This document presents a case study of obstetrical hemorrhage involving placenta previa. It summarizes the patient's history, including previous cesarean deliveries, and current presentation with vaginal bleeding. Ultrasound revealed the placenta was located at the cervical os. The resident discusses management of placenta previa, including expectant care and risk factors for hemorrhage. Complications like placenta accrete syndrome are also reviewed, where the placenta invades the uterine wall, increasing bleeding risks.

1. Case Presentation On
Obstetrical Hemorrhage
Hale T., O & G Yr-1 Resident,
Mekelle University,
College of Health Sciences, Dep't of OB-GYN
May 26, 2016

2. • Contents
– Case Summary
– Discussion
• Placenta Previa
• Placenta Accrete Syndrome
– Comments and Recommendations
Hale T., M.D., Resident Physician 2

3. • Objectives
– To summarize the case and
– To discuss on management of
• Placenta previa
• Placenta accrete syndrome
Hale T., M.D., Resident Physician 3

4. Case Summary
• HPP
– 35 year old, G-3, P-2 (both alive, both via C/S)
– LNMP: 01/02/08 E.C., GA = 32 wks + 2 D (reliable)
– Earliest Ultrasound:
• on 02/07/08 E.C.
– Gestational age: 22 Weeks + 6 Days
– Anterior placenta, 2.6 cms away from the
internal Os
– ANC follow up at Mekelle Hospital
4Hale T., M.D., Resident Physician

5. • Currently presents with the complaint of:
– Vaginal bleeding
• Bright red
• Minimal in amount
• Only 1 episode
• Previous obstetric history
– History of 2 cesarean deliveries,
• 1st for the possible indication of NRFHRP
• 2nd for the possible indication of PROM +
Previous C/D
Hale T., M.D., Resident Physician 5

6. • Physical Exam on the day of admission
– HEENT
• Pink conjunctiva, nonicteric sclera
– Abdomen
• 30 weeks sized gravid uterus,
• Longuitidinal lie, cephalic
• FHB: 140 bpm
• Vertical midline old scar
• No tenderness
– GUS
• No active vaginal bleeding
– CNS
• Conscious and oriented
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7. • Admission Diagnosis
– Early preterm pregnancy
– APH 20 Abruptio Placenta to R/O Placenta
Previa with 2 Previous CD
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8. R. No. Investigations
1. Hemoglobin 13.3
2. BG and Rh O Postive
3. RBS 106
4. Urinalysis Blood +3
5. HBsAg Neg
6. VDRL Nonreactive
8Hale T., M.D., Resident Physician

9. • Obstetric Ultrasound
– Singleton, alive , IUPx
– FHB +ve
– AGA: 34 weeks + 6 Days
– EFW: 2494 grams
– Placenta is ant. and lower margin reaches cervical Os
– Peripheral hypervascular with color dopler
– GBM, FBM seen
– Adequate AF
– No gross congenital anomaly seen
• Index
– 3rd TM Px
– Placenta Previa Marginalis
– ? Adherent Placenta
– RBPP
9Hale T., M.D., Resident Physician

10. • Management
– Admit to high risk ward
– Secure IV line
– Dexamethasone 6 mg IV BID
– FeFol 1 tab PO BID
– Follow her with APH and Kick charts
– Prepare 02 units of cross-matched blood
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11. Discussion
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12. Introduction
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13. • Any degree of bleeding in a pregnant
mother is pathologic; excluding
– Implantation bleeding
– Bloody show
– Bleeding in the third stage of labor
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15. • Placenta Previa
– Placenta goes before the fetus into the birth
canal
– Implantation of a placenta in the lower uterine
segment (adjucent or over the internal Os)
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16. • New classification of placental
implantation
– Normally implanted
– Placenta previa
– Low lying placenta
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17. • Degrees of Placenta Previa
Hale T., M.D., Resident Physician 17

18. Ultrasound in Obstetrics & Gynecology_ A Practical Approach - Clip 10.6.mp4
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22. • GA greater than 16 weeks
– Placenta > 2 cms away from Os - Normal
– Placenta < 2 cms but not covering - PP
• Follow up U/S at 32 weeks
– Placental edge > 2 cms
» Do color dopler U/S at 32 weeks to rule out vasa
previa
– Still less than 2 cms
» Follow up U/S at 36 weeks
Hale T., M.D., Resident Physician 22

23. Placenta Previa
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24. Ultrasound in Obstetrics & Gynecology_ A Practical Approach - Clip 13.1.mp4
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28. • Placental Migration
– Apparent movement of the placenta away
from the internal os
• Imprecision of two-dimensional sonography
• Differential growth of the lower and upper
uterine segments
– A low-lying placenta is less likely to “migrate”
within a uterus with a prior cesarean
hysterotomy scar
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29. • Also
– Lengthening of the lower uterine segment
– Progressive unidirectional growth of
trophoblastic tissue toward the fundus
– Placental atrophy
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32. • Predictors of hemorrhage in PP
– Placentas that cover the os
– Placentas near the Os have a greater risk of
bleeding if the placental edge is thick (>1 cm)
– Identification of an echo-free space in the
placental edge covering the internal os
– Cervical length ≤3 cm
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33. • Admission
– After 28 weeks
– Before 28 weeks
• If there is bleeding or contraction
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34. • Classification
– Placenta Previa
• Internal os is covered partially or
completely by placenta
– Low lying placenta
• Placental edge does not reach the internal
os and remains outside a 2-cm wide
perimeter around the os
– Somewhat but not always related is vasa
previa, in which fetal vessels course through
membranes and present at the cervical os
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35. • Incidence
– 0.3% or
– 1 per 300-400 deliveries
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36. • Risk Factors
1. Maternal age
• Age above 35 years
2. Multiparity
• Para 5 and above (80% of cases of PP are
multipara)
3. Prior Cesarean deliveries / Myomectomy /
Hysterectomy / Prior curretage
• 8 fold if they had more than 4 CD
4. Cigarrete Smoking
• Compensatory placental hypertrophy
• Decidual vasculopathy
5. Elevated Prenatal Screening MSAFP Level
• increased risk for previa and a host of other
abnormalitiesHale T., M.D., Resident Physician 36

