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PLACENTA PREVIA

DR. ITSURA M P
OBS/GYNAECOLOGY

OUTLINE

Case description
Introduction and definition
Incidence, pathogenesis and risk factors
Clinical features
Diagnosis
Management
Summary

CASE

Para 4+1 G 6
Presented at 31 weeks with PV bleeding.
Previous obstetric performance

2 previous scars
2 SVD deliveries
All alive and well

PMHx: Known asthmatic.


FSHx: Smoker, Occasionally drinks.

Ultrasound: Singleton pregnancy, Posterior


placenta previa IV, liquor normal.CGA
corresponded to dates.
U/E/C & FHG: Essentially normal.
GXM 1 unit, O +ve
Done: celestone, IV fluids, pethidine
administered, bed rest.

INTRODUCTION

Placenta previa refers to placenta tissue


overlying or proximate to internal os.

Bleeding is the main complication.

Bleeding can range from only spotting to


massive life threatening haemorrhage.

Placenta configuration/classification

I) Complete previa
Internal os is equidistant from anterior
and posterior edges.
Also classified as TYPE IV
Account for approximately 2030% of all
placenta previa.

2) Partial or type III.


placental edge covers internal os which
must be partly dilated for this to occur.
3) Marginal or type II.
Placenta adjacent to internal os but not
covering it.
Can be Anterior or Posterior

4)Low lying placenta or type I


. Apparent placenta previa in 2nd trimester
Placenta in low segment but exact
relationship to os not determined
Placenta edge lies within 2-3cm from os
Low lying placenta associated with increased
risk of bleeding and other perinatal outcome.
Oppenheimer et al. what is a low-lying placenta Am JOG 1991

classification

Incidence

4 in 1000 pregnancies greater than 20 weeks

Facz,AS,ananth-Etiology and risk factors for PP; an overview. J. Maternal


fetal neonat med 2003

Risk factors

What are the risk factors to placenta previa?

Grouped according to pathogenetic


mechanism.

I) Endometrial scarring in upper


segment
Initial nidation in unscarred area or growth
towards unscarred low segment
Parity 0.2% in nulliparity
5% in grand multipara
Increased maternal age;
0.03% in nulliparas 20-29 years
0.25% in nulliparas >40years

Endometrial scarring

Increased number of prior caesarian section


>10% after >4 caesarian section
Prior curettage for miscarriage.

II) Placental surface


Need for increased placenta surface area to
compensate for reduction in uteroplacental
oxygen or nutrient delivery

smoking

high altitude

multiple gestationtwins 3.9% per 1000 live birth


single term 2.8 per 1000 live birth

III) Gestational age


Migration of placenta
Theories.Growth of low segment
-0.5cm at 20 weeks
-5cm at term
.Unidirectional growth of trophoblastic
tissues toward fundus within stationary
uterus (Trophotropism)

IV) Fetal sex

Fetal sex male > female 14% increase


106:100
? Larger placenta associated with male fetus
?delay in implantation of blastocyst.

MacGillivray et al Placenta previa and sex ratio at birth. Br med J 1986

Clinical manifestation
I) Painless vaginal bleeding after 20 weeks
70-80 %
2) Uterine contraction - 10-20% associated
with bleeding
3) Asymptomatic detected by ultra sound
< 10%

Bleeding
1/3 initial bleeding in < 30 weeks
associated with transfusion , pre-term
delivery and high perinatal mortality
1/3 bleed between 30-36 weeks
1/3 bleed after 36 weeks
10% reach term without bleeding
Bleeding more in third trimester

Bleeding mechanism

Contraction of uterus leads to dilation and


effacement of cervix.
Low segment develops in 3rd trimester.
Changes in cervix and low uterine segment
apply shearing forces at the inelastic
placental attachment site resulting in
placental detachment /bleeding.
Coitus and VE can also cause separation.

Associated conditions

Placenta accreta 5-10% of placenta previa


Malpresentation - non cephalic mostly.
Premature rupture of membrane (PROM)
Intra uterine growth restriction (IUGR) upto
16%

Ananth CV et al Relationship among PP,IUGR,PROM,Preterm delivery.


Am J OG 2001

Associated factors ct

Vasa previa and velemetous umbilical cord


insertion
Congenital anomalies.

