Placenta Previa

Placenta previa is implantation of the placenta over or near the internal os of the cervix. Typically, bright red painless vaginal bleeding occurs during late pregnancy. Diagnosis is by transvaginal or abdominal ultrasonography. Treatment is bed rest for minor vaginal bleeding before 36 wk gestation or, after 36 wk or in refractory cases, immediate delivery, usually by cesarean section. Placenta previa may be total (covering the internal os completely), partial (covering part of the os), or marginal (at the edge of the os), or the placenta may be low-lying (near the os without reaching it). Incidence of placenta previa is 1/200 deliveries. Risk factors include multiparity, prior cesarean delivery, uterine abnormalities that inhibit normal implantation (eg, fibroids), smoking, and multifetal pregnancy. If placenta previa occurs during early pregnancy, it usually resolves by 20 wk as the uterus enlarges. Symptoms, Signs, and Diagnosis Symptoms usually first occur in late pregnancy. Then, sudden, painless vaginal bleeding often begins; the blood may be bright red, and bleeding may be heavy, sometimes resulting in hemorrhagic shock. If placenta previa is present, pelvic examination may increase bleeding, sometimes causing sudden, massive bleeding; thus, if vaginal bleeding occurs after 20 wk, pelvic examination is contraindicated unless placenta previa is first ruled out by ultrasonography. Placenta previa frequently cannot be distinguished from abruptio placentae except by ultrasonography. Transvaginal ultrasonography is an accurate, safe way to diagnose placenta previa. Treatment Treatment of minor vaginal bleeding before about 34 wk is hospitalization, bed rest, and avoidance of sexual intercourse, which can cause bleeding by initiating contractions or causing direct trauma. If bleeding stops, ambulation and usually hospital discharge are allowed. Delivery is indicated if bleeding is heavy, uncontrolled, or both or if fetal lungs are mature, usually at 36 wk. Delivery is almost always by cesarean section, but vaginal delivery may be possible for women with a low-lying placenta if the fetal head effectively compresses the placenta and labor is already advanced or if the pregnancy is < 23 wk and rapid delivery is expected. Hemorrhagic shock is treated (see Shock and Fluid Resuscitation: Prognosis and Treatment).

Preeclampsia and Eclampsia
Preeclampsia is pregnancy-induced hypertension plus proteinuria. Eclampsia is unexplained generalized seizures in patients with preeclampsia. Preeclampsia and eclampsia develop between 20 wk gestation and the end of the 1st wk postpartum. Diagnosis is clinical and by urine protein measurement. Treatment is with IV Mg sulfate and usually rapid delivery. Preeclampsia affects 3 to 7% of pregnant women, usually primigravidas and women with preexisting hypertension (see Pregnancy Complicated by Disease: Hypertension

confusion. eventually damaging multiple organs. Untreated preeclampsia usually smolders for a variable time. obesity. particularly the brain. Diffuse or multifocal vasospasm can result in ischemia. Petechiae may reflect a bleeding tendency. However. renal disorders. tests detect the HELLP syndrome (hemolysis. and 24-h urine protein. Nondependent edema such as facial or hand swelling (the patient's ring may no longer fit her finger) is more specific than dependent edema. increased endothelin (an endothelium-derived vasoconstrictor).in Pregnancy) or vascular disorders (eg. Etiology Cause and pathophysiology of preeclampsia and eclampsia are unknown. which can progress to seizures (eclampsia). manifestations may include headache. Lipid peroxidation of cell membranes induced by free radicals may contribute to preeclampsia. CBC. Severe preeclampsia may cause organ damage. and measurement of serum electrolytes. and oliguria (reflecting decreased plasma volume or ischemic acute tubular necrosis). and increased soluble Flt-1 (a circulating receptor for vascular endothelial growth factor). preeclampsia or poor outcome in previous pregnancies. urate. Contributors to vasospasm may include decreased prostacyclin (an endotheliumderived vasodilator). Tests include urinalysis. shortness of breath or dyspnea (reflecting pulmonary edema or acute respiratory distress syndrome [ARDS]). creatine clearance. liver function tests. BUN. diabetic vasculopathy). Diagnosis Diagnosis is suggested by symptoms or presence of hypertension. which occurs in 1/200 patients with preeclampsia. frank coagulopathy is rare unless abruptio placentae is also present. a family history of preeclampsia. leading to platelet activation. multifetal pregnancy. Other signs may include increased reflex reactivity. Untreated eclampsia is usually fatal. Factors may include poorly developed uterine placental spiral arterioles (which decrease uteroplacental blood flow in late pregnancy) and placental ischemia or infarction. antiphospholipid antibody syndrome—see Thrombotic Disorders: Antiphospholipid Antibody Syndrome). Occasionally. visual disturbances. epigastric or right upper quadrant abdominal pain (reflecting hepatic ischemia or capsular enlargement). elevated liver function tests. possibly secondary to endothelial cell dysfunction. Preeclampsia is diagnosed when pregnant women have new-onset hypertension (BP ≥ 140/90 mm Hg) plus unexplained proteinuria of ≥ 1+ on dipstick on 2 occasions at least 4 h apart after 20 wk. Symptoms and Signs Preeclampsia may be asymptomatic or may cause edema or excessive weight gain. nausea. indicating neuromuscular irritability. Other risk factors may include maternal age < 20. and thrombotic disorders (eg. and liver. then suddenly progresses to eclampsia. The coagulation system is activated. vomiting. most often in the 1st 4 days. platelet count. Fetal growth restriction may result. and low platelets). . Preeclampsia develops during pregnancy and eclampsia usually does. but 25% of eclampsia cases develop postpartum. kidneys. creatinine.

