Placenta praevia.

Definitions:
Lateral Placenta praevia, = grade 1:
placenta reaches lower uterine segment but not os of the cervix
Marginal Placenta praevia, = grade 2:
placenta reaches internal os but does not cover it
Partial Placenta praevia, = grade 3:
placenta partly covers os when closed but not completely when open, so might still allow vaginal birth
Central Placenta praevia, = grade 4:
Placenta covers the whole area of the os completely, lies centrally over the os

Changing of grade over time:

In the last months before the delivery the lower uterine segment stretches a lot, so a partial placenta praevia at 7
months can become a marginal placenta praevia at nine months.

Problems with Placenta praevia: APH and PPH:

The central placenta praevia will sometimes not bleed till the cervix starts to efface (APH)
A marginal or partial placenta praevia may start to bleed a long time before (APH)

In lateral and marginal placenta praevia also more chance of (PPH)

Diagnosis:
Placenta Praevia can be discovered by USS. With abdominal USS in 50% difficult to locate placenta exactly.

Frequency of placenta praevia:

at 20 weeks 5%
at term 0.3 – 0.9%

More frequent if:

multiparous women, use of cocaine, smoking tobacco, twins, triplets, assisted pregnancies. (old age not sure)

After a Ceasarean Section.

Management:
FIRST ABC:
- If bleeding has occurred Hb and crossmatching must be done.
- scan is made and diagnosis becomes clear, however a vaginal scan would be much more accurate than an
abdominal scan.

Depending on the severety of the bloodloss a decision will be made to do a Caesarean Section or to expect
whether a vaginal delivery will be possible.

Exceptional problems: placenta accreta, increta, percreta

Previous CS(n) placenta praevia (%) placenta accreta (%) placenta accreta if placenta previa (%)
0 0,26 0,004-0,01 2-5
1 0,65 0,16-0,30 14-24
2 1,8 0,26-1,6 23-47
3 3 1,20-5,1 29-40
4 10 2,30-9,1 33-67

Literature used:
- Manual of Standard Managements in Obstetrics and Gynaecology for Doctors, H.E.O.s and Nurses in Papua
New Guinea. Sixth edition, 2010
- The MOET course Manual. Managing Obstetric Emergencies and Trauma 2nd edition 2009
- NVOG richtlijnen 2008 bloedverlies tweede helft zwangerschap

Gert4/documents/lectures for residents/xxplacenta praevia.doc

Gert van den Berg, tropical doctor, dept. of Obstetrics and Gynaecology, Modilon General Hospital, Madang