Background

Placenta previa involves implantation of the placenta over the internal cervical os. Variants include complete implantation over the os (complete placenta previa), a placental edge partially covering the os (partial placenta previa) or the placenta approaching the border of the os (marginal placenta previa). A low-lying placenta implants in the caudad one half to one third of the uterus or within 2-3 cm from the os.

Placenta previa.

Placenta previa covering the entire cervical

os.

Placenta previa partially separated from the lower uterine segment.

Placenta previa invading the lower uterine segment and covering the cervical os.

Pathophysiology
Placental implantation is initiated by the embryo (embryonic plate) adhering in the lower (caudad) uterus. With placental attachment and growth, the developing placenta may cover the cervical os. However, it is thought that a defective decidual vascularization occurs over the cervix, possibly secondary to inflammatory or atrophic changes. As such, sections of the placenta having undergone atrophic changes could persist as a vasa previa. A leading cause of third trimester hemorrhage, placenta previa presents classically as painless bleeding. Bleeding is thought to occur in association with the development of the lower uterine segment in the third trimester. Placental attachment is disrupted as this area gradually thins in preparation for the onset of labor. When this occurs, bleeding occurs at the implantation site as the uterus is unable to contract adequately and stop the flow of blood from the open vessels. Thrombin release from the bleeding sites

promotes uterine contractions and leads to a vicious cycle of bleeding-contractions-placental separationbleeding.

Epidemiology
Frequency
United States Placenta previa occurs in 0.3-0.5% of all pregnancies. The risks increase 1.5- to 5-fold with a history of cesarean delivery. A recent meta-analysis showed that the rate of placenta previa increases with increasing numbers of cesarean deliveries, with a rate of 1% after 1 cesarean delivery, 2.8% after 3 cesarean deliveries, and as high as 3.7% after 5 cesarean deliveries.[1] Despite this increased incidence after cesarean delivery, recent studies show that a previous cesarean delivery did not increase the odds of detecting a placenta previa on second-trimester ultrasonography. However, ultrasonography is useful in determining the rate of placental migration observed at 28-36 weeks' gestation, which may identify patients who are more likely to deliver vaginally with resolution of the previa. Of all placenta previas, the frequency of complete placenta previa ranges from 20-45%, partial placenta previa accounts for approximately 30%, and marginal placenta previa accounts for the remaining 25-50%.

Mortality/Morbidity
Table. Relative Risk of Morbidities in Patients With Placenta Previa (Open Table in a new window) Morbidities Antepartum bleeding Relative Risk 10

Need for hysterectomy 33 Blood transfusion Septicemia Thrombophlebitis Endometritis 10 5.5 5 6.6[2]

The maternal mortality rate associated with placenta previa ranges from 2-3%. Maternal mortality is 0.03% in the United States. Neonatal mortality associated with placenta previa is as high as 1.2%.[3]

Race
Placenta previa has no predilection for any race.

Sex
Placenta previa only occurs in pregnant women.

Age
Age is associated with a varying prevalence of placenta previa. The risk of placenta previa in relation to age is as follows: Aged 12-19 years - 1%