phenytoin Some Trade Names DILANTIN Click for Drug Monograph or valium can be given to stop seizures. Patients with excess Mg levels (eg. corticosteroids are given for 48 h. and IV hydralazine Some Trade Names APRESOLINE Click for Drug Monograph or labetalol Some Trade Names NORMODYNE TRANDATE . and fetal heart rate are monitored continuously or several times a day. a few hours of stabilizing medical treatment to lower BP to 140 to 155/90 to 105 mm Hg. Whether patients with mild preeclampsia always require Mg sulfate before delivery is controversial. these patients are given IV Ringer's lactate or 0. If preeclampsia is mild. risk of early delivery is balanced against severity of the preeclampsia and response to treatment.Preeclampsia is classified as severe based on symptoms. For term pregnancy. Mg sulfate 4 g IV over 20 min is followed by a constant IV infusion of about 1 to 3 g/h. outpatient treatment is possible. Patients with severe preeclampsia or with eclampsia are often admitted to the ICU. which usually optimizes fetal health. immediate delivery after maternal stabilization is safest. with supplemental doses as necessary. Patients with severe preeclampsia require Mg sulfate as soon as diagnosis is made. a normal salt intake. it includes strict bed rest. presence of fetal growth restriction. However. Treatment aims to optimize maternal health. including results that indicate HELLP syndrome. Exceptions include advanced prematurity when mild preeclampsia does not progress and severe preeclampsia that improves with hospitalization. increased fluid intake. Patients with mild eclampsia that does not immediately abate. All hospitalized patients are checked frequently for seizures. urine protein ≥ 5 g in a 24-h collection or ≥ 3+ in 2 samples obtained ≥ 4 h apart. BP ≥ 160/110 mm Hg on 2 occasions ≥ 6 h apart. and to resolve seizures and reduce reflex reactivity. severe preeclampsia. hypotonia. Treatment Definitive treatment is delivery. lying on the left side whenever possible. Continued management by the obstetrician is mandatory. and serum Mg levels (therapeutic range. BP. and laboratory tests. If Mg therapy is ineffective. IV Mg sulfate may cause lethargy. Delivery is mandated at 34 wk or when deterioration of maternal or fetal status or documentation of fetal lung maturity occurs. serious neonatal complications are uncommon. and evaluation every 2 or 3 days. 4 to 7 mEq/L). When delivery is delayed before about 32 to 34 wk in patients who are not clinically deteriorating. other evidence of organ damage. and vaginal bleeding. For pregnancies < 37 wk. reflexes. As part of stabilization. BP. and transient respiratory depression in neonates.9% normal saline solution at about 125 mL/h (to increase urine output) and IV Mg sulfate (to stop or prevent seizures and reduce reflex reactivity and BP). with Mg levels > 10 mEq/L or a sudden decrease in reflex reactivity) or hypoventilation are treated with Ca gluconate 1 g IV. or eclampsia require hospitalization. and then delivery. Eclampsia always requires delivery after seizures and severe hypertension have been controlled. and urine output < 500 mL in 24 h. symptoms of severe preeclampsia. Dose is adjusted based on the patient's reflexes.

