Placenta previa (Implantation of placenta in lower uterus)

When the placenta is implanted partially or completely over the lower uterine segment,
it is called placenta previa. When the inelastic placenta sheared off by the dilation of
lower uterine segment for expulsion of fetus, leads to bleeding.

Incidence - 1 in 200 deliveries in the hospital.

Cause -
The exact cause of implantation of the placenta in the lower segment is not known.
It is more common in women who have:
- Abnormally shaped uterus 
- Many previous pregnancies
- Multiple pregnancy (twins, triplets, etc.)
- Due to history of surgery, c-section, previous pregnancy, or abortion.

Women who smoke or have their children at an older age may also have an increased risk.

Types or degrees -
There are 4 types of placenta previa depending upon the degree of extension of placenta
to the lower segment.

1. Type I (low lying) - The major part of the placenta is attached to the upper segment
   and only the lower margin encroaches to the lower segment but not upto the cervical
   os (opening).

2. Type II (marginal) - The placenta reaches the marginal of the internal os but not cover it.

3. Type III (incomplete or partial central) - The placenta cover the internal os partially.

4. Type IV (central or total) - The placenta completely covers the internal os even after
    it is fully dilated.

Symptoms -
The only symptoms of placenta previa is vaginal bleeding. The classical features of bleeding
are sudden onset, painless, apparently causeless and recurrent.

Diagnosis -
This condition is diagnosed by ultrasonography.

Antepartum haemorrhage

It is defined as bleeding from or into the genital tract after the 28th week of pregnancy but before the birth of baby. The first and second stage of labour are thus included. The 28th week is taken arbitarily as the lower limit of fetal viability.

Causes -
The causes of antepartum haemorrhage fall into the following categories. On an average, the incidence of placenta praevia, abruptio placentae and indeterminate group is almost same.

Effect of excessive vomiting in pregnancy

1. Metabolic changes -
- Inadequate intake of food results in glycogen depletion. For the energy supply, the fat
  reserve is broken down.
- Due to low carbohydrate, there is incomplete oxidation of fat and accumulation of ketone
  bodies in the blood.
- The acetone is ultimately excreted through the kidneys and in the breath.
- There is also increase in endogenous tissue protein metabolism resulting in excessive
  excretion of non-protein nitrogen in the urine.
- Water and electrolyte metabolism are seriously affected leading to biochemical and
  circulatory changes.

2. Biochemical changes - 
- Loss of water and salts in the vomitus resulting in fall in plasma sodium, potassium
  and chlorides.
- The urinary chloride may be well below the normal 5 gm/litre or may even be absent.
- Hepatic dysfunction results in acidosis and ketosis with rise in blood urea and uric acid ,
  hypoglycaemia, hypoproteinaemia, and hypovitaminosis.

3. Circulatory changes - 
There is haemoconcentration leading to rise in haemoglobin percentage, RBC count and
haematocrit values. There is slight increase in the white cell count with increase in eosinophils.
There is concomitant reduction of extracellular fluid.

Hyperemesis gravidarum during pregnancy

It is a severe type of vomiting of pregnancy which has got deleterious effect on the health 
of the mother and/or incapacitates her in day to day activities.

Incidence - Less than 1 in 1000 pregnancy.

Etiology -
The etiology is obscure but the following are the known facts :
- It is mostly limited to the first trimester.
- It is more common in first pregnancy.
- It has got a familial history -mother and sister also suffer from the same manifestation.
- It is more prevalent in multiple pregnancy.
- It is more common in unplanned pregnancies.

Causes -
The exact causes are not known. There are some theories for hyperemesis gravidarum.
1. Hormonal - Progesterone excess leading to relaxation of the cardiac sphincter and
    simultaneous retention of gastric fluids due to impaired gastric motility.
2. Psychogenic - It probably aggravates the nausea once it begins. But neurogenic element
    sometimes plays a role, as evidenced by its subsidence after shifting the patient from the
    home surroundings.
3. Dietary deficiency - Probably due to low carbohydrate reserve, as it happens after a night
    without food.
4. Allergic or immunological basis.
5. Decrease gastric motility is found to cause nausea.

Sign and symptoms -
- Dry coated tongue.
- Sunken eyes.
- Acetone smell in breath.
- Tachycardia.
- Hypotension.
- Rise in temperature.
- Oliguria.
- Epigestric pain.
- Constipation.

Management -
Principles -
- To control vomiting.
- To correct the fluids and electrolytes.
- To prevent or to detect complications at earliest stage.

Hospitalization - 
Whenever a patient is stamped as a case of hyperemesis gravidarum, she is admitted in hospital.

Fluids - 
Oral feeding is withheld for at least 24 hours after the cessation of vomiting. During this period,
fluid is given through intravenous drip method. The amount of fluid to be infused in 24 hours is
approximate 3 litres, of which half is 5% dextrose and half is Ringer's solution.

Drugs -
a) Antiemetics drugs
- Promethazine (Phenargan) 25 mg
- Prochlorperazine (Stemetil) 5 mg
- Triflupromazine (Siquil) 10 mg
may be administered twice or thrice daily IM.
b) Nutritional support with vitamin B1, B6, B12 and vitamin C are given.

