Placenta praevia
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Transvaginal ultrasound has higher accuracy than transabdominal ultrasound for diagnosing placenta previa, with 99% positive predictive value and 1-2% false negative rate compared to 95% and 7% respectively. Management of placenta previa involves abstaining from sexual activity and pelvic exams after 20 weeks of gestation, monthly ultrasounds to check if placenta has moved, and considering tocolytic therapy for bleeding. Surgical options include uterine packing with balloons, brace sutures, stepwise devascularization by ligating uterine and internal iliac arteries, and hysterectomy as a last resort. Uterine artery embolization is also an option to preserve fertility while
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Placenta praevia
- 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
- 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
- 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
- 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
- 22. B –Lynch sutureB –Lynch suture
- 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
- 24. Vertical compression suturesVertical compression sutures
- 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
- 31. Internal iliac artery ligationInternal iliac artery ligation Bleeding fromBleeding from Lower uterine segmentLower uterine segment CervixCervix VaginaVagina Paravaginal areasParavaginal areas
- 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
Editor's Notes
- 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
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