Placenta previa

The placenta provides the fetus with oxygen and nutrients and
takes away waste such as carbon dioxide via the umbilical cord.
Definition   
• Placenta previa is a condition that may occur during
pregnancy when the placenta attached wholly or partly to the
lower segment of the uterus and obstructs the cervical
opening to the vagina (birth canal).
• Placenta praevia occurs in 0.5% of all pregnancies and
accounts for 20% of all cases of antepartum haemorrage.
• First episode of bleeding occurs after 36th gestational week in
60% of cases,between 32nd and 36th week in 30% and before
32nd week in 10%.
 Incidence
• The incidence of placenta previa is
approximately 1 out of 200 births.
• increases with each pregnancy, and it is
estimated that the incidence in women
who have had 6 or more previous
deliveries may be as high as 1 in 20 births.
• doubled in multiple pregnancy (such as
twins and triplets).
 Etiology
• Endometrium factors:
– a scarred endometrium (lining of the uterus)
from previous trauma, surgery, or infection.
– Curretage for several times
– an abnormal uterus
• Placental factors
– Large
– abnormal formation of the placenta.
• Development retardation of fertilized egg
 Risk factors
• multiparity (previous deliveries).
• multiple pregnancy.
• previous myomectomy (removal of uterine
fibroids through an incision in the uterus)
• previous C-section (if the scar is low and
close to the vaginal cervix region).
• smoking
• Abortion.
 classification
• Complete placenta previa
• Partial placenta previa
• Marginal placenta previa
• Low lying placenta
• Complete (total) placenta previa: entire cervical os is
covered by placenta.
• Partial placenta previa:the margin of the placenta
extends across but not all of the internal os.
• Marginal:edge of the placenta lies adjacent to the
internal os
• Low lying placenta:placenta is located near but not
directly adjacent to the internal os.
 Clinical findings
• Symptoms   
– Spotting during the first and second trimesters
– Sudden, painless, and profuse
vaginal bleeding in pregnancy during the third
trimester (usually after 28 weeks)
--Bleeding may not occur until after labor starts
in some cases
--Anemia,shock
• Signs
– The uterus is usually soft and relaxed.
– There is no tenderness and fetal heart sounds
present.
– The fetal position is oblique ( // ) or transverse
( == ) in about 15% of cases.Because placenta
occupies the lower segment and prevent the
head entering pelvis.
– Fetal distress is not usually present unless
vaginal blood loss has been heavy enough to
induce maternal shock, placenta abruptio, or a
cord accident occurs.
– No digital examination
 Caution
Double setup vaginal examination
• No digital vaginal or rectal examination
is performed in case of placenta previa .
Only as a final and definitive event and
only under conditions of double set up.
• This procedure involves careful evaluation
of the cervix in the operation room with
full preparations for rapid cesarean
section.
 Diagnosis
• History
• Symptom
• Vaginal examination
• Ultrasonography
• Placenta and membrane examination after
delivery
Painless vaginal bleed:
• First bleeding episode is 29~30 weeks
• Bleeding is caused by separation of part of the
placenta from the lower uterine segment and
cervix,possibly in response to mild uterine
contractions.
 Accessory examinations
• Ultrasonography:
– Accuracy 95%
– 34th week
– If the placenta lies in the posterior portion of the lower uterine
segment,its exact relation with the internal os may be more
difficult to ascertain. In these instances,transvaginal
ultrasonography is useful adjunct to the transabdominal
approach.

• Postpartum examination of placenta and

membrane
– 7cm
Differential diagnosis
• Placental abruption
• Vessel(vasa) Previa
• Cervical polypus
• Cervical erosion
• Cervical carcinoma
 Complications   
• Maternal complications
– major hemorrhage, shock, and death.
– Implanted placenta
– Anemia and infection
• Fetal complications
– Prematurity (infant is less than 36 weeks gestation) is
responsible for about 60% of infant deaths secondary
to placenta previa.
– Fetal blood loss or hemorrhage may occur because of
the placenta tearing away from the uterine wall during
labor. It may also occur with entry into the uterus
during a C-section delivery.
 Treatment
The course of treatment depends on
• the amount of abnormal uterine bleeding
• whether the fetus is developed enough to
survive outside the uterus
• the amount of placenta over the cervix
• the position of the fetus
• the parity (number of previous births) for the
mother
• the presence or absence of labor.
• Before 37 weeks of gestation any patient with antepartum haemorrage
secondary to placenta preavia should be managed conservatively,provided
the bleeding is not profuse or prolonged.
• After admission,she should be kept nil orally and rested in bed.
• If patient bleeds more than 6 pads within 24hrs or develops uterine
contraction,c-section should be done.
• If bleeding subsides,she should be kept in hospital and managed
conservatively.
• She should be given Iron and folic Acid supplements and Hb conc should be
done weekly to ensure she does not develop anaemia.
• Ultrasound should be done fortnightly to check growth of fetus and placental
migration.
• An elective c-section is done at 38 to 39 weeks of gestation if patient does
not bleed further .
• If antepartum haemorrage occurs any time after 37weeks of gestation,an
emergency C-section should be done.
Early in pregnancy,
– transfusions may be given to replace
maternal blood loss.
– Medications may be given to prevent
premature labor, prolonging pregnancy to at
least 36 weeks.
• Cesarean section is the method for delivery. It has
proven to be the most important factor in reducing
maternal and infant death rates.
• The main risk with a vaginal delivery with a praevia is
that as you are trying to bring down the head or a leg,
you might separate more of the placenta and increase
the bleeding.
Immediate delivery

• Indications:

 When the bleeding is profuse and life is threatening , no

matter the fetus is mature or unmature ,alive or dead.

If bleeding continues but is neither profuse nor

life threatening and the gestation is more than
34 weeks.
 Expectations (prognosis)
• The maternal prognosis (probable
outcome) is excellent when managed
appropriately. This is done by hospitalizing
those at risk who are exhibiting signs and
symptoms, and by performing C-section
delivery.
Thank You