4. Transabdominal Transvaginal
accuracy +ve 95% -ve 7% +ve 99% -ve 1-2%
Abd. Vs TVs'+ & - Inability to locate internal Os
Obesity
Accosting shadow of fetal head
Post placenta difficult to locate
Full bladder – false & +ve
Shorter distance from Cx
Use of high frequency
Better resolution
Probe under direct vision
5.
6.
7.
8.
9.
10.
11.
12. AbstinenceAbstinence
No PV exam. After 20 wkNo PV exam. After 20 wk
Reporting to hospital whenever bleeding episodeReporting to hospital whenever bleeding episode
Monthly usg to know if praevia resolvedMonthly usg to know if praevia resolved
activity is a predisposing factor for the vaginal bleeding associated with placentaactivity is a predisposing factor for the vaginal bleeding associated with placenta
praevia, and would consider tocolytic therapy in a stable patientpraevia, and would consider tocolytic therapy in a stable patient
13.
14.
15.
16.
17.
18.
19. Only in cases in which blood loss is minimal and thereOnly in cases in which blood loss is minimal and there
isis a desire for preservation of fertilitya desire for preservation of fertility
Uterine packageUterine package
Bakri balloon catheter---Bakri balloon catheter---
tamponade effect as uterine packingtamponade effect as uterine packing
Occlusive balloon catheters in internal iliac arteryOcclusive balloon catheters in internal iliac artery
20.
21. Surgical ManagementSurgical Management
• PastPast
– Intra uterine packingIntra uterine packing
– Ligation of uterine arteryLigation of uterine artery
– Ligation of Internal iliac arteryLigation of Internal iliac artery
– Step wise devascularizationStep wise devascularization
– HysterectomyHysterectomy
• TotalTotal
• SubtotalSubtotal
• NewerNewer
– Brace suturesBrace sutures
23. Hayman uterine compressionHayman uterine compression
suturesuture
Uterine cavity not openedUterine cavity not opened
Uterine cavity not exploredUterine cavity not explored
Quicker to applyQuicker to apply
No feedback data on fertility outcomeNo feedback data on fertility outcome
Morbidity feedback data limitedMorbidity feedback data limited
Unequal tension leads to segmental ischemiaUnequal tension leads to segmental ischemia
25. Cho –multiple squareCho –multiple square
suturessuturesMultiple full thickness square sutures appliedMultiple full thickness square sutures applied
Uterine cavity drainage restrictionUterine cavity drainage restriction
No feedback data on fertility outcomeNo feedback data on fertility outcome
Morbidity feedback data limitedMorbidity feedback data limited
Rhythmic contraction not facilitatedRhythmic contraction not facilitated
Production of multiple uterine synechiaeProduction of multiple uterine synechiae
30. Stepwise devascularisationStepwise devascularisation
• Uterine artery ligationUterine artery ligation
– UnilateralUnilateral
– BilateralBilateral
– Upper –at the level of the uterine border besideUpper –at the level of the uterine border beside
the upper part of lower uterine segmentthe upper part of lower uterine segment
– Lower –bleeding from lower uterine segmentLower –bleeding from lower uterine segment
– Ligature 3 -5 cm below the upper ligatureLigature 3 -5 cm below the upper ligature
• Ligature should include significantLigature should include significant
amount of uterine myometriumamount of uterine myometrium
• No :0 or 1 absorbable suture materialNo :0 or 1 absorbable suture material
• 80 -95 % success rate80 -95 % success rate
32. Uterine artery embolisationUterine artery embolisation
Potential to preserve fertilityPotential to preserve fertility
Prophylactic embolization in elective CS withProphylactic embolization in elective CS with
adherent placentaadherent placenta
Procedure of choice for PPH prior to surgicalProcedure of choice for PPH prior to surgical
interventionintervention
Secondary PPHSecondary PPH
ComplicationsComplications
HematomaHematoma
InfectionInfection
Contrast related side effectsContrast related side effects
Uterine ischemiaUterine ischemia
Bladder necrosisBladder necrosis
Placenta praevia is a leading and potentially life-threatening cause of third-trimester bleeding
Overall incidence is about 0.4% in pregnancies exceeding 20 weeks’ gestation
Technological advances have improved maternal and neonatal outcomes after placenta praevia
Placenta praevia is a leading and potentially life-threatening cause of third-trimester bleeding
Overall incidence is about 0.4% in pregnancies exceeding 20 weeks’ gestation
Technological advances have improved maternal and neonatal outcomes after placenta praevia
Placenta praevia is a leading and potentially life-threatening cause of third-trimester bleeding
Overall incidence is about 0.4% in pregnancies exceeding 20 weeks’ gestation
Technological advances have improved maternal and neonatal outcomes after placenta praevia
Good after noon all
Its a great pleasure to be here at Amravati
Long back in pg days we attended amogs at Nagpur 1990
We traveled form here & our night stay was at chikaldara
My memories are freshened by this visit
Placenta praevia is a such an entity
Its like a bomb with a fuse which can go bang any time
Advances in Imaging and timely intervention giving very good results as compared to our ug days
But still it’s may become nightmare for obstetrician in some situation
Let us see how we can deal with it
Praevia often begins with painless vaginal bleeding – warning hemorrhage
Ultrasound examination is strongly recommended for all women with vaginal bleeding during pregnancy.
