1. PLACENTA PREVIA

2. 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

4. 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

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

6. 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

7. 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

8. 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

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

13. 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

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

15. 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

16. 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

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

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

19. 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

20. 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

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

22. 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

23. 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

24. 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

25. 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