Aged 20-29 years - 0.33% Aged 30-39 years - 1% Older than 40 years - 2%

Plasenta Previa
Oleh : Ari Susanto, Amk Plasenta adalah bagian dari kehamilan yang penting. Dimana plasenta memiliki peranan berupa transport zat dari ibu ke janin, penghasil hormon yang berguna selama kehamilan, serta sebagai barier1. Melihat pentingnya peranan dari plasenta maka bila terjadi kelainan pada plasenta akan menyebabkan kelainan pada janin ataupun mengganggu proses persalinan. Kelainan pada plasenta dapat berupa gangguan fungsi dari plasenta ataupun gangguan implantasi dari plasenta. Gangguan dari implantasi plasenta dapat berupa kelainan letak implantasinya ataupun kelainan dari kedalaman implantasinya. Berdasarkan data yang didapatkan badan kesehatan duni World Health Organization (WHO), prevalensi plasenta previa pada tahun 2008, sekitar 458 dari 100.000 kelahiran setiap tahunnya, sedangkan prevalensi plasenta previa pada tahun 2009, sekitar 320 dari 100.000 kelahiran. (WHO, 2009) Namun sebelum membicarakan mengenai plasenta yang abnormal maka terlebih dahulu akan dibahas sedikit mengenai keadaan plasenta yang normal. Penyebab plasenta previa secara pasti sulit ditentukan, tetapi ada beberapafaktor yang meningkatkan risiko terjadinya plasenta previa, misalnya bekasoperasi rahim (bekas sesar atau operasi mioma), sering mengalami infeksirahim (radang panggul), kehamilan ganda, pernah plasenta previa, atau kelainan bawaan rahim. Plasenta previa didefinisikan sebagai suatu keadaan seluruh atau sebagian plasenta ber-insersi di ostium uteri internum, sehingga menutupi seluruh atau sebagian dari jalan lahir. Prevalensi plasenta previa di negara maju berkisar antara 0,26 - 2,00 % dari seluruh jumlah kehamilan. Sedangkan di Indonesia pada tahun 2009 dilaporkan oleh beberapa peneliti berkisar antara 2,4 - 3,56 % dari seluruh kehamilan sekitar 5 dari 500 kelahiran setiap tahunnya. Angka kejadian plasenta previa relative tetap dalam tiga dekade sampai dengan pertengahan tahun 1980, yaitu rata-rata 0,36-0,37 %, tetapi pada dekade selanjutnya angka kejadian meningkat menjadi 0,48 %, mungkin disebabkan karena meningkatnya faktor risiko terjadinya plasenta previa seperti umur ibu hamil semakin tua, kelahiran secara bedah sesar, paritas yang tinggi serta meningkatnya jumlah abortus yang terjadi, terutama abortus provokatus. Angka kejadian dari plasenta previa adalah 0,5% atau 1 diantara 200 persalinan. Di Rumah Sakit Dr. Cipto Mangunkusumo terjadi 42 kasus plasenta previa di antara 6587 persalinan yang terdaftar, atau kira-kira 2 di antara 250 persalinan terdaftar. (RSCM, 2009). Penyebab terjadinya plasenta previa belum diketahui secara pasti, namun kerusakan dari endometrium pada persalinan sebelumnya dan gangguan vaskularisasi desidua dianggap sebagai mekanisme yang mungkin menjadi faktor penyebab terjadinya plasenta previa. . Dari beberapa penelitian diketahui bahwa telah dapat dibuktikan adanya faktor-faktor risiko terjadinya

plasenta previa termasuk umur ibu, banyaknya jumlah kehamilan dan kelahiran, merokok selama hamil dan riwayat operasi sesar. Meskipun sudah ada beberapa penulis yang menghubungkan antara riwayat abortus spontan dan induksi abortus dengan kejadian plasenta previa tetapi hubungan itu masih menjadi kontroversi. Suatu penelitian metaanalisis mengenai hubungan antara plasenta previa dengan riwayat seksio sesarea dan abortus di Amerika Serikat (1997) telah menunjukkan bahwa wanita dengan riwayat seksio sesarea minimal satu kali mempunyai risiko 2,6 kali untuk menjadi plasenta previa pada kehamilan berikutnya, dan risiko ini bertambah sesuai dengan bertambahnya banyaknya riwayat seksio sesarea.(4) Penelitian lain di Inggris (1986) juga menemukan hubungan yang sangat bermakna antara plasenta previa dan riwayat seksio sesarea, demikian juga penelitian lain menemukan hubungan yang kuat. Dari penelitian terdahulu pernah dilaporkan hubungan antara riwayat abortus spontan dengan kejadian plasenta previa mereka menemukan odds ratio plasenta previa dihubungkan dengan riwayat abortus spontan satu kali menjadi 1,6 kali dan risiko terjadinya plasenta previa meningkat dengan jumlah riwayat abortus yang semakin banyak. Walaupun demikian, hubungan antara plasenta previa dan riwayat abortus masih kontroversial, seperti pada penelitian Heija AT(1999) tidak menemukan hubungan yang bermakna antara riwayat abortus dan terjadinya plasenta previa, demikian juga Zhou W (2001) hanya menemukan hubungan yang lemah antara keduanya. Dari beberapa penelitian didapatkan bahwa pengaruh paritas terhadap terjadinya plasenta previa cukup besar, hal ini mungkin disebabkan terjadinya respon inflamasi dan perubahan atrofi di permukaan endomterium. Penelitian yang mendukung pengaruh paritas terhadap terjadinya plasenta previa diantaranya Lira PJ (1995), Abu-Heija AT (1999), Eniola AO( 2002). Namun penelitian yang lain didapatkan bahwa ternyata efek dari paritas kurang mempengaruhi terjadinya plasenta previa dibandingkan faktor risiko yang lain ( Clark SL, 1985). Bahkan penelitian oleh Parazzini F di Milan (1994) menemukan tidak ada korelasi antara kehamilan berulang dengan terjadinya plasenta previa. Sedangkan di Sumatera Utara menurut Depkes Medan, pada tahun 2008 prevalensi plasenta previa terjadi sekitar 8 dari 250 kelahiran setiap tahun, pada tahun 2009 prevalensi plasenta previa terjadi sekitar 2 dari 250 kelahiran setiap tahun. (Depkes Medan, 2009) Demikian pula halnya pengaruh jarak kehamilan dengan terjadinya plasenta previa masih menjadi kontroversi, seperti pada penelitian Wax Jr (2000) yang mendapatkan bahwa interval antara seksio sesarea dengan konsepsi berikutnya yang mempunyai korelasi dengan plasenta previa tapi bukan interval antara dua persalinan pervaginam.