Crane JM Neonatal outcomes with PP. Obstet Gynacol 1999

Diagnosis

High index of suspicion


Bleeding after 20 weeks no vaginal
examination until ultra sound has been done
History and physical examination.
vital signs
abdominal findings

Differential diagnosis

Third trimester bleeding


Placenta previa 22%
Abruption 31%
Others
47%
-Obstetric
-Gynaecological

Ultra sound
Transabdominal
-over distended bladder
-posterior previa in cephalic presentation
can be missed
Transvaginal relationship of placenta to
cervical os.
Translabial/ transperineal
Repeat ultrasound 28-32 weeks

Persistence after 2nd trimester


diagnosis

Complete previa doesnt migrate.


Marginal and low lying migrate in upto 90%
Normal implantation occurs by 28-32week.
Repeat scan recommended at 34week to
confirm final diagnosis.

Dashe JS Persistence of PP according to gest age. Obstet Gynacol. 2002

M. R. I

Used in selected cases only

It is costly, limited availability.

Management of placenta previa

Management of placenta previa


Depends on three case scenarios below:
Asymptomatic mothers discovered by
routine scan
Actively bleeding mothers
Mothers who are stable after one or more
episodes of active bleeding

Asymptomatic PP>20wks

Sonographic follow up. Serial 4 weeks


interval after 28 weeks
Avoidance of coitus or vaginal exam
Exercise restriction ( less physical activity.)
Counselling
? Hospitalization benefit if not bleeding.

Acute care/ emergency situation


I.V line /crystalloids
Maintain haemodynamic stability and
adequate urine output 30ml / hour
GXM blood group and antibody screen
Transfusion when need be.
Changes in haemodynamic parameters and
rate of bleeding should be noted.
(BP, maternal/ fetal heart rates, peripheral
perfusion, urine out put)

Management of acute case ct


Coagulation screen if co-existing abruptio placenta
or massive transfusion.
Fetal monitoring
Maternal monitoring
-Bp, heart rate, Foleys catheter, vaginal blood loss
Tocolysis- No tocolysis to actively bleeding women
Consider if conservative management is the way
forward.

Indication for delivery

Non reassuring fetal status


Life threatening refractory maternal
haemorrhage
Significant vaginal bleeding after 34 weeks

Delivery
Caeserian section and or vaginal delivery
depending on type and condition of mother.
Anaesthesia
-general anaesthesia when
haemodynamicaly unstable
-regional when stable

Conservative management
When no significant (<500mls) bleed
prolongation lasted < 17 days.
Hospitalization versus outpatient
case base analysis.
-patient return to hospital quickly
-adult companion 24hours
-reliable and able to maintain bed rest
understand the risk

Conservative mnx ct

Correct anaemia. - iron supplements


Constipation management. stool softeners
Autologous blood donation Hb > 11.0g/dl
Steroids 24-34 weeks.
Rhesus immune globulin _ with initial bleeding.
Fetal assessment.
Tocolysis
Cerclage- no benefit so far

Delivery
Timing -Amniocentesis at 36, 37 weeks
-delivery by 38 weeks.
Route of delivery
-complete previa caesarian section
-low lying placenta role of SVD when edge >2cm
from OS
Double set up.
Marginal previa _ Risk of emergency delivery hence
elective caesarian section preferable.

procedure

2 4 units of blood
Be ready for emergency caesarian
hysterectomy.
Avoid placenta on entry to uterus.
Fast and skill in delivery helps

outcome

Hemorrhage APH ,intra-partum and PPH


increased incidence
Maternal mortality - <1% in developed
countries
Neonatal morbidity/mortality
pre term delivery
Associated conditions
Recurrence rate 4 - 8%

Summary

Placenta in low lying segment could be


complete,partial,marginal or low-lying.
Previous c/s and multiple gestation are risk
factors
Presentation is commonly painless PV
bleeding
Associated with PROM, IUGR,vasa previa.

Summary

Diagnosis is by scan, 90% of 2nd trimester


diagnosis resolve by 3rd trimester.
Outpatient Vs hospitalization depends on
case assessment
Generally C/S recommended unless
placental edge >2cm from internal os.
PP is associated with other obstetric
conditions which needs to be looked for.

Thank you.