Placenta Previa

Dr. H. Nuswil Bernolian, SpOG(K)

 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
 Prior D&C or C-section
 Multiparity
 Advance age – independent risk factor vs.
multiparity
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?
 Time of diagnosis or onset of symptoms
 Location of placenta previa

Repeat ultrasound at 24 – 28
weeks’ gestation
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?
 Malpresentation
 Preterm premature rupture of membrane
Diagnostic test?

Ultrasound
Placenta Previa: ultrasound

Placenta
Placenta Previa: ultrasound
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
Variations of placenta accreta
Placenta accreta: ultrasound
Vasa Previa?
Vasa Previa
Vasa Previa
Vasa Previa
Vasa Previa
 Rupture
 Compression of
vessels
 Perinatal mortality
rate – 50 – 75%
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
 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
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
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
 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 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
 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
Placenta Abruption
 What is placental
abruption?

Premature separation of placenta from the

uterus
Epidemiology
 Incident 1 in 86 to 1 in 206 births
 One-third of all antepartum bleeding
Pathogenesis
 Maternal vascular disruption in decidua
basalis
 Acute versus chronic
Types of placental abruption
16% 81% 4%
Types of placenta hemorrhage
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 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 presentations?
 ± Vaginal bleeding
 Uterine contraction or tetany and pain
 Abdominal pain
 DIC
 10-20% of placental abruption
 Associated with fetal demise
 Fetal compromise
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
Ultrasound: subchorionic abruption
Ultrasound: retroplacental abruption
Ultrasound: retroplacental abruption
Blood tests?
 CBC – hemoglobin and platelets
 Fibrinogen
 Normal 450 mg/dL
 <150 mg/dL – severe DIC
 Fibrin degradation products
 PT and PTT
Management?
 Hemodynamic monitoring
 Urine output with Foley
 BP drop – late stage, 2-3 liter of blood loss
 Fetal monitoring
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?
 Bleeding into myometrium leading to uterine
atony and hemorrhage
 Treatment
 Most respond to oxytocin and methergine
 Hysterectomy for uncontrolled bleeding