Placenta praevia
From Wikipedia, the free encyclopedia

Placenta previa

Classification and external resources

Diagram showing a placenta praevia (Grade IV)

ICD-10

O44, P02.0

ICD-9

641.0, 641.1

MedlinePlus

000900

MeSH

D010923

Placenta praevia (placenta previa AE) is an obstetric complication in which theplacenta is inserted partially or wholly in lower uterine segment.[1] It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum haemorrhage (vaginal bleeding). It affects approximately 0.4-0.5% of all labours.[2] In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a normal pregnancy the placenta does not overlie. If the placenta does overlie the lower segment, as is the case with placenta praevia, it may shear off and a small section may bleed.
Contents
[hide]

1 Etiopathogenesis

o o

1.1 Grades 1.2 Risk factors

2 Clinical features 3 Diagnosis

o o

3.1 Clinical 3.2 Confirmatory

4 Management

4.1 Mode of delivery

5 Complications

o o

5.1 Maternal 5.2 Fetal

6 Epidemiology 7 History 8 References

[edit]Etiopathogenesis
Exact etiology of placenta praevia is unknown. It is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection. These factors may reduce differential growth of lower segement, resulting in less upward shift in placental position as preganacy advances.[3]

[edit]Grades
Traditionally, four grades of placenta praevia are defined:[1]

Grade

Description

Placenta is in lower segment, but the lower edge does not reach internal os

II

Lower edge of placenta reaches internal os, but does not cover it

III

Placenta covers internal os partially

IV

Placenta covers internal os completely

[edit]Risk

factors

The following have been identified as risk factors for placenta praevia:

Risk factors with their odds ratio Risk factor Maternal age 40 (vs. < 20) Illicit drugs 1 previous Cesarean section

[4]

Odds ratio 9.1 2.8 2.7 2.3 1.9 1.9 1.6 1.7 1.1

Previous placenta previa (recurrence rate 48%) , caesarean delivery, ,myomectomy or endometrium damage caused by D&C.[5]
[5] [6] [7]

Alcohol use during pregnancy.[8] Women who have had previous pregnancies, especially a

large number of closely spaced pregnancies, are at higher Parity 5 (vs. para 0) risk due to uterine damage.
[7]

Smoking during pregnancy[1]; cocaine use during pregnancy[9] [10]

Parity 24 (vs. para 0) Prior abortion Smoking Congenital anomalies Male fetus (vs. female)

Women who are younger than 20 are at higher risk and women older than 35 are at increasing risk as they get older.