37. • Also...
– Multifetal gestation
– Infertility treatment
– Uterine instrumentation
– Abortion
– Male fetus
– Nonwhite race
– Previous placenta previa
Hale T., M.D., Resident Physician 37

38. • Pathogenesis
– Suboptimal endometrium in the upper
endometrial cavity
• Droping down theory
– Large placenta
– Defective decidualization
– Persistence of chorionic activity
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39. • Pathophysiology
– Changes in the cervix and lower uterine
segment apply shearing forces to the
inelastic placental attachment site,
resulting in partial detachment
• Lower uterine segment - Soft and friable
– Vaginal examination or
– Coitus
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40. • Clinical Feature
– Asymptomatic
– Vaginal bleeding
• Painless
• Without warning
– Sentinel bleed
• Ceases and recurs
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41. • Sequele
– Severe bleeding
– Preterm birth
– Cesarean delivery
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42. • Other associated problems with PP
– Preterm labor and rupture of the membranes
– Malpresentation
– Intrauterine growth restriction
– Vasa previa and velamentous umbilical cord
– Congenital anomalies
– Amniotic fluid embolism
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43. • Coagulation Defects
– Placenta previa rarely complicated by
coagulopathy
• Placental thromboplastin readily escape through
the cervical canal
• Paucity of large myometrial veins
Hale T., M.D., Resident Physician 43

44. • Diagnosis
– Historical presentation
– Double set-up technique
• Almost obsolete
– Sonographic placental localization
• 96% accuracy,
• 100% negative predictive value
– Transabdominal
– Transperineal
– Transvaginal
– MRI
• For evaluation of placenta accreta
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45. Management
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47. • Expectant management
– Candidates?
– When should termination be effected?
– Home or Hospital?
Hale T., M.D., Resident Physician 47

48. Placenta Accrete Syndrome
• Abnormally implanted placenta
– Placenta Accrete Syndromes
• Placenta accreta, increta, percreta
– Abnormally firm placental attachment
– Poorly developed decidua that lines the lower uterine
segment
– Previa overlying a prior cesarean incision conveys a
particularly high risk for accreta carries a major risk
of placental accrete Syndrome
Hale T., M.D., Resident Physician 48

49. • Abnormality of placental implantation
– Anchoring placental villi normally attaches to
the decidua
• Accreta
– Anchoring placental villi attach to myometrium
• Increta
– Anchoring placental villi penetrate into the myometrium
• Percreta
– Anchoring placental villi penetrate through the
myometrium to the uterine serosa or adjacent organs
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51. • Incidence
– Increasing at an alarming rate
– Accreta > Increta > Percreta
Hale T., M.D., Resident Physician 51

52. • Pathogenesis
– Defective decidualization
– Excessive extravillous trophoblastic invasion
– Defective maternal vascular remodeling in the
area of a hysterotomy scar
– Partial or complete dehiscence of a uterine
scar
Hale T., M.D., Resident Physician 52

53. • Risk Factors
– Placenta previa
– Placenta previa after previous CD scar
– Adavanced maternal age
– Multiparity
– Endometrial ablation
– Prior endometrial irradiation
– Leiomyomas
– Uterine anomalies
– Smoking
Hale T., M.D., Resident Physician 53

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57. Risk of Placenta Accreta Syndrome - In the absence of PP
Hale T., M.D., Resident Physician 57

58. • Clinical Presentation
– Life threatening torential bleeding during an
attempt to separate the placenta manually
– No plane of separation
– 2/3 of peripartum hysterectomies
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59. • Sequelae
– Unplanned surgeries / Hysterectomies
– Death
– ARDS
– DIC
– PPH
– Preterm birth
– SGA infants
Hale T., M.D., Resident Physician 59

60. • Ultrasound Predictors of PPH in a patient
with APH (Placenta Previa)
– If there is placenta accreta syndrome
– Thickness of the lower edge > 1 cms
– If placenta covers the internal Os
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61. • Imaging
– Sonography
• Conventional
• 3-D Ultrasound
• Color dopler
– MRI
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62. Ultrasound Diagnostic Findings in Placenta Accreta
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A. Normal Placenta B. Placenta Accreta

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69. • MRI Diagnositc Features of Placenta
Accreta
1. Uterine bulging
2. Heterogenous signal intensity
3. Dark intraplacental bands
4. Abnormal placental vascularity
5. Focal interruptions in the myometrial wall
6. Tenting of the bladder
7. Invasion of nearby organs
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72. • Lab
– Elevated maternal serum AFP
– Hematuria
– Histology
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73. • Management
– Team work
– Always CD
– Hysterectomy Vs Conservative
– Leaving the placenta for natural resoprtion
– Use of systemic methotrexate
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74. Recommendations
• In this patient
– Placental Accreta Syndrome should be rulled
in or out with dopler study
– Infraumblical midline abdominal incision
should be planned
– Mother should be counseled on histeroctomy
and OR materials should be prepared for
hysterctomy
– The most senior person in the labor ward
should be involved in the OTHale T., M.D., Resident Physician 74

75. REFERENCES
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76. REFERENCES
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77. REFERENCES
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78. Thank you for listening!
Hale T., M.D., Resident Physician 78