it occurs in about 5 to 10% of pregnancies. creatinine clearance < 60 mL/min. chronic hypertension should be considered. elevated liver enzymes. which can cause vasospasm. growth restriction. including hypertensive encephalopathy. Both types of hypertension increase risk of preeclampsia.) Hypertension (BP ≥ 140/90 mm Hg) during pregnancy can be classified as chronic or gestational. stroke. followed by furosemide Some Trade Names LASIX Click for Drug Monograph 10 to 20 mg IV. if labor is active. if not resolved before delivery. Chronic hypertension complicates about 1 to 5% of all pregnancies. and the HELLP syndrome (hemolysis. Fetal mortality or morbidity increases because of decreased uteroplacental blood flow. Patients should be evaluated every 1 to 2 wk postpartum with periodic BP measurement. Persistent oliguria is treated with a fluid challenge. renal failure.Click for Drug Monograph is given in a titrated dose to lower BP to 140 to 155/90 to 105 mm Hg. determining intravascular volume and cardiac output with a Swan-Ganz catheter may be considered. Gestational hypertension develops after 20 wk gestation (typically after 37 wk) and remits by 6 wk postpartum. Outcomes are worse if hypertension is severe (BP > 180/100 mm Hg) or accompanied by renal insufficiency (eg. left ventricular failure. more commonly in multifetal pregnancy. Chronic hypertension is BP that is high before pregnancy or before 20 wk gestation. If fluids plus furosemide Some Trade Names LASIX Click for Drug Monograph are ineffective. ambulation is allowed. If the cervix is unfavorable and prompt vaginal delivery is unlikely. If BP remains high after 8 wk postpartum. If severe hypertension occurs for the . The most efficient method of delivery should be used. Diagnosis and Treatment BP is measured routinely at prenatal visits. hypoxia. Anuric patients with normovolemia may require renal vasodilators or dialysis. beginning within 6 to 12 h. eclampsia (see Abnormalities of Pregnancy: Preeclampsia and Eclampsia). usually resolve rapidly afterward. Preeclampsia and eclampsia. and other causes of maternal mortality or morbidity. delivery by cesarean section is indicated. and low platelet count). a dilute IV infusion of oxytocin Some Trade Names PITOCIN SYNTOCINON Click for Drug Monograph is given to accelerate labor. Last full review/revision November 2005 hypertension in pregnancies (See also Arterial Hypertension. As patients gradually improve. diuretics are not used otherwise. If the cervix is favorable and rapid vaginal delivery seems feasible. the membranes are ruptured. and abruptio placentae. serum creatinine > 2 mg/dL [180 μmol/L]).

Diuretics reduce effective maternal circulating blood volume. adverse effects include headaches and pretibial edema. Initial methyldopa Some Trade Names ALDOMET Click for Drug Monograph dose is 250 mg po bid. Cushing's syndrome. If chronic hypertension is mild (140/90 to 150/100 mm Hg) and if BP is labile. the issue is whether and when risks of drug treatment outweigh risks of untreated disease. drug therapy is indicated. Adverse effects of β-blockers include increased risk of fetal growth restriction. and maternal depression (see Table 2: Pregnancy Complicated by Disease: Drugs With Adverse Effects During Pregnancy ). SLE. usually extended-release nifedipine Some Trade Names ADALAT PROCARDIA Click for Drug Monograph . First-line drugs for hypertension during pregnancy include methyldopa Some Trade Names ALDOMET Click for Drug Monograph . may be preferred because it is given once/day (initial dose of 30 to 60 mg). coarctation of the aorta. The most commonly used β-blocker is labetalol Some Trade Names NORMODYNE TRANDATE Click for Drug Monograph (a β-blocker with some α1-blocking effects). tests to rule out renal artery stenosis. ACE inhibitors are contraindicated because risk of fetal urinary tract abnormalities is increased. However. . if these conservative measures do not decrease BP. Treatment of mild to moderate hypertension during pregnancy is controversial. and Ca channel blockers. Thiazide diuretics can adversely affect the fetus and should be avoided during pregnancy if possible. making perinatal risks similar to those for patients without hypertension. decreasing maternal BP with drugs may acutely decrease uteroplacental blood flow. Because the uteroplacental circulation is maximally dilated and cannot autoregulate. and pheochromocytoma should be considered (see Arterial Hypertension: Testing). and symptomatic orthostatic hypotension occur. Ca channel blockers. consistent reduction increases risk of fetal growth restriction. drastically reduced physical activity often appears to decrease BP and improve fetal growth. increased as needed to 2 g/day or sometimes more unless excessive somnolence. β-blockers. which can be used alone or with methyldopa Some Trade Names ALDOMET Click for Drug Monograph when the maximum daily dose of methyldopa Some Trade Names ALDOMET Click for Drug Monograph has been reached. decreased maternal energy levels. depression.1st time in pregnant women who do not have a multifetal pregnancy or gestational trophoblastic disease.

Hospitalization is also often required for much of the latter part of pregnancy. Risk of complications. If the woman's condition worsens. stillbirth) is increased significantly. Delivery should occur by 38 wk or earlier if severe preeclampsia or fetal growth restriction is detected or fetal testing is nonreassuring. growth restriction. total urinary protein. a Ca channel blocker. Fetal growth is monitored with monthly ultrasound examinations. is indicated. including BUN and serum creatinine. both maternal (progression of end-organ dysfunction or preeclampsia) and fetal (prematurity. antenatal testing begins at 32 wk. creatinine clearance. pregnancy termination may be recommended. Patients must be taught to self-monitor BP and should have renal function testing every trimester. or a combination of these drugs. immediate evaluation. drug therapy is indicated: the drug or drugs used before pregnancy. . and funduscopy. If continuation of pregnancy is strongly desired despite the risk. If chronic hypertension is severe (≥ 180/110 mm Hg). methyldopa Some Trade Names ALDOMET Click for Drug Monograph .If chronic hypertension is moderate (150/100 to 180/110 mm Hg). several antihypertensives are often required. a β-blocker.

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