Women with a large placentae from twins or erythroblastosis are at higher risk.

Race is a controversial risk factor, with some studies finding that people from Asia and Africa are at higher risk and others finding no difference.

Pregnancy-induced hypertension 0.4

Placental pathology (Vellamentous insertion, succinturiate lobes, bipartite i.e. bilobed placenta etc.)[5]

Placenta previa is itself a risk factor of placenta accreta.

[edit]Clinical

features

Women with placenta previa often present with painless, bright red vaginal bleeding. This commonly occurs around 32 weeks ofgestation, but can be as early as late mid-trimester.[11] This bleeding often starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation. Women may also present as a case of failure of engagement of fetal head.[7]

[edit]Diagnosis [edit]Clinical
History may reveal antepartum hemorrage. Abdominal examination and usually finds the uterus non-tender, soft and relaxed. Leopold's Maneuvers may find the fetus in an oblique or breech position or lying transverse

as a result of the abnormal position of the placenta. Malpresentation is found in about 35% cases. [12] Vaginal examinaton is avoided in known cases of placenta praevia.[1]

[edit]Confirmatory
Praevia can be confirmed with an ultrasound.[13] Transvaginal ultrasound has superior accuracy as compared to transabdominal one, thus allowing measurement of distance between placenta and cervical os. This has rendered traditional classification of placenta praevia obsolete.[14] [15] [16] [17] False positives may be due to following reasons:[18]

Overfilled bladder compressing lower uterine segment Myometrial contraction simulating placental tissue in abnormally low location Early pregnancy low position, which in third trimester may be entirely normal due to differential growth of the uterus.

In such cases, repeat scanning is done after an interval of 15-30 minutes. In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with an examination in the surgical theatre. The proper timing of an examination in theatre is important. If the woman is not bleeding severely she can be managed non-operatively until the 36th week. By this time the baby's chance of survival is as good as at full term.

[edit]Management
An initial assessment to determine the status of the mother and fetus is required. Although mothers used to be treated in the hospital from the first bleeding episode until birth, it is now considered safe to treat placenta praevia on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the fetus are in distress. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary.

[edit]Mode

of delivery

There is debate as to whether vaginal delivery or delivery by caesarean section is the safest method. The mode of delivery is determined by clinical state of the mother, fetus and ultrasound findings. In minor degrees (traditional grade I and II), vaginal delivery is possible. RCOG recommends that placenta should be at least 2 cm away from internal os for an attempted vaginal delivery.[19] When a vaginal delivery is attempted, consultant obstetrician and anesthetists are present in delivery suite. In cases of fetal distress and major degrees (traditional grade III and IV) a caesarean section is indicated. Caesarian section is contraindicated in cases of disseminated intravascular coagulation. Obstetrician may need to divide the anterior lying placenta. In

such cases, blood loss is expected to be high and thus blood and blood products are always kept ready. In rare cases, hysterectomy may be required.[20]

[edit]Complications [edit]Maternal
Antepartum hemorrhage Malpresentation Abnormal placentation Postpartum hemorrhage Placenta praevia increases the risk of puerperal sepsis and postpartum haemorrhage because the lower segment to which the placenta was attached contracts less well post-delivery.

[edit]Fetal
IUGR (15% incidence)[5] Premature delivery Death

[edit]Epidemiology
Placenta previa occurs approximately one of every 250 births. One third of all antepartum hemorrhage occurs due to placenta previa.[citation needed] It has been suggested that incidence of placenta praevia is increasing due to increased rate of Caesarian section.[21] Perinatal mortality rate of placenta praevia is 3-4 times higher than normal pregnancies.[22]

[edit]History
In places where a Caesarean section could not be performed due to the lack of a surgeon or equipment, infant could be delivered vaginally. There were two ways of doing this with a placenta praevia:

The baby's head can be brought down to the placental site (if necessary with Willet's forceps or a vulsellum) and a weight attached to his scalp

A leg can be brought down and the baby's buttocks used to compress the placental site

The goal of this type of delivery is to save the mother, and both methods will often kill the baby. These methods were used for many years before Caesarean section and saved the lives of both mothers and babies with this condition.