Placenta previa

1. PLACENTA PREVIA
&
PLACENTA ACCRETA
NAME: DR. SALINI A/P BALAKRISHNAN

2. PLACENTA PREVIA
Defined as implantation of placenta
over or near the internal cervical os
of the cervix
Leading cause of vaginal bleeding in
the 2nd and 3rd trimester

3. RISK FACTORS
Previous placenta previa
Previous Caesarean sections
Previous termination of pregnancy
Multiparity
Advanced maternal age (> 40 years old)
Multiple pregnancy
Smoking
Assisted conception
Endometriosis

4. CLASSIFICATION

5. CLINICAL PRESENTATION
Recurrent, Painless bright red vagina bleeding
- onset of bleeding depends on degree of praevia (i.e. complete bleed earlier)
- Initially, bleeding may be minimal and cease spontaneously but can be catastrophic
later
- Bleeding at onset of labour can occur with marginal placenta praevia

6. PHYSICAL EXAMINATION
GENERAL EXAMINATION - pallor, may or may not be in shock depending on the amount of bleeding
PER ABDOMEN - uterus is soft, relaxed and non tender
- malpresentation
- foetal parts are easily palpable and FHS may be normal
- the presenting part is floating
* Stalworthy’s sign may be seen in type II b placenta praevia ( Suprapubic pressure on the fetal head elicits a deceleration
in the fetal heart rate)
PER VAGINAL NOT BE DONE IN CASE OF APH unless placenta praevia is ruled out
Per speculum examination to exclude local lesions is only permissible when placenta previa has been excluded by
ultrasound

7. INVESTIGATIONS
FULL BLOOD COUNT
ABO/RH compability - GXM ( at least 4 units of blood)
Trans abdominal ultrasound- for placenta localisation
Transvaginal ultrasonography- superior to TAS
- evaluate cervical length

8. MANAGEMENT
Diagnosis should be confirmed
Admit the patient
Management depends on :
- quantity of bleeding
- overall physical condition of the mother
- overall fetus condition and fetal maturity
EXPECTANT LINE OF MANAGEMENT
ACTIVE LINE OF MANAGEMENT

9. EXPECTANT MANAGMENT
MACAFEE- JOHNSON’S REGIME
Aim to continue pregnancy for fetal lungs to mature without compromising maternal health
PREREQUISITES
Stable maternal health (HB >10)
Period of gestation is less than 37 weeks
Fetal wellbeing is assured on USG
No active bleeding is present
Availabilty of blood transfusion
Facilities for Caesarean section if required

10. CONDUCT OF EXPECTANT MANAGEMENT
Bed rest
Hb%, blood grouping
Fetal surveillance with USG
Blood transfusion to correction anemia
Tocolytics- if vaginal bleeding associated with uterine contraction
Corticosteroids to improve fetal lung maturity and reduce respiratory distress
Rh immunoglobulins given to all Rh negative mothers

11. ACTIVE LINE OF MANAGEMENT
LOWER SEGMENT CAESAREAN SECTION
Indications for an emergency Caesarean section
1. Bleeding is heavy irrespective of fetal viability or maturity
2. Major degree placenta previa ( type II posterior, type III and type IV)
3. Fetal distress
4. Obstetrics factors like CPD, fetal malpresentation

12. DEFINITE MANAGEMENT
SEVERE BLEEDING
 In- patient monitoring
 Stabilize the patient – arrange and cross-match at least four units of blood transfusion if required.
 Facilities for emergency Caesarean section available
 The following steps need to be taken:
 2 large bore IV cannula need to be inserted and IV fluids crystalloid or collaid must be started
while awaiting for blood.
 Monitoring of pulse, blood pressure and amount of vaginal bleeding to be done at every half
hourly intervals.
 Input-output charting at hourly intervals.
 The blood sample should be taken and sent for complete blood count, blood grouping and
cross-matching.
 Severe bleeding is usually due to a major degree of placenta praevia. The definitive treatment
in these cases would be immediate delivery by caesarean section.

13. DEFINITE MANAGEMENT
Mild to Moderate Bleeding
The initial steps as in severe bleeding
The timing for delivery is these patients must be based upon the period of gestation as follows. The patient who is
haemodynamically stable and has no further loss, requires conservative management.
a. Period of gestation ≥ 36 weeks
 Must be delivered by performing caesarean section
 Until complete dose of corticosteroids has been administered, the delivery should be
preferably delayed
 If fetus achieved lung maturity, can deliver. If not, intramuscular corticosteroid injection must be given to the mother.
 Until complete dose of corticosteroids has been administered, the delivery should be preferably delayed.
 During this waiting period, the patient must be kept under intensive monitoring.
 Tocolytic agents can be used to prevent uterine activity.
 If the patient remains stable for next 24-48 hours, patient becomes candidate for expectant management.
 If the patient does not remain stable for the next 24-48 hours, patient must be delivered by a caesarean section.
b. Period of gestation 32-36 weeks

14. COMPlICATIONS
FETAL
- prematurity
- intrauterine hypoxia
- fetal malpresentation
- preterm premature rupture of membrane
MATERNAL
- hemorrhage and hypovolemic shock
- anemia
- acute renal failure
-Pituitary necrosis ( Sheehan syndrome)
-Postpartum hemorrhage
- Hysterectomy

15. PLACENTA ACCRETA
Placenta accreta occurs when there is a defect of the decidua basalis, in conjuction with an imperfect
development of the Nitabuch membrane (a fibrinoid layer that seperates the decidua basalis from the
placental villi) resulting in abnormally invasive implantation of the placenta

16. DEGREE OF SEVERITY/ TYPES OF PLACENTA ACCRETA
1) Accreta, in which the placenta adheres on the myometrium without invasion into
the muscle
2) Increta, in which it invades into the myometrium
3) Percreta, in which it invades the full thickness of the uterine wall and
possible other pelvic structures, most frequently the bladder

17. RISK FACTORS
 Placenta previa with or without previous uterine surgery
 Previous myomectomy
 Previous caesarean delivery
 Asherman’s syndrome.
 Submucous leiomyomata.
 Maternal age of 36 years and older

18. ETIOLOGY
 Defective decidual formation
 Implantation in lower uterine segment
 Caesarean scar
 Uterine incision or curettage
 Manual removal of placenta
 Abortive agents
 Uterine infection

19. CLINICAL COURSE
 Maternal Serum Alpha Fetoprotein level – increased
 Ante partum haemorrhage
 Uterine rupture before labour

20. DIAGNOSIS
Ultrasound
 Loss of the normal hypoechogenic zone between the placenta and myometrium
 Abnormality of the smooth interface between the uterus and bladder
 A Swiss-cheese appearance to the placenta
 Pulsatile flow of maternal blood
Colour flow doppler imaging
• turbulent lacunar blood flow, increased subplacental vascularity, gaps in myometrial flow and
vessels bridging to the uterine margin
MRI
• features of dark intraplacental bands , abnormal bulging of placenta or uterus, abnormal or
disorganized placental blood vessels
• it is not preferred recommended modality for the initial evalution

21. MANAGEMENT
Total Placenta Accreta
 Hysterectomy
 Conservative :
1. Cutting umbilical cord
2. Antibiotics
Other measures
 Blood replacement
 Uterine and internal iliac artery ligation
 Angiographic embolization
 Argon beam coagulation

22. MANAGEMENT

23. COMPLICATION
 Haemorrhage
 Shock
 Infection
 Sub involution of uterus
 Secondary postpartum haemorrhage
 Formation of placental polyp

24. Thank you