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Placenta previa

Prepared by:

Dr. Gehanath Baral


MBBS,DGO,MD
Senior Consultant Gynecologist & Obstetrician: Government of Nepal
Visiting Professor: CTGU
17th April, 2007

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APH
• Bleeding from or into genital tract after the age of viability of fetus or
after 28 weeks of pregnancy before the onset of labor.

APH

Unexplained Extra
Placental
70%
25% placental
5%

Placenta Abruptio
Cx Cx Varicose Local
Previa Placentae
polyp cancer vein trauma
35% 35%

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• Placenta previa = Complete or
partial implantation of placenta
in lower uterine segment.

• Abruptio placenta = APH due to


premature separation of the
normally situated placenta.

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Placenta previa
• Predisposition factors:

• Multiparity

• Elderly>35yrs

• Uterine scars

• Large placental size or succenturiate lobe

• Smoking (compensatory hypertrophy)

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Pathology
• Placenta may be adherent to less decidualised lower
segment.Increased degeneration n infarction

• Vasa previa in battledore or Velamentous placenta may


bleed easily due to cord position

• Soft n friable Cx n lower segment due to increased


vascularity

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Types of placenta

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Types of placenta

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Types of placenta

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Types of placenta

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Types of placenta

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Types/Grades of placenta previa
1- Low lying

2- Marginal
– 2A- Anterior
– 2B- Posterior

3- Eccentric

4- Central

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1- Low lying
2- Marginal

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3- Eccentric
4- Central

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2- Marginal
2A- Anterior
2B- Posterior

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Cause of bleeding
Rate of placental growth slows down

Lower segment dilates

Shearing off of the placenta from uterine wall

Opening up of utero-placental vessels

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C/F:
1. Sudden, Painless, Causeless, Recurrent bleeding
2. Anemia proportionate to blood loss

3. Uterine size consistent with gestation


4. Uterus: relaxed, soft and non-tender
5. Persistent malpresentation
6. Floating head, Easily displaceable
7. Stallworthy’s sign: fetal bradycardia due to placental
compression by head

8. Fresh/bright red color bleeding

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Diagnosis
1. USG:
– TAS
– TVS
– Color doppler flow study

2. MRI

3. MRI>TVS>TAS

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D/D:
1. Abruptio placentae

2. Vasa previa

3. Cx polyp/carcinoma

4. Circumvalate placenta

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Placenta previa Abruptio placentae
Nature of bleeding Painless, Causeless, Painful, with PET/Trauma,
Recurrent Continuous
Character of Revealed Concealed, Revealed or Mixed
C/F bleeding
Anemia Proportionate Out of proportion
PET Not relevant In 1/3rd
Uterine ht. Proportionate Bigger
Feel of uterus Soft n relaxed Tense, tender n rigid
O/E
Malpresentation Common Unrelated
FHS Usually +ve Usually -ve
Placentography In lower segment In upper segment
P/V Placenta can be felt Placenta can’t be felt

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Complication
Maternal:
Fetal:
1. Bleeding and shock
1. Prematurity
2. Malpresentation
2. Asphyxia
3. Cord prolapse
3. IUFD
4. Increased operative
intervention 4. Congenital
malformation
5. PPH

6. Retained placenta

7. Subinvolution and sepsis

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Mortality factor
Maternal:

Hemorrhage and Shock

Fetal:
1. Prematurity
2. Asphyxia
3. Congenital malformation

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Treatment
1. Assess general condition

2. Blood for Hb, Grouping, X-matching

3. I/V line with Crystalloid

4. Gentle abd. Examn

5. No P/V examn

6. USG for placentation, fetal maturity and viability

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Watchful T/T
Indication: Management:

• No active bleeding • Bed rest

• Preterm<37weeks • Steroid

• Normal fetus • Blood transfusion


if needed
• Normal Hb>10gm/dl

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Active T/T: Vag.del/CS

1. >37weeks

2. Excessive bleeding

3. Dead/ Malformed fetus

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Vaginal delivery: CS:

• For type 1 and 2A • For type 2B, 3 and 4

• ARM • Vag.del failed or


complicated
• Augmentation
• Associated complicating
factors

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Abruptio placentae

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Abruptio placentae
Types of bleeding:

1. Retroplacental clot (RPC)

2. Concealed bleed

3. Revealed bleed

4. Mixed

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Retroplacental clot (RPC)

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Concealed bleed

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Revealed bleed

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Mixed bleed

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Cause
1. Idiopathic
2. Advanced age >35yrs/Grandemultigravida
3. Smoking/Cocaine abuse
4. PET: Vasospasm  Endothelial injury 
Extravasations
5. Trauma: Assault/RTA,ECV, Amniocentesis
6. Sudden uterine decompression: Polyhydramnios,
PROM, 2nd twin
7. Short cord

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Amniocentesis: proper n faulty

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Pathogenesis
• Bleeding into decidua basalis
• Decidual hematoma
• Separation of placenta
• Degeneration n necrosis of decidual plate n adjacent
placenta
• Retroplacental hematoma formation
• Confined behind placenta
• Escapes between membrane n uterine wall
• Access to amniotic cavity after rupturing membrane
• Massive intravasation into uterine muscle

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Couvelaire uterus

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Complication
Maternal: Fetal:

• Bleeding and shock


• Coagulopathy
• Prematurity
• Renal failure
• Hepatic failure • Asphyxia

• PPH
• Death
• Puerperal sepsis

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Coagulation profile
1. CT: Increased

2. PTT: Increased

3. Platelets: Decreased (<100,000/cmm)

4. Fibrinogen: Decreased (<150mg/dl)

5. FDP: Increased

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Clinical classification
Bleeding Uterus Shock FHS/Fetus DIC/Renal
failure

Grade 0 No Relaxed and No Good No


non-tender

Grade 1 Slight Irritable No Good No

Grade 2 Mild to Tender No Distress or No


moderate Death

Grade 3 Severe Markedly Yes IUFD Yes


tender

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C/F: Depends on amount of bleeding n separation
Revealed Concealed Mixed
Pain Continued discomfort or pain Intense continuous pain
Bleeding Dark colored blood Dark colored blood

G.C. No shock Shock present


Anemia Proportionate pallor Improportionate pallor

S/S of PET PET +/- PET+


Uterine Ht. Proportionate Bigger and globular
Uterine feel Local tenderness, frequent Tense ,tender, rigid
contractions
Fetal parts Easily palpable Difficult to palpate
FHS + -
Urine output Normal Decreased

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Amount of bleeding
1. Mild bleed: 3. Severe loss:
– <15% loss
– Asymptomatic – 30-40% loss

– State of shock due to:


2. Moderate bleed:
• Bleeding
– 15-30% loss
• Coagulopathy
– Low BP, MAP & Pulse
pressure
– High pulse

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D/D
1. Ruptured uterus

2. Tonic uterine contraction

3. Twisted ovarian cyst

4. Intestinal/Appedicular perforation

5. Acute hydramnios

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Rupture of Uterus:

True Rupture: Scar Dehiscence:


• Contractions stop • Dehiscence may be silent
• Continuous pain – no bleeding
• Tender abdomen • Fetal distress
• Fundus ill-defined • Haematuria
• PV Bleeding • Vague uterine outline
• FHS low or absent • Failed induction

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Management
• Revealed type: ARM + Augmentation

1. In labor
2. Term not in labor
3. Preterm not in labor but continuous bleeding

• Concealed type:

1. ARM + Augmentation
2. If failed or complicated  CS

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