A 29-year-old woman, G1P1, was referred to a private hospital because of vaginal bleeding after cervical cerclage. She had previously delivered vaginally her first female infant (3,536 g) after cervical cerclage under the diagnosis of cervical incompetency. In the pregnancy discussed here, cervical cerclage was performed at 15 weeks gestation for the prevention of preterm delivery. Ultrasonography at that time demonstrated no abnormal findings. Twelve days after surgery sudden vaginal bleeding occurred. On admission in the 17th week of gestation, slight bleeding from the external cervical os was noted, and ultrasonography in our hospital demonstrated placenta previa. The placenta overlapped the internal cervical os and the distance from the lower placental edge to the internal os was 28 mm (2.8cm). Despite the administration of oral ritodrine hydrochloride, a β-adrenergic stimulant, bleeding continued in the amount of approximately 800 ml per day. The position of the placenta did not change. After appropriate counseling, the patient chose to terminate the pregnancy because she did not want to undergo the risk of life-threatening bleeding. Cervical os was still closed, and emergency cesarean section was performed at 18 weeksí gestations, 6 days after admission. OB-Gynecologist opened the abdomen with a vertical midline incision. A transverse incision of the lower uterine segment was made, and an infant weighing 175 g was delivered. The placenta covered the internal cervical os and was ablated easily. A double-layer closure was performed as usual. The operative bleeding, including amniotic fluid, was 900 ml, but the bleeding continued after surgery. The hemoglobin value was decreased from 8.3 g/dl to 5.6 g/dl, and 5 units of banked concentrated red blood cells were transfused with prophylactic administration of gabexate mesylate for disseminated intravascular coagulation. After the blood transfusion, bleeding decreased gradually. The patient was discharged in good condition 12 days after surgery. Two years later, she had a normal pregnancy, with the placental position being normal, and delivered by cesarean section to a male infant weighing 3,010 g. No uterine abnormalities were evident during the surgery.
1. Based on the case above, discuss the risk factors and signs and symptoms of placenta previa that are present in the patient.
2. Is cervical cerclage done with the patients the predisposing factor of placenta previa? Why? Why not?
3. Discuss and enumerate the nursing management of a patient having massive blood loss and undergoing blood transfusion due to placenta previa.