Placenta Previa

General Data R.L. 33 y/o G4P3 (3002), PU 37 3/7 weeks AOG Married Filipino Roman Catholic General Data

scheduled Cesarean section Reason for consult

Past Medical History (-) hypertension (-) diabetes mellitus (-) bronchial asthma (-) thyroid disease No known allergies s/p LTCS IIIx (Ix for CPD) Past Medical History

Personal and Social History nonsmoker and alcoholic beverage non- drinker Personal and Social History

Family History (+) hypertension – father (+) bronchial asthma – mother (-) diabetes mellitus (-) cancer Family History

Gynecologic History Menstrual History Menarche – 11 y/o Interval – regular, 28 days LMP: October 25, 2009 Duration – 2-3 days PMP: Sptember 2009 Amount – 3-4 ppd, fully-soaked Symptoms – (+) dysmenorrhea, day 1 Sexual History Coitarche – 21 y/o; single sexual partner; (-) dyspareunia, postcoital bleeding; (-) history of STI Contraception Use: (+) use of OCPs x 2 months (2006); no IUDs Latest PAP smear was in June 2010: Normal results Gynecologic History

Obstetric History G4P3 (3002) G1 (2000) – delivered to a live full term baby boy via primary LTCS for cephalopelvic disproportion attended by doctor – Fabella Hospital, BW 2kg, neonatal death x 10 days, neonatal sepsis secondary to meconium aspiration G2 (2001) – delivered to a live full term baby girl via repeat LTCS attended by doctor – SLMC G3 (2005) – delivered to a live full term baby boy via repeat LTCS attended by doctor – SLMC G4 – present pregnancy Obstetric History

Prenatal History First Trimester SecondTrimester ThirdTrimester FPNCU (4 mos AOG) (+) multivitamins, ferrous sulfate, folic acid No maternal illness Antenatal tests HbsAg nonreactive Blood type O+ RPNCU OGCT N (+) multivitamins, ferrous sulfate 2 bleeding episodes (see HPI) Prenatal History

History of Present Illness 4 months AOG  FPNCU 5 months AOG  (+) vaginal bleeding, ~10 ppd fully soaked No hypogastric abdominal pain, no uterine contractions, no foul smelling vaginal discharge, no passage of meaty tissue, no fever Sought consult TVS: placenta previa totalis Prescribed Isoxilan tablet (Duvadilan) TID x 7 days History of Present Illness

6 months  (+) vaginal bleeding, 5 ppd/fully soaked Same associated signs and symptoms took Isoxilan tablet TID x 3 days (self- medicated) did not seek consult Few hours prior to admission  repeat TVS placenta previa totalis to consider placenta accreta scheduled Cesarean section

Review of Systems General HEENT Pulmonary Cardiovascular Denies fever or malaise HEENT Denies headache, blurring of vision, hearing problems, epistaxis, tooth or throat pain Pulmonary Denies cough or dyspnea Cardiovascular Denies palpitations or chest pain Gastrointestinal Denies diarrhea and constipation No nausea and vomiting, anorexia Review of Systems

Neurologic/Psychiatric Urinary Denies dysuria, frequency, nocturia Endocrine Denies polyuria, polydipsia, tremors Hematopoietic Denies easy bruisability Musculoskeletal Denies myalgia or arhtralgia Neurologic/Psychiatric Denies change in sensorium or behavior

Conscious, coherent, not in cardio- respiratory distress, intermittently in pain BP: 110/70mmHg CR: 80/min, regular RR: 20/min, regular T: 36.8oC Skin: no suspicious lesions Head: skull normocephalic, atraumatic Eyes: pink palpebral conjunctivae, anicteric sclerae Neck: supple neck, with no palpable neck mass, no neck vein engorgement Physical Examination

Lungs: symmetrical chest expansion, no rib retractions, clear and equal breath sounds Heart: adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: globular abdomen, (+) midline scar; FH 33cm, EFW 3255g, FHT 140bpm; LM 1: breech LM 2: fetal back on maternal left LM 3: unengaged Non tender abdomen, no rigidity Full and equal pulses, no cyanosis Physical Examination

External pelvic examination: no lesions, redness, excoriations, hyper/hypopigmentations IE deferred Pelvic Examination

Salient Features Subjective ~5 mos (+) vaginal bleeding, ~300 mL 33 yoG4P3 (3002), PU 37 3/7 weeks AOG (-) HPN, s/p LTCS IIIx (Ix for CPD) Non smoker RPNCU since ~4mos AOG, no maternal illnesses, with 2 episodes of vaginal bleeding in the 2nd trimester. ~5 mos (+) vaginal bleeding, ~300 mL No hypogastric abdominal pain, no uterine contractions, no foul smelling vaginal discharge, no passage of meaty tissue, no fever TVS: placenta previa Isoxilan tablet (Duvadilan) TID x 7 days (+) vaginal bleed ~150ml @ 6 mos AOG Few hours PTA, TVS was done which showed: Placenta previa totalis t/c placenta accreta  scheduled CS Salient Features

Salient Features Objective Conscious, coherent, not in cardio- respiratory distress, intermittently in pain BP: 110/70mmHg CR: 80/min, regular RR: 20/min, regular T: 36.8oC Abdomen: globular abdomen, (+) midline scar; FH 33cm, EFW 3255g, FHT 140bpm; LM 1: breech LM 2: fetal back on maternal left LM 3: unengaged No abdominal tenderness, no rigidity Salient Features

