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Placenta Previa

Placenta Previa

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Published by acchan06
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Published by: acchan06 on Feb 16, 2014
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02/16/2014

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Introduction:
 The placenta is implanted in the lower uterine segment near or over the internal cervical os. The degree to which the internal cervical os is covered by the placenta has been used to classify four types of  placenta previa; total, partial, marginal and low
 –
lying. In total previa the internal os is entirely covered by the placenta. Partial placenta previa implies incomplete coverage of the internal os. Marginal placenta previa indicates that only an edge of the placenta extends to the margin of the internal os. And the last is the low
 –
 lying placenta has been used when the placenta is implanted in the lower uterine segment but not reach the os. The more descriptive classification that includes placenta previa is in the third trimester. The incidence of  placenta previa is approximately 0.5% of births. The most important risk factors are previous placenta previa, previous cesarean birth, and suction curettage for miscarriage or induced abortion, possible related to endometrial scarring. The risk also increases with multiple gestations because of the larger placental area, closely spaced pregnancies, advanced maternal age older than 34 years, African or Asian ethnicity, male fetal sex, smoking, cocaine use, multiparity, and tobacco use.
Classification of Placenta Previa:
 1. Total Previa- the placenta completely covers the internal cervical os. 2. Partial Previa- the placenta covers a part of the internal cervical os. 3. Marginal Previa- the edge of the placenta lies at the margin of the internal cervical os and may be exposed during dilatation. 4. Low-lying placenta- the placenta is implanted in the lower uterine segment but does not reach to the internal os of the cervix.
Predisposing Factors:
 1. Multiparity (80% of affected clients are multiparous) 2. Advanced maternal age (older than 35 years old in 33% of cases 3. Multiple gestation 4. Previous Cesarean birth 5. Uterine Incisions 6. Prior placenta previa ( incidence is 12 times greater in women with previous placenta previa)
Complications for the baby include:
 
 
 
Problems for the baby, secondary to acute blood loss
 
Intrauterine growth retardation due to poor placental perfusion
 
Increased incidence of congenital anomalies
Clinical Manifestations:
 
 
Painless vaginal bleeding > occurs after 20 weeks of gestation, bright red in color associated with the stretching and thinning of the lower uterine segment that occurs in third trimester.
 
 Adequately contract and stop blood flow from open vessels.
 
Stop blood flow from open vessels
 
Decreasing urinary output
Normal Placenta During Childbirth
 
Process of placental growth and uterine wall changes during pregnancy
 1. The placenta grows with the placental site during pregnancy. 2. During pregnancy and early labor the area of the placental site probably changes little, even during uterine contractions. 3. The semirigid, noncontractile placenta cannot alter its surface area.
Anatomy of the uterine/placental compartment at the time of birth
 1. The cotyledons of the maternal surface of the placenta extend into the decidua basalis, which forms a natural cleavage plane between the placenta and the uterine wall. 2. There are interlacing uterine muscle bundles, consisting of tiny myofibrils, around the branches of the uterine arteries that run through the wall of the uterus to the placental area. 3. The placental site is usually located on either the anterior or the posterior uterine wall.
 
4. The amniotic membranes are adhered to the inner wall of the uterus except where the placenta is located  Anatomy of Female Reproductive System Physiology of Female Reproductive System  Anatomy and Physiology of Male Reproductive System 
Pathophysiology
 No specific cause of  placenta previa has yet been found but it is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection. In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a normal pregnancy the placenta does not overlie it, so there is no bleeding. If the placenta does overlie the lower segment, it may shear off and a small section may bleed. Women with placenta previa often present with painless, bright red vaginal bleeding. This bleeding often starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation. Abdominal examination usually finds the uterus non-tender and
relaxed. Leopold’s Maneuvers may find the fetus in an oblique or breech position or
lying transverse as a result of the abnormal position of the placenta. Praevia can be confirmed with an ultrasound.[3] In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with an examination in the surgical theatre. The proper timing of an examination in theatre is important. If the woman is not bleeding severely she can be managed non-operatively until the 36th week. By this
time the baby’s chance of survival is as good as at full term.
 

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