Traditional classification of placenta praevia is like this - complete , partial , marginal , low lying
New depending on placental edge to int.os distance – complete, incomplete, low lying
What are the various Investigations to confirm placenta praevia
In the past x-ray placentography was a method
Amniography ,pubic angiography, cystography are some to complete list
Ultrasound gives accurate diagnosis most of the time
But MRI I.V. Radio active isotope & thermography are newer methods
Tran abdominal ultrasound- accuracy as high as 95% and a false-negative rate of 7%
affected by maternal obesity,
Acoustic shadowing of the fetal head in a cephalic presentation
, inability to locate the internal cervical os
And difficulty imaging a posterior placenta and the lateral uterine walls.
a full maternal bladder—
usually helpful in transabdominal ultrasound imaging—may cause a false-positive diagnosis if the bladder is overly distended
the cervix would appear artificially elongated and give a normally implanted placenta the appearance of encroachment into the internal cervical os.
Tran abdominal ultrasound- accuracy as high as 95% and a false-negative rate of 7%
affected by maternal obesity,
Acoustic shadowing of the fetal head in a cephalic presentation
, inability to locate the internal cervical os
And difficulty imaging a posterior placenta and the lateral uterine walls.
a full maternal bladder—
usually helpful in transabdominal ultrasound imaging—may cause a false-positive diagnosis if the bladder is overly distended
the cervix would appear artificially elongated and give a normally implanted placenta the appearance of encroachment into the internal cervical os.
Here we can see how Over distended bladder affects findings
Contractions in uterus can also give you false findings so better to avoid such time
TVs usg more accurate than transabdominal
Which can be seen here
If you add color to usg it will stamp the diagnosis of praevia
Here we can also see cord nicely after adding color
At the same time
Some abnormalities of cord insertion & placenta like membranous battledore also will be detected
which are common with praevia
There is a 2 fold increased in risk of congenital malformation in cases of praevia
so “target usg for fetal anomaly “is recommended
Risk of fetal growth restriction warrants heightened surveillance
fetal growth restriction occurs in 16% of women with placenta praevia and is correlated with the number of ante partum bleeding episodes
3D usg & power Doppler is like flying drone intrauterine
Gives much more information especially in placenta accreta
See for normal plane of separation between placenta villi & uterine wall & intervening fibrinoid layer of Nitabuch – its absence is a clue
Danger ahead….
The latest camera function is selfi mode
MRI
Here In praevia MRI gives accurate information in case of doubt like in placenta accrete.
Here we can get degree of invasion correctly
Now comes
when a obstetrician should intervene? Surgical strike or quiet negotiations
Management of pt. with praevia in third trimester depends on
the extent of hemorrhage & fetal gestation age, type of praevia ,distance between internal os , edge of placenta ,thickness of placenta & other factors
At approximately 36 weeks’ gestation assess fetal lung maturity or achieve lung maturity by betnesol
Elective cesarean delivery can then be planned if pulmonary maturity is documented
Outpatient management possible only for women who have never bled after diagnosis in 2d trimester
If placenta praevia persists at 24 wks there is risk of complications of 50%
after 32 wk risk raised to 75%
Any woman with placenta previa who presents with vaginal bleeding should be admitted to the labor and delivery unit for immediate evaluation of maternal and fetal status, including an estimation of gestational age.
If hemorrhage is life-threatening, deliver immediately
Here is a practical management protocol nicely given from American journal 2015
Based on
Gestational age, edge os relationship thickness at term, prior scar, maturity & extent of bleeding
Management of asymptomatic patients with suspected praevia on usg at 2nd trimester
This is a management of vasa praevia many times associated with previa
And here is same for velamentous cord insertion
When massive bleeding then evacuate uterus early irrespective of fetal status
Maternal health to be considered
if the hemorrhage is judged to be massive and life-threatening, resuscitative measures and immediate delivery are necessary to avoid serious maternal morbidity.
Recommended measures include constant monitoring of maternal status, aggressive IV fluid resuscitation, transfusion of blood and blood products, assessment of fetal status, and immediate delivery without regard to the maturity of the fetus.
While dealing with praevia snatching of hemorrhage is important
How that can be achieved ?
At vaginal delivery
ARM can keep pressure of fetus on placenta
Traction on presetting part can be done
Increase oxytocine drip deliver fast
At lscs
If bleeding from lower segment sinusoids
Pre incision ligation of vessels
Focused repair / compression /bracketing of area / stepwise devascularisation
Elective embolization or occlusion of the hypogastric or uterine arteries has proved to be safe and effective for postpartum hemorrhage, with a success rate of more than 90% in women with normal coagulation
elective catheterization with a balloon-tipped catheter can be used prophylactically to reduce blood flow to the placenta
Either inflate those balloon or block those vessel with foam
Even in cases of complete praevia & accrete surgery will be bloodless
Before thanking you all my request
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