis, D., Mynbaev, O., ...&Malvasi, A. (2016). Assisted Reproductive Technique Complications in Pregnancy. In Management and Therapy of Early Pregnancy Complications(pp. 209-253). Springer International Publishing. Pantoja, T., Abalos, E., Chapman, E., Vera, C., & Serrano, V. P. (2015).Oxytocin for preventing postpartum haemorrhage (PPH) in non‐facility birth settings. The Cochrane Library. Placenta Previa. (2011). Retrieved October 26, 2016, from http://bodyandhealth.canada.com/condition/getcondition/Placenta-Previa Rosman, A. N., Vlemmix, F., Beuckens, A., Rijnders, M. E., Opmeer, B. C., Mol, B. W. J., ... &Fleuren, M. A. (2014). Facilitators and barriers to external cephalic version for breech presentation at term among health care providers in the Netherlands: A quantitative analysis. Midwifery, 30(3), e145-e150. Stöppler, M. M. (2012). Placenta Previa Symptoms, Treatment, Causes - What are the symptoms of placenta previa?- MedicineNet. Retrieved from http://www.medicinenet.com/pregnancy_placenta_previa/page3.html World Health Organization. (2012). WHO recommendatioins for the prevention and treatment or postpartum haemorrhage: evidence base. Read More