EASTZONE MEDICO LEGAL

1. PLACENTA PREVIA & ACCRETA
MANAGEMENT
Abnormally located placenta in the lower uterine segment
over the cervical os ( major placenta previa) or just
reaching the os ( minor placenta previa).
Diagnosed by ultrasound ( abdominally or
vaginally).
MRI for any suspicion of accreta or precreta.
CBC , Blood grouping, Cross - matching.
Maintain pre operativeHb. > 9 – 10 g/dl.
Asymptomaticminor previa follow up patient , till
36 weeks as out patient, then admit to hospitaland elective
caesarean section at 38 weeks.

2. Asymptomaticmajor previa , do proper counseling
either to keep in hospitaltill delivery or follow up as out
patient provided closed proximity with thehospital.
Symptomatic( history of bleeding ) with major
placenta previa , admit to hospitalfrom 34 weeks of gestation.
Give prophylacticthromboembolic stocking.
• Encourage gentle mobility.
• If at risk of DVT, give prophylacticanticoagulant as hospital
protocol.
• Elective caesarean section should be planned at 38 weeks
unless severe bleeding occur.
• If accreta is suspected, arrange for uterine artery embo-
lization or internal iliac artery ligation depending on the
facility and delivery at 36 – 38 weeks.
Placenta can be left in place or to proceed for hysterectomy , if
there is severe bleeding.

3. In massive haemorrhage :
Give uterotonic agents
Bi manual compression
Uterine packing
B-Lynch
Uterine or internal iliac ligation
Hysterectomy
CORD PROLAPSE
Cord prolapsed occur when the umbilical cord lies before
the presenting part after rupture of the membranes ( fore-
waters). If the forewaters are still intact it is defined as
cord presentation.
Cord prolapse is diagnosed by vaginal examination which
must be performed immediately after spontaneous rupture
of the membranes.

4. Fetal heart beat must be checked once the diagnosis is
made.
The person making thediagnosis must keep his/her
hands in the vagina in attempt to keep the cord from being
compressed by thepresenting part.
The woman should be asked to assume the knee
chest position as it seems likely that will relieve cord
compression or to put patient head down ( trendling position).
The fetal heart should be monitored.
If less than fully dilated and fetus is viable, an
immediate
caesarean section is considered.
• If the cervix is fully dilated and head engaged , obstetrician
may decide instrumental delivery.

5. • If the cord is prolapsed outside thevagina, dehydration and
spasmof the cord vessel is possible, so should be replaced it in
the vagina.
• The Paediatrician should be present at delivery time.
• Following delivery, arterial and venous cord blood should be
taken for blood analysis.
PRETERM LABOUR
Defined as labour pain at 24 weeks and less than 37 com-
pleted weeks gestation with at least 2 painful contractions
every 10 minutes , cervical changes with: Cervical
dilation > 2 cm. ( 1 – 3 cm) or effacement > 50 % or
change in cervical dilatation or effacement by serial
examination.
Patient assessment abdominally & vaginally.
Fetal monitoring – CTG, ultrasound to exclude fetal
abnormality.

6. A plan of management should be decided by the
most senior obstetrician available in conjunction with the
Paediatrician team. In utero transfer , if needed it should be
arranged.
Steroid therapy may be effective in maturing the
fetal lungs, and to reduce the incidence and severity of
neonatal respiratory distress syndrome, given up to 36 weeks
gestational age (Dexamethazone 12 mg. I.M. every 12 hours
for 2 doses).
Epidural analgesia is ideal if available. Other
analgesia to be minimized.
Tocolytics when waiting for Corticosteroid action or intra –
uterine transfer in presence of the uterine contraction.
24 – 32 Week:
Prostaglandin Synthetase Inhibitor :

7. Indomethacin 50 - 100 mg Rectally loading then 25 mg.
Orally every 4 – 6 hours x 48 hours
or Calcium Channel Blockers
Nifedipine - 20 mg orally then 10 – 20 mg. every
6 – 8 hours up to 48 hours
32 – 34 Week:
1- Nifedipine or
2-ß – Adenergic Receptor Agonist:
A. Ritodrine - 100 mg. Ritodrine HCL in 500 ml LR , 15 ml/ hr
= 0.05 mg/min.
Monitor the patient to detect :
FHR > 180 baseline

8. Maternalpulse > 140
MaternalBP < 90/50
ECG changes
Hypotension unresponsiveto position change
Respiratory symptoms:tachycardia, shortness of
breath, chest pain
Excessive maternal nervousness, palpitations,
tremors or headache
Vaginal bleeding
B. Terbutaline
IV Infusion - 2.5 - 5 mcg/min. increased by
1.5 – 5 mcg/min. every 20 – 30 minutes to a maximum dose
25 mcg/min. till uterine contraction stops.
Then reduce the dose to the lowest dose that maintain the
uterine quiescence.

9. 1. Atosiban (Tractocile)
Initial bolus dose of 6.75 mg. over one minute followed by
an infusion of 18 mg/hr. for 3 hours, then 6 mg./hr for up
to3- Magnesium Sulphate
4 - 6 gms. Loading dose over 20 minutes
2 – 4 gms continuous infusion
4- Antibiotics - Avoids broad spectrum antibiotic
Antibiotics are used as prophylaxis against Group B
Beta – Streptococcus only
( Ampicillin 2 grams IV every 6 hours).