Placenta prévia: um estudo baseado nas teorias de enfermagem / Placenta previa: a study based on nursing theories / Placenta previa: un estudio basado en las teorías de enfermería

Introdução: A gestação, apesar de ser um processo fisiológico na saúde da mulher, é uma etapa complexa que exige atenção diferenciada na assistência à saúde. Outrossim, existem algumas condições que provocam danos durante essa fase, como a placenta prévia. Objetivo: Este estudo tem como escopo evidenciar o processo de enfermagem frente à assistência à gestante com tal diagnóstico. Metodologia: A pesquisa tem caráter qualitativo, teórico com subsídio na bibliografia científica, envolvendo a compreensão holística e integral da paciente para a implementação de estratégia para o processo de enfermagem. A partir do estudo das teorias e da fisiopatologia e impactos clínicos, empregou-se as taxonomias do NANDA-I para traçar os diagnósticos de enfermagens mais condizentes. Resultados: Foram identificados 15 diagnósticos que contemplaram os dez domínios encontrados no NANDA. Considerações Finais: Os dados eleitos e o confronto com a literatura enfatizam a relevância positiva na prescrição de diagnósticos de enfermagem na escolha dos cuidados prestados e as teorias subsidiam a assistência materno-fetal.

Introduction: Pregnancy, despite being a physiological process in women's health, is a complex stage that requires special attention in health care. Also, there are some conditions that cause damage during this phase, such as placenta previa. Objective: The purpose of this study is to highlight the nursing process regarding care for pregnant women with such a diagnosis. Methodology: The research is qualitative, theoretical with support in the scientific bibliography, involving the patients holistic and integral understanding for the implementation of a strategy for the nursing process. Based on the study of theories and pathophysiology and clinical impacts, the NANDA-I taxonomies were used to outline the most consistent nursing diagnoses. Results: 15 diagnoses were identified that included the ten domains found in NANDA. Final Considerations: The chosen data and the confrontation with the literature emphasize the positive relevance in the prescription of nursing diagnoses in the choice of care provided and the theories subsidize maternal-fetal assistance.

Introducción: El embarazo, a pesar de ser un proceso fisiológico en la salud de la mujer, es una etapa compleja que requiere especial atención en el cuidado de la salud. Además, existen algunas condiciones que causan daños durante esta fase, como la placenta previa. Objetivo: El propósito de este estudio es resaltar el proceso de enfermería en relación con la atención a las gestantes con dicho diagnóstico. Metodología: La investigación es cualitativa, teórica con apoyo en la bibliografía científica, involucrando la comprensión holística e integral de las pacientes para la implementación de una estrategia para el proceso de enfermería. Con base en el estudio de teorías y fisiopatología e impactos clínicos, se utilizaron las taxonomías NANDA-I para delinear los diagnósticos de enfermería más consistentes. Resultados: Se identificaron 15 diagnósticos que incluían los diez dominios encontrados en la NANDA. Consideraciones finales: Los datos escogidos y la confrontación con la literatura enfatizan la relevancia positiva en la prescripción de los diagnósticos de enfermería en la elección de los cuidados prestados y las teorías subsidian la asistencia materno-fetal.

Acretismo placentário e suas complicações / Placental accretism and its complications

Acretismo é um termo genérico que significa uma invasão trofoblástica anormal da placenta em parte ou, mais raramente, na totalidade do miométrio, podendo inclusive chegar à serosa. Esse evento ocorre mais comumente em uma região de cicatriz uterina prévia, onde há um defeito na decidualização. A principal consequência disso é a necessidade frequente de histerectomia puerperal, acarretando grande morbidade materna. Este artigo apresenta o caso de uma gestante com placenta percreta, com acometimento vesical e de colo uterino que necessitou de histerectomia total. Além disso, no pós-operatório, apresentou fístula vesicoabdominal. O objetivo deste artigo é demonstrar as complicações do acretismo placentário e as maneiras de tentar reduzi-lo. O aumento nas proporções de nascimentos via parto cesariana, sem que haja evidências claras de que isso interfira na queda da mortalidade e/ou morbidade materna e neonatal, sugere que estejam sendo indicadas muito mais cesarianas que o necessário. Para redução nas taxas de cesariana e, consequentemente, das complicações dela, como nos casos de acretismo, é necessário repensar a cultura do cuidado da prática clínica em obstetrícia.(AU)

