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Placenta Previa. Hai Ho, MD Department of Family Practice. What is placenta previa?. Implantation of placenta over cervical os. Types of placenta previa. Who are at risk for placenta previa?. Endometrial scarring of upper segment of uterus – implantation in lower uterine segment

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Placenta Previa

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Placenta previa
Placenta Previa

Hai Ho, MD

Department of Family Practice


What is placenta previa
What is placenta previa?

Implantation of placenta over cervical os



Who are at risk for placenta previa
Who are at risk for placenta previa?

  • Endometrial scarring of upper segment of uterus – implantation in lower uterine segment

    • Prior D&C or C-section

    • Multiparity

    • Advance age – independent risk factor vs. multiparity


Who are at risk for placenta previa1
Who are at risk for placenta previa?

  • Reduction in uteroplacental oxygen or nutrient delivery – compensation by increasing placental surface area

    • Male

    • High altitude

    • Maternal smoking


Factors that determine persistence of placenta previa
Factors that determine persistence of placenta previa?

  • Time of diagnosis or onset of symptoms

  • Location of placenta previa

Placental Migration

Repeat ultrasound at 24 – 28 weeks’ gestation


Clinical presentations
Clinical presentations?

  • Painless vaginal bleeding – 70-80%

    • 1/3 prior to 30 weeks

    • Mostly during third trimester – shearing force from lower uterine segment growth and cervical dilation

    • Sexual intercourse

  • Uterine contraction – 10-20%


Fetal complications
Fetal complications?

  • Malpresentation

  • Preterm premature rupture of membrane


Diagnostic test
Diagnostic test?

Ultrasound


Placenta previa ultrasound
Placenta Previa: ultrasound

Placenta

Bladder

Cervix



Placenta accreta
Placenta accreta?

  • Abnormal attachment of the placenta to the uterine wall (decidua) such that the chorionic villi invade abnormally into the myometrium

  • Primary deficiency of or secondary loss of decidual elements (decidua basalis)

  • Associated with placenta previa in 5-10% of the case

  • Proportional to the number of prior Cesarean sections





Vasa previa1
Vasa Previa

Velamentous insertion


Vasa previa2
Vasa Previa

Velamentous insertion


Vasa previa3
Vasa Previa

Velamentous insertion


Vasa previa4
Vasa Previa

  • Rupture

  • Compression of vessels

  • Perinatal mortality rate – 50 – 75%


Management of placenta previa
Management of placenta previa?

Individualized based on (not much evidence):

  • Gestational age

  • Amount of bleeding

  • Fetal condition and presentation


Preterm with minimal or resolved bleeding
Preterm with minimal or resolved bleeding

  • Expectant management – bed rest with bathroom privilege

  • Periodic maternal hematocrit

  • Prophylactic transfusion to maintain hematocrit > 30% only with continuous low-grade bleeding with falling hematocrit unresponsive to iron therapy


Preterm with minimal or resolved bleeding1
Preterm with minimal or resolved bleeding

  • Fetal heart rate monitoring only with active bleeding

  • Ultrasound every 3 weeks – fetal growth, AFI, placenta location

  • Rhogam for RhD-negative mother


Preterm with minimal or resolved bleeding2
Preterm with minimal or resolved bleeding

  • Amniocentesis weekly starting at 36 weeks to assess lung maturity – delivered when lungs reach maturity

  • Betamethasone or dexamethasone between 24 – 34 weeks’ gestation to enhance lung maturity

  • Tocolysis – magnesium sulfate


Active bleeding
Active bleeding

  • Stabilize mother hemodynamically

  • Deliver by Cesarean section

  • Rhogam in Rh-negative mother

  • Betamethasone or dexamethasone between 24 – 34 weeks’ gestation to enhance lung maturity


Management of placenta previa1
Management of placenta previa

  • No large clinical trials for the recommendations

  • Consider hospitalization in third-trimester

  • Antepartum fetal surveillance

  • Corticosteroid for lung maturity

  • Delivery at 36-37 weeks’ gestation


Management of placenta accreta
Management of placenta accreta

  • Cesarean hysterectomy

  • Uterine conservation

    • Placental removal and oversewing uterine defect

    • Localized resection and uterine repair

    • Leaving the placenta in situ and treat with antibiotics and removing it later



What is placental abruption
What is placental abruption?

Premature separation of placenta from the uterus


Epidemiology
Epidemiology

  • Incident 1 in 86 to 1 in 206 births

  • One-third of all antepartum bleeding


Pathogenesis
Pathogenesis

  • Maternal vascular disruption in decidua basalis

  • Acute versus chronic




Risk factors for placental abruption
Risk factors for placental abruption?

  • Maternal hypertension

  • Maternal age and parity – conflicting data

  • Blunt trauma – motor vehicle accident and maternal battering

  • Tobacco smoking and cocaine


Risk factors for placental abruption1
Risk factors for placental abruption

  • Prior history of placental abruption

    • 5-15% recurrence

    • After 2 consecutive abruptions, 25% recurrence

  • Sudden decompression of uterus in polyhydramnios or multiple gestation (after first twin delivery) – rare

  • Thrombophilia such as factor V Leiden mutation


Clinical presentations1
Clinical presentations?

  • ± Vaginal bleeding

  • Uterine contraction or tetany and pain

  • Abdominal pain

  • DIC

    • 10-20% of placental abruption

    • Associated with fetal demise

  • Fetal compromise


Diagnostic test1
Diagnostic test?

  • Ultrasound

    • Sensitivity ~ 50%

    • Miss in acute phase because blood could be isoechoic compared to placenta

    • Hematoma resolution – hypoechoic in 1 week and sonolucent in 2 weeks

  • Blood tests





Blood tests
Blood tests?

  • CBC – hemoglobin and platelets

  • Fibrinogen

    • Normal 450 mg/dL

    • <150 mg/dL – severe DIC

  • Fibrin degradation products

  • PT and PTT


Management
Management?

  • Hemodynamic monitoring

    • Urine output with Foley

    • BP drop – late stage, 2-3 liter of blood loss

  • Fetal monitoring


Management delivery
Management: delivery

  • Timing

    • Severity of placental abruption

    • Fetal maturity - consider tocolysis with MgSO4 and corticosteroid (24-34 weeks)

    • Correction of DIC with transfusion of PRBC, FFP, platelets to maintain hematocrit > 25%, fibrinogen >150-200 mg/dL, and platelets > 60,000/m3

  • Mode: vaginal vs. Cesarean-section


Couvelaire uterus
Couvelaire uterus?

  • Bleeding into myometrium leading to uterine atony and hemorrhage

  • Treatment

    • Most respond to oxytocin and methergine

    • Hysterectomy for uncontrolled bleeding



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