Diet -
- At first, dry carbohydrate foods like biscuit, bread and toast are given.
- Small but frequent feeds are recommended.

Complications -
- Neurological complications such as peripheral neuritis.
- Stress ulcer in stomach.
- Esophageal tear or rupture.
- Jaundice.
- Deep vein thrombosis.

Vomiting in pregnancy (morning sickness)

Vomiting is a symptoms which may be related to pregnancy or may be a manifestation of
some medical-surgical-gynaecological complications which can occur at any time during
pregnancy. It commonly occur between 5 to 18 weeks of pregnancy.

Causes -
The causes of vomiting is not clear. Several theroies such as increased level of the stomach
contents, increased hormone level, acute fulminating preeclampsia and psycological factors
have been proposed.

Types -
The vomiting related to pregnant state and depending upon the severity, it is classified as :
a) Simple vomiting of pregnancy
b) Hyperemesis gravidarum


                   Simple vomiting (morning sickness or emesis gravidarum)
The patient complains of nausea and occasional sickness on rising in the morning. Slight
vomiting is so common in early pregnancy (about 50% of women) that it is considered as
a symptom of pregnancy. The vomitus is small and clear or bile stained.
It does not produce any impairment of health or restrict the normal activities of the women. 
The features disappears with  or without treatment by 12-14th week of pregnancy.

Management -
- Taking of dry toast or biscuit and avoidance of fatty and spicy foods are enough to relieve
  the symptoms in majority.
- Avoiding food or not eating may actually make nausea worse. Try eating to avoid an empty 
  stomach, which may aggravate nausea.
- Antiemetic drugs- trifluoperazine 1 mg twice daily.
- Patient is advised to take plenty of fluids and fruit juice.


                                        Hyperemesis gravidarum 
It is a severe type of vomiting of pregnancy which has got deleterious effect on the health of
the mother and/or incapacitates her in day to day activities. For details about hyperemesis
gravidarum, visit the following page :
http://pregnancyandlabour.blogspot.in/2014/01/hyperemesis-gravidarum-during-pregnancy.html

Management of normal puerperium

Immediately following delivery, the patient should be closely observed. She may be given
a drink of her choice or something to eat, if she is hungry.

Principles - 
- To give all out attention in to restore the health status of the mother.
- To prevent infection.
- To take care of the breasts, including promotion of lactation and nursing of the child.
- To motivate the mother for contraception.

General management -

Rest and ambulance -
It is indeed difficult to categories an uniform period of rest. After a good resting period,
the patient becomes fresh and can breast feed the baby or moves out of bed to go to the
toilet. Early ambulation is encouraged.

Que. - What is the benefits of early ambulation after delivery ?
Ans. -  Advantages of early ambulation are:
           - Provide a sense of well-being.
           - Bladder complications and constipation are reduced.
           - Facilitates uterine drainage.
           - Hastens involution of uterus.
           - Lessens puerperal venous thrombosis and embolism.

Hospital stay -
Early discharge from the hospital is an almost universal procedure. If adequate supervision
by trained health visitors is provided, there is no harm in early discharge.

Diet -
The patient should be on normal diet of her choice. If the patient is lactating, high calories,
adequate protein, fat, plenty of fluids, minerals and vitamins are to be given.

Care of the bladder -
The patient is encouraged to pass urine following delivery as soon as convenient. If the patient
fails to pass urine, catheterisation should be done. Catheterisation is also indicated in case of
incomplete emptying of bladder.

Care of the bawel -
The problem of constipation is much less because of early ambulation and liberalisation of the
dietary intake. A diet containing sufficient roughage and fluids is enough to move the bowel.
If necessary, mild laxative such as Igol (isopgol husk) two teaspoons may be given at bed time.

Sleep -
The patient is in need of rest, both physical and mental. So she should be protected against
worries and undue fatigue. Sleep is ensured providing adequate physical and emotional support.

Care of the vulva and episiotomy -
Shortly after delivery, the vulva and buttocks are washed with soapwater down over the anus
and a sterile pad is applied. The patient should look after personal cleanliness of the vulval
region. The perineal wound should be dressed with spirit and antiseptic power after each act
micturition and defaecation or at least twice a day.

Care of the breast -
The nipple should be washed with sterile water before each feeding. It should be cleaned
and kept dry after the feeding is over. Nipple soreness is avoided by frequent short feeding
rather than the prolonged feeding, keeping the nipple clean and dry.

Lactation suppression

Suppression of lactation becomes necessary if the baby is born dead or dies in the neonatal
period or if breast feeding is contraindicated.

Mechanical method for lactation suppression -
It may be used in cases where the lactation is to be suppressed after the establishment of
milk secretion.
i) The patient should stop breast feeding.
ii) She should not express or pump out the milk from the breast.
iii) A tight compression bandage is applied for about 2-3 days.
iv) Analgesic tablet containing aspirin and ice packs are given to given to relieve pain and
    breast engorgement.

Drugs for lactation suppression - 
Bromocriptine (dopamine agonist that inhibits prolactin) 2.5 mg, 1 tablet daily for 10-14 days
may be given (with caution).
Side effects are:
- Hypertension
- Rebound breast engorgement
- Myocardial infarction
- Puerperal stroke.
Puerperal breast engorgement though painful, is never fatal.