Accretism is a generic term that means an abnormal trophoblastic invasion of the placenta in part or, more rarely, in the entire myometrium, which may even reach the serosa. This event most commonly occurs in a region of previous uterine scar, where there is a decidualization defect. The main consequence of this is the frequent need for puerperal hysterectomy, causing great maternal morbidity. This article presents the case of a pregnant woman with placenta percreta, with bladder and uterine cervix involvement, who required hysterectomy. In addition, postoperatively, presented a vesico-abdominal fistula. The purpose of this article is to demonstrate the complications of placental accretism and ways to try it. The increase in the proportion of births via cesarean delivery, without clear evidences that this interferes with the decrease in maternal and neonatal mortality and/or morbidity, suggests that much more cesarean sections are being indicated than necessary. To reduce cesarean rates and consequently, its complications, as in cases of accretism, it is necessary to rethink the culture of care in clinical practice in obstetrics.(AU)

Expression of Cripto-1 in the placenta and its role in placenta accreta and placenta previa.

OBJECTIVES: This study Aims to explore the role of placental Cripto-1 in the incidence of an adherent placenta. MATERIAL AND METHODS: Ten pregnant women with placenta increta, 20 pregnant women with placenta previa and 30 women with normal pregnant were enrolled in this study. Reverse transcription-polymerase chain reaction (RT-PCR) was used to measure the expression of Cripto-1 in the placenta while as the analysis of placental Cripto-1 was performed by Western blotting RESULTS: The placenta increta group showed higher levels of Cripto-1 in the center of the increta as compared to the non-implantation area. The level of placental Cripto-1 in the placenta increta was higher than that of the placenta accrete. The expression of placental Cripto-1 in the placenta increta and placenta previa groups was higher than that of control. CONCLUSIONS: Placental Cripto-1 is involved in the regulation of placental tissue invasion. Additionally, excessive placental growth or penetration into the myometrium are likely to be involved in the development of placenta increta.

Impact of placenta previa with placenta accreta spectrum disorder on fetal growth.

OBJECTIVES: To evaluate fetal growth in pregnancies complicated by placenta previa with or without placenta accreta spectrum (PAS) disorder, compared with in pregnancies with a low-lying placenta. METHODS: This was a multicenter retrospective cohort study of singleton pregnancies complicated by placenta previa with or without PAS disorder, for which maternal characteristics, ultrasound-estimated fetal weight and birth weight were available. Four maternal-fetal medicine units participated in data collection of diagnosis, treatment and outcome. The control group comprised singleton pregnancies with a low-lying placenta (0.5-2 cm from the internal os). The diagnosis of PAS and depth of invasion were confirmed at delivery using both a predefined clinical grading score and histopathological examination. For comparison of pregnancy characteristics and fetal growth parameters, the study groups were matched for smoking status, ethnic origin, fetal sex and gestational age at delivery. RESULTS: The study included 82 women with placenta previa with PAS disorder, subdivided into adherent (n = 35) and invasive (n = 47) PAS subgroups, and 146 women with placenta previa without PAS disorder. There were 64 controls with a low-lying placenta. There was no significant difference in the incidence of small-for-gestational age (SGA) (birth weight ≤ 10th percentile) and large-for-gestational age (LGA) (birth weight ≥ 90th  percentile) between the study groups. Median gestational age at diagnosis was significantly lower in pregnancies with placenta previa without PAS disorder than in the low-lying placenta group (P = 0.002). No significant difference was found between pregnancies complicated by placenta previa with PAS disorder and those without for any of the variables. Median estimated fetal weight percentile was significantly lower in the adherent compared with the invasive previa-PAS subgroup (P = 0.047). Actual birth weight percentile at delivery did not differ significantly between the subgroups (P = 0.804). CONCLUSIONS: No difference was seen in fetal growth in pregnancies complicated by placenta previa with PAS disorder compared with those without and compared with those with a low-lying placenta. There was also no increased incidence of either SGA or LGA neonates in pregnancies with placenta previa and PAS disorder compared with those with placenta previa with spontaneous separation of the placenta at birth. Adverse neonatal outcome in pregnancies complicated by placenta previa and PAS disorder is linked to premature delivery and not to impaired fetal growth. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Major obstetric hemorrhage.

