PLACENTA PREVIA

DEFINITION When the placenta is implanted partially or completely over the lower uterine segment(over and adjacent to the internal os)it is called placenta previa

INCIDENCE O.5 – 1% among hospital deliveries 80% cases found in multiparous women Increase incidence beyond 35yrs Increase incidence with high birth order and multiple pregnancy

ETIOLOGY Persistence of chorionic activity Defective decidua THEORIES POSTULATED Dropping down theory Persistence of chorionic activity Defective decidua Big surface area of the placenta

ETIOLOGY…..Contd Increased maternal age HIGH RISK FACTORS Multiparity Increased maternal age Previous cesarean section or any other scar in the uterus Placental size and abnormality Smoking Prior curettage

PATHOLOGICAL ANATOMY PLACENTA Large and thin Tongue shaped extension from the main placental mass Extensive area of degeneration and calcification Placenta may be morbidly adherent UMBILICAL CORD Attached to the margin or into the membrane Insertion of the cord may be close to the internal os Fetal vessels may run across the internal os LOWER UTERINE SEGMENT Increased vascularity The lower uterine segment and the cervix becomes soft and more friable

TYPES OR DEGREE TYPE I – Low – lying Major part of the placenta is attached to the upper segment Only the lower margin encroaches to the lower segment But not up to the os TYPE II – Marginal Placenta reaches the margin of the internal os But does not cover it TYPE III – Incomplete or partial central Placenta covers the internal os partially TYPE IV – Central or total Placenta covers the internal os even after it is fully dilated

CLINICAL FEATURES SYMPTOMS VAGINAL BLEEDING Sudden onset Painless Causeless Recurrent SIGNS General condition and anemia are proportionate to the visible blood loss

CLINICAL FEATURES……Contd ABDOMINAL EXAMINATION The size of the uterus proportionate to the period of gestation The uterus feels relaxed, soft and elastic without any localised area of tenderness Persistence of malpresentation Head is floating Fetal heart sound Stallworthy’s sign

CLINICAL FEATURES……Contd VULVAL INSPECTION Bright red or dark coloured Amount of blood loss VAGINAL EXAMINATION MUST NOT BE DONE OUTSIDE THE OT

CONFIRMATION OF DIAGNOSIS LOCALISATION OF PLACENTA SONOGRAPHY TAS TVS Transperineal ultrasound Color Doppler flow study MAGNETIC RESONANCE IMAGING CLINICAL By internal examination(double set up examination) Direct visualization during cesarean section Examination of the placenta following vaginal delivery

COMPLICATION MATERNAL DURING PREGNANCY APH Malpresentation Premature labor DURING LABOUR Early rupture of the membrane Cord prolapse Slow dilation Intrapartum haemorrhage Increased incidence of operative interference PPH PUERPERINM Sepsis Subinvolution Embolism

COMPLICATION FETAL Low birth weight Asphyxia Intrauterine death Birth injuries Congenital malformation

MANAGEMENT PREVENTION Adequate antenatal care Antenatal diagnosis Warning haemorrhage should not be ignored Colour doppler USG

MANAGEMENT…..Contd AT HOME Put to bed To assess the blood loss Quick but gentle abdominal examination Vaginal examination must not be done TRANSFER TO HOSPITAL Emergency Dextrose saline drip Accompanied by persons for donation ADMISSION TO HOSPITAL Considered as APH

MANAGEMENT…..Contd IMMEDIATE ATTENSION Amount of the blood loss Blood samples are taken A large bore IV cannula is sited Infusion of NS Gentle abdominal palpation Inspection of vulva

MANAGEMENT…..Contd Active management FORMULATION OF LINE OF TREATMENT Expectant management Active management

EXPECTANT MANAGEMENT VITAL PREREQUISITES Availability of blood transfusion Facilities for cesarean section throughout 24hrs SELECTION OF CASES Mother is in good health status Duration of pregnancy less than 37 weeks Active vaginal bleeding is absent Fetal well being is assured

EXPECTANT MANAGEMENT…..Contd CONDUCT OF EXPECTANT TREATMENT Bed rest with bathroom privileges Investigations Periodic inspection Supplementary hematinics A gentle speculum examination Use of tocolysis Rh immunoglobulin Termination done at 37 weeks Steroid therapy

ACTIVE MANAGEMENT INDICATIONS Bleeding occurs at or after 37 weeks of pregnancy Patient is in labour Patient is exsaguinated state on admission Bleeding is continuing and of moderate degree Baby is dead or known to be congenitally malformed

DEFINITIVE MANAGEMENT CESAREAN DELIVERY Placental edge is within 2cm from the internal os VAGINAL DELIVERY Placental edge is clearly 2-3cm away from the internal os