1. Placenta Previa

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

3. scheduled Cesarean section
Reason for consult

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

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

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

7. Gynecologic History Menstrual History Menarche – 11 y/o
Interval – regular, 28 days LMP: October 25, 2009
Duration – 2-3 days PMP: Sptember 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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 6 mos AOG
Few hours PTA, TVS was done which showed:
Placenta previa totalis t/c placenta accreta  scheduled CS
Salient Features

18. 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

19. 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

20. Differential Diagnosis
Placenta Previa
Abruptio Placenta
Spontaneous Abortion
Cervicitis
Differential Diagnosis

21. Placenta Previa

22. 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

23. 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

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

26. 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

27. 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:

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

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

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

31. 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:

32. 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.

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Thank You

41. 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

42. 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 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.

43. 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).