Major obstetric hemorrhage is a challenge for anesthesiologists because it remains responsible for over 10% of maternal deaths in high-income countries. A standardized multidisciplinary management, described in locally validated protocols and based on international guidelines is mandatory to prevent these deaths. The first difficulty relies on the systematic underestimation of the bleeding. Collection bags must be used to facilitate the diagnosis and therefore rapid management. The etiologies in antenatal or postpartum must be well-known in order to be treated adequately. A rapid recourse to prostaglandins (sulprostone in France) may reverse uterine atony. Invasive approach with surgery or radiology should be promptly implemented (uterine artery or internal iliac artery ligations±uterus plication) and hysterectomy should then be timely considered. Simultaneously, early and aggressive resuscitation with large-bore venous accesses should be implemented for rapid and massive transfusion (4:4:1 RBC:FFP:platelets ratio), along with an early use of fibrinogen concentrates and tranexamic acid. This transfusion strategy may be then guided by thromboelastography or thromboelastometry and bedside hemoglobin measurements. Activated factor VII remains indicated only before or after hysterectomy in case of uncontrolled bleeding. Management of placentation abnormalities (placenta previa, accreta, increta, percreta) must be well mastered as these etiologies may generate cataclysmic hemorrhages that can be and have to be anticipated.

Local injection of vasopressin reduces the blood loss during cesarean section in placenta previa.

AIM: The aim of this study was to evaluate the effect of local injection of vasopressin on blood loss and secondary impact on complications during cesarean section in patients with placenta previa. MATERIAL AND METHODS: We retrospectively reviewed the medical records of all patients diagnosed with placenta previa admitted to our hospital. Two consecutive periods were compared. During period B, 59 patients underwent the local injection of a vasopressin solution (4 U in 20 mL of saline) into the placental implantation site after placental delivery. During period A, 50 patients underwent cesarean section without vasopressin injection, and were analyzed as a control group. The estimated blood loss was recorded, as were the complications during surgery. In addition, the expression of the vasopressin V1α receptor in uterine smooth muscle was evaluated by immunohistochemistry. RESULTS: The mean estimated blood loss was significantly lower in the vasopressin group than in the control group. There were no statistically significant differences with surgical complications. The vasopressin V1α receptor was highly expressed in smooth muscle cells in the lower segment of the uterine body, whereas the immunoreactivity for the oxytocin receptor was faint in the lower segment. CONCLUSION: The local injection of vasopressin into the placental implantation site significantly reduced the blood loss without increasing the morbidity.

MRI of the placenta - a short review.

While ultrasound is still the gold standard method of placental investigation, magnetic resonance imaging (MRI) has certain benefits. In advanced gestational age, obese women, and posterior placental location, MRI is advantageous due to the larger field of view and its multiplanar capabilities. Some pathologies are seen more clearly in MRI, such as infarctions and placental invasive disorders. The future development is towards functional placental MRI. Placental MRI has become an important complementary method for evaluation of placental anatomy and pathologies contributing to fetal problems such as intrauterine growth restriction.

The frequency and clinical significance of intra-amniotic infection and/or inflammation in women with placenta previa and vaginal bleeding: an unexpected observation.

OBJECTIVE: Idiopathic vaginal bleeding, a common complication of pregnancy, increases the risk of small-for-gestational age (SGA) neonate, preeclampsia and preterm delivery and can be the only clinical manifestation of intra-amniotic infection and/or inflammation (IAI). Placenta previa is thought to be protective against ascending intrauterine infection, yet an excess of histologic chorioamnionitis has been reported in this condition. The aim of this study was to determine the frequency and clinical significance of IAI in women with placenta previa and vaginal bleeding in the absence of preterm labor. STUDY DESIGN: A retrospective cohort study including 35 women with placenta previa and vaginal bleeding <37 weeks of gestation who underwent amniocentesis was undertaken. Patients with multiple gestations were excluded. Intra-amniotic infection was defined as a positive culture for microorganisms, and intra-amniotic inflammation as an elevated amniotic fluid interleukin (IL)-6 concentration. IL-6 concentrations were determined by ELISA in 28 amniotic fluid samples available. Non-parametric statistics were used for analysis. RESULTS: 1) The prevalence of intra-amniotic infection was 5.7% (2/35), and that of IAI was 17.9% (5/28); 2) the gestational age at delivery was lower in patients with IAI than in those without IAI [29.4 weeks, interquartile range (IQR): 23.1-34.7 vs. 35.4 weeks, IQR: 33.9-36.9; P=0.028]; and 3) patients with placenta previa and IAI had a higher rate of delivery within 48 h (80% (4/5) vs. 19% (4/21); P=0.008) than those without IAI. CONCLUSIONS: Patients with placenta previa presenting with vaginal bleeding have intra-amniotic infection in 5.7% of the cases, and IAI in 17.9%. IAI in patients with placenta previa and vaginal bleeding is a risk factor for preterm delivery within 48 h.

Comparison of maternal risk factors between placental abruption and placenta previa.

