Management of Type II Placenta Previa

Dr. Geetha Balsarkar, Associate Professor and Unit incharge, Nowrosjee Wadia Maternity Hospital, Seth G.S. Medical college, Parel , Mumbai Joint Asst. Secretary to the Editor, Journal of Obstetrics and Gynecology of India, Secretary, AMWI, Mumbai branch

Classification Type I or low lying: The placenta encroaches the lower segment of the uterus but does not infringe on the cervical os Type II or marginal: The placenta touches, but does not cover, the top of the cervix. Type III or partial: The placenta partially covers the top of the cervix Type IV or complete: The placenta completely covers the top of the cervix

Diagnosis DO NOT DIAGNOSE via vaginal exam! (Exception-”double setup”) Ultrasound is the easiest, most reliable way to diagnose (95-98+% accuracy) False positive- ultrasound with distended bladder Transvaginal or transperineal often superior to transabdominal methods

Migration Clinically important bleeding is not likely before 24-26 weeks gestation The clinically important diagnosis of placenta previa is therefore a late second or early third trimester diagnosis Migration is a misnomer- the placental attachment does not change, the relative growth of the lower segment does

Intervention 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. Bedrest probably indicated Antenatal testing probably indicated

McCafee regime of expectant management

Evaluation Evaluation for possibility of accreta needs to be considered Consideration for RHIG in rh negative patients with bleeding Episodic AFS testing with bleeding events Vigilance regarding fetal growth Follow up ultrasound if indicated

Associated conditions Abnormal presentation (placenta raises presenting part) Oblique lie Transverse lie Placental abruption Placenta accreta (especially if prior ceserean section) Postpartum hemorrhage

Think Accreta Previous cesarean scars Previous myomectomy scars Twins or multiple gestation Grand multipara

Counseling Risk of severe life-threatening hemorrhage Risk of fetal death Risk of maternal death Blood transfusion may be necessary Hysterectomy may be needed to control bleeding

Conservative measures If the bleeding is not life threatening or, if initially severe but begins to settle, then there is a place for conservative measures If the fetus is still preterm and the bleeding is under control, a policy of conservative management should be followed, at least until fetal maturity is achieved.

Management Protocol Late pregnancy bleeding Ceserean delivery indications 37 weeks or Unstable: Heavy bleed, hypotension, fetal distress

Delivery Delivery should depend upon type of previa – Complete previa = c/section – Low lying = (probable attempted vaginaldelivery – Marginal/partial = (it depends!) Consider “double setup” for uncertain cases

Delivery Immediate delivery of the fetus may be indicated if the fetus is mature 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 in a bleeding episode

Vaginal delivery Tertiary center Blood crossmatched and ready Fetal monitoring Gentle PV examination ???? To assess progess of labour Everything ready for LSCS

Thank you