G4P3(3002) PU 37 3/7 weeks AOG, cephalic, not in labor, placenta previa totalis, t/c placenta accreta previous LTCS IIIx (Ix for cephalopelvic disproportion) Clinical Impression

Differential Diagnosis Placenta Previa Abruptio Placenta Spontaneous Abortion Cervicitis Differential Diagnosis

Placenta Previa

Placenta Previa is a condition where the placenta lies low in the uterus and partially or completely covers the cervix. used to describe a placenta that is implanted over or very near the internal cervical os DEFINITION

Four degrees of abnormalities Total placenta previa the internal os is covered completely by placenta Partial placenta previa the internal os is partially covered by placenta Marginal placenta previa the edge of the placenta is at the margin of the internal os Low-lying placenta the placenta is implanted in the lower uterine segment such that the placental edge does not reach the internal os, but is in close proximity to it Vasa previa the fetal vessels course through membranes and present at the cervical os (uncommon, associated with higher rate of fetal death Four degrees of abnormalities

Placenta previa affects about 1 in 200 pregnant women (Iyasu et al Incidence

Placenta previa is more common in women who have had one or more of the following: Increasing maternal age Multiparity Prior cesarean delivery Surgery on the uterus Smoking Multiple gestation (larger surface area of the placenta) Risk Factors

Placenta Previa is associated with: Placenta accreta, placenta increta or placenta percreta Secondary to the poorly developed decidua on the lower uterine segment. Placenta Previa is associated with:

Placenta accreta -- Abnormal adherence of the placenta to the myometrial wall, with absence of decidua basalis.

Placenta increta-- placenta attaches deep into the uterine wall and penetrates into the uterine muscle, but does not penetrate the uterine serosa

Placenta percreta-- Placental villi penetrate myometrium and through to uterine serosa.

Clinical Findings: Painless hemorrhage (most characteristic) Due to tearing of placental attachments during the formation of the LUS or during cervical dilatation Bleeding occurs at the implantation site as the uterus is unable to contract adequately and stop the flow of blood from the open vessels. Hemorrhage persists after delivery because of the LUS contracts poorly so it cannot constrict the torn vessels. May also be due to lacerations in the cervix and LUS following manual removal of adherent placenta Usually does not appear until the end of the second trimester Usually ceases spontaneously only to recur Clinical Findings:

Pathophysiology Placental implantation is initiated by the embryo adhering in the lower 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.

Diagnosis can seldom be established by clinical examination unless a finger is passed thru the cervix the placenta is palpated. Such examination is never permissible because even the gentlest examination may cause torrential hemorrhage. Such examination is rarely necessary since placental location can be obtained by sonography. Diagnosis

The most useful and inexpensive study is transvaginal ultrasonography that provides >95% accuracy in identifying a placenta previa An alternative would be transabdominal ultrasonography that can be 95% accurate; however, the false-positive and false- negative rates can range from 2-25%. Imaging Studies

MRI may be used for planning the delivery in that it may help identify placenta accreta, placenta increta, or placenta percreta. These invasive placental abnormalities are more common (eg, placenta accrete occurs in up to 0.2% of pregnancies) due to the increase in cesarean deliveries, advancing maternal age, hypertensive disease, smoking, and placenta previa cases. Imaging Studies

MRI is no more sensitive in diagnosing placenta accreta that ultrasonography, but it may be superior for the posterior placenta accreta or the more invasive increta and percreta. Imaging Studies

Management Preterm fetus but with no active bleeding: Close observation In some cases, prolonged hospitalization is ideal but the patient is discharged after bleeding has stopped and fetus is assessed to be healthy. If bleeding persists, preparation for immediate surgery is indicated. Management

Additionally, tocolytics may also be considered in cases of minimal bleeding and extreme prematurity to administer antenatal corticosteroids. If more than one episode of bleeding occurs during gestation (at viability or >24 wk), the clinician should consider hospitalization until delivery given the increased potential for placental abruption and fetal demise. Management

Cesarean delivery is necessary in practically all cases of placenta previa. Poorly contractile nature of the LUS there may be uncontrollable hemorrhage following placental removal. Oversew the implantation site with 0-chromic sutures Bilateral uterine artery ligation or internal iliac artery ligation Tightly packing the LUS with gauze If bleeding persists  hysterectomy Management

Thank You

Surgical Care The distance between the placental edge and internal cervical os on transvaginal ultrasonography after 35 weeks’ gestation is valuable in planning route of delivery. When the placental edge is greater than 2 cm from the internal cervical os, women can be offered a trial of labour with a high expectation of success. However, a distance of less than 2 cm from the os is associated with a higher cesarean rate, although vaginal delivery is still possible depending on the clinical circumstances. Delivery

The timing of delivery is often driven by the patients history and an increased risk for bleeding with advancing gestation. Most authorities recommend delivery at 36- 37 weeks' gestation after confirming fetal lung maturity via amniocentesis. However, if the fetal lung maturity testing is immature or is not available, then delivery is often scheduled for 38 weeks' gestation.

Most often a low transverse uterine incision is used; however, a vertical uterine incision may be considered secondary to an anterior placenta and risk of fetal bleeding. If the patient is at increased risk for invasive placentation (accreta, increta, or percreta), then the patient and surgical team must be prepared prior to delivery. These invasive placentations carry a high mortality rate (7% with placenta accreta) as well as a high morbidity rate (blood transfusion, infection, adjacent organ damage).