The purpose of this study was to compare risk factors between placental abruption and placenta previa among primiparous and multiparous singleton pregnancies. We analyzed data from a population-based retrospective cohort with singleton pregnancies in the United States for 1995 to 2000. Maternal risk factors for placenta previa and placental abruption were examined using multiple logistic regressions. A total of 5,630,854 primiparous and 11,026,768 multiparous singleton pregnancies were available for final analyses after excluding subjects with missing information on outcomes or important exposures. Placental abruption was recorded in 4.8 per 1000 primiparous singleton births and 5.9 per 1000 multiparous singleton pregnancies. The occurrence of placenta previa was 1.9 per 1000 primiparous singleton pregnancies and 3.9 per 1000 multiparous singleton pregnancies. The effects of maternal age, race, parity, and previous cesarean section were stronger on placenta previa than on placental abruption, and the effects of cigarette smoking, alcohol drinking, and prenatal care were stronger on placental abruption than on placenta previa. A composite outcome of selected medical and pregnancy complications was related with placental abruption but not with placental previa. Placental abruption is more likely to be affected by conditions occurring during pregnancy, and placenta previa is more likely to be affected by conditions existing prior to pregnancy.

Arterial embolization for haemorrhage in the obstetric patient.

Arterial embolization is a safe and effective treatment for persistent post-partum haemorrhage that is unresponsive to conservative management. Embolization should be the treatment of choice in these patients provided that suitable radiological skills and equipment are available. Embolization is potentially useful in patients with antepartum haemorrhage in the last trimester or in patients at high risk for antepartum haemorrhage.

Relationship between pregnancy-induced hypertension and placenta previa: a population-based study.

OBJECTIVE: Our purpose was to investigate, in a large population-based cohort, the hypothesis that the risk of pregnancy-induced hypertension is lower among pregnancies complicated by placenta previa compared with pregnancies occurring in women with fundally implanted placentas. STUDY DESIGN: Data for this retrospective cohort study were derived from the computerized Atlee perinatal database of the Reproductive Care Program, Nova Scotia, Canada. Women who were delivered in the province between 1980 and 1993 were included in the study. Patients with pregnancy-induced hypertension were clinically diagnosed by the presence of elevated blood pressure, proteinuria, or edema. The risk of pregnancy-induced hypertension was compared between women diagnosed with placenta previa and those with a normally implanted placenta, after adjustment for potential confounders through multivariable logistic regression models based on the method of generalized estimating equations. RESULTS: During the 14 years (1980 to 1993), 121,082 singleton pregnancies were registered in the program, 416 (0.4%) of which had a confirmed diagnosis of placenta previa. Women with chronic hypertension had a relative risk of 1.2 (95% confidence interval 0.4 to 3.7) for placenta previa compared with normotensive women. However, the risk of pregnancy-induced hypertension was reduced by half among those with placenta previa (relative risk 0.5, 95% confidence interval 0.3 to 0.7). Adjustments for potential confounders, including maternal age, parity, prepregnancy body weight, prior cesarean delivery, prior spontaneous or induced abortions, and cigarette smoking, had no influence on this association. Analyses on the basis of stratification of women by parity (nulliparous vs multiparous), cigarette smoking (smoker vs nonsmoker), and gestational duration (< 28, 28 to 32, 33 to 36, and > 37 completed weeks) consistently showed reduced risks for pregnancy-induced hypertension among women with placenta previa, indicating that the association was not a result of shortened duration of gestation among women with placenta previa. CONCLUSIONS: The results from this study clearly show a decreased frequency of pregnancy-induced hypertension among those pregnancies with placenta previa. We speculate that the pathophysiologic mechanisms for this finding may be due to altered placental perfusion seen among women diagnosed with placenta previa.

Clinical features of and cardiotocographic findings for premature infants with antenatal periventricular leukomalacia.

OBJECTIVE: To clarify the clinical features of and cardiotocographic findings for premature infants with antenatal periventricular leukomalacia (PVL). METHODS: Antenatal PVL was judged to be present if a cyst greater than 3 mm in largest diameter was detected in the periventricular region by the 14th day of life on cranial ultrasonography. The clinical features of and cardiotocographic findings for 12 premature infants with antenatal PVL born within 1 year were compared with those of 12 infants chosen as control group matched in gestational age at birth from the premature infants without antenatal PVL born within the study period. RESULTS: Abnormalities of the umbilical cord such as coiling, excessive torsion and membrane insertion were observed more frequently for infants with antenatal PVL (58.3%) than for control infants (16.7%) (P<0.05). Frequent moderate variable deceleration on the fetal cardiogram was also observed more frequently for infants with antenatal PVL (80.0%) than for control infants (27.3%) (P<0.05). CONCLUSION: Abnormalities of the umbilical cord and frequent moderate variable deceleration on fetal cardiotocogram appear to be causes of antenatal PVL in premature infants.

Characterization of placenta accreta using transvaginal sonography and color Doppler imaging.

The safe use of transvaginal sonography in patients with placenta previa has been confirmed, and has revolutionized precise placental localization. The aim of our study was to evaluate the efficacy of transvaginal sonography and color-coded blood flow in the prediction of placenta accreta. Twenty-one patients with persistent placenta previa were scanned using transvaginal sonography and color-coded flow. Suspicion for placenta accreta consisted of total placenta previa at term with several placental lacunae exhibiting marked or turbulent blood flow, as seen with color Doppler transvaginal sonography from within the placenta, extending into the surrounding tissues. Five of the patients exhibited sonographic placental patterns suspicious for placenta accreta and one patient exhibited placental and cervical blood flow described as lacunar. Five Cesarean hysterectomies were performed for placenta accreta. Every placenta accreta was correctly diagnosed sonographically by the use of color flow studies. One patient with suspicion of placenta accreta delivered at another institution, a Cesarean hysterectomy was performed, and the pathology was confirmed. The one placenta previa exhibiting turbulent lacunar flow in the cervical area only was not confirmed to be an accreta at Cesarean section, although hemostasis was difficult at the placental bed. The remaining 15 patients with placenta previa and who on sonography were not suspicious for placenta accreta underwent uncomplicated Cesarean section. Transvaginal sonography and color Doppler imaging improve the diagnostic accuracy in the prediction of placenta accreta in patients with persistent placenta previa. A pattern of turbulent blood flow extending from the placenta into the surrounding tissues should alert the physician to the possibility of placenta accreta.

Antenatal bleeding and fetal heart rate.

Objective of the paper was to determine the fetal heart rate (FHR) changes that occur in preterm fetuses whose mothers have suffered antepartum bleeding, versus uncomplicated controls. Over a 12-year span, 91 patients with significant antenatal bleeding (bleeding requiring inhospital observation) were examined and compared to 75 controls with uncomplicated normal pregnancies. None of the women were in labor and all were evaluated at 25-37 weeks' gestation. Excluded were: patients with any other complication (i.e., premature rupture of membranes, intrauterine growth retardation, diabetes, hypertension, collagen vascular disease, postuterine surgery, substance abuse and twins). Analysis of the FHR tracings included baseline heart rate, long-term FHR variability, and number and amplitude of FHR accelerations in 20-min segments. There was no difference in baseline heart rate in the preterm fetuses of pregnancies complicated by antepartum bleeding versus controls. However, the parameters associated with FHR reactivity (number of accelerations in 20 min, and amplitude of accelerations) were higher to a statistically significant degree in fetuses of pregnancies complicated by antenatal bleeding than in controls. Fetuses of mothers suffering antenatal bleeding exhibited significant higher rates of reactive FHR patterns at earlier gestational ages than did controls. In conclusion, there is a significant increase in FHR reactivity in pregnancies in which significant antenatal bleeding occurs, suggesting a probable acceleration in fetal central nervous system maturation in these fetuses.

Perinatal growth hormone (GH) physiology: effect of GH-releasing factor on maternal and fetal secretion of pituitary and placental GH.

To study regulation of the secretion of human pituitary GH (hGH) and placental GH (hPGH) in the pregnant woman and human fetus, the GH-releasing factor Sermorelin [GRF-(1-29)-NH2] was administered to pregnant women at term (n = 5), just before elective cesarean section; saline was administered in control studies (n = 5). The effects of GRF-(1-29)-NH2 administration on maternal and fetal serum concentrations of hGH and GRF-(1-29)-NH2 and maternal serum levels of hPGH were evaluated at birth. The mean time span between injection and birth was 20 min (range, 15-25 min). Cord serum hGH concentrations were similar in infants of GRF-(1-29)-NH2-injected mothers and control infants. GRF-(1-29)-NH2 elicited a consistent but small rise in maternal hGH serum concentrations (P = 0.08), whereas hPGH concentrations remained unaltered. Finally, GRF-(1-29)-NH2 concentrations were undetectable in cord serum, but readily detectable in concomitantly obtained maternal serum. In conclusion, these data suggest that hGH secretion in the pregnant woman at term is suppressed at the pituitary level, that GRF does not affect hPGH secretion, and that fetal hGH secretion is independent of circulating maternal GRF, probably because of lack of transplacental GRF passage.