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Supervisor : dr. Pim Gonta, Sp. OG

PLACENTAPREVIA

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GENERAL CONSIDERATIONS

Placenta Previa : A placenta implanted over / verynear the internal cervical ostium (after 28 weeks)

: !"" for women 19 years or youner and is in "" for women older than !"

"#! $ mortality in Antepartum #aemorrhae

in %"" &irt's (only 2$% are complete)

9$% of patients will &e parous'

Grand mu(tiparas

 hiher incidence : 1 in 2$'$ percent hiher in multifetal gestations

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CLASSI)ICATION

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ETIOLOG* 

+u(tiparit

Advan-in ae

Previous SC de(iver

A lare placenta

A&normal forms ofplacentation (i'e'succenturiate lo&e)

ultiple estation

*moke +iarettes(increased twofold inwomen who smokedciarettes )

/(eedin in placenta previa could &e

caused &y:1' echanical separation of the

placenta from its implantation site,

2' Placentitis, or

!' -upture of poorly supported venous

lakes in the decidua &asalis

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SmptomsPain(ess vaina( &(eedin 01"$2*pontaneous,After coitus

 .he most characteristic symptomate prenancy (after the 28th week) and

delivery+haracteristics: sudden, painless and

profuse

Contra-tions

No smptoms-outine ultrasound 0ndin

Anemia or s'o-3 

-epeated &leedin anemia#eavy &leedin shock

A&norma( 4eta( positionA hih presentin part

reech presentation (often)

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P'si-a( )indins

leedin on speculum e3am

+ervical dilation

A&normal position/lie

4on5reassurin fetal status6f sini0cant &leedin: .achycardia

Postural hypertension*hock

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Dianosis5istorPainless hemorrhaeAt late prenancy or delivery#istory of curettae or +aesarean *ection

Sins7terus is soft, rela3ed and nontender'+ontraction may &e palpated'A hih presentin part cant &e pressed

into the pelvic inlet' reech presentation

etal heart tones may&e disappear(shock or a&ruption)

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Dianosis

Spe-u(um e6amination-ule out local causes of &leedin, such

as cervical erosion or polyp or cancer'

Limited vaina( e6amination0se(dom used2Palpation of the vainal fornices to

learn if there is an intervenin

&oiness &etween the forni3 andpresentin part'

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Dianosis

7(trasoundA&dominal 9"% accurate to

detect

 .ransvainal (.7*) will detectalmost all+onsider what placental location a .7* may 0nd that

  was missed on a&dominal

+RI

C'e-3 t'e p(a-enta andmem&rane a4ter de(iver

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DI))ERENTIALDIAGNOSIS

PLASENTA PREVIAvs

  A/R7PTIOPLASENTA

Painless

Appears less distress

A&domen is soft, non tender

etal parts easily felt

A&normal presentation

7sually normal +.; 4o coaulation defects initially

4o Association with Pre5<clampsia

Painful

Appears more distress

A&domen is tensed, tender

etal parts di=cult to feel

4ormal presentation

A&normal +.; more likely +oaulations defects may occur early

Association with Pre5<clampsia

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P(a-enta previa

&ruptio p(a-enta

P(a-enta a--reta

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+ANAGE+ENT

>epends on:amount of uterine &leedin

duration of prenancy and via&ility of the fetus

deree of placenta previapresentation, position, and station of the fetusravidity and parity of the patient

status of the cervi3

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+anaement

6nitial evaluation/dianosis

?&serve/admit to @>

6 access, routine (may&e serial) la&s

+ontinuous electronic fetal monitorin+ontinuous at least initallyay re5evaluate later if sta&le, no further

&leedin

 >elivery

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+anaement Less t'an 89 3s estation # e6pe-tant

manaement i4 sta&(e, reassurined rest (neotia&le)

4o vainal e3ams (not neotia&le)

*teroids for lun maturation (B!2 wks)

Possi&le manaement at home after 1st &leedC$% will have recurrent vainal &leedin

&efore !D completed weeks reEuirinemerent cesarean

89; ee3s estation+esarean delivery if positive fetal lun

maturity &y amniocentesis

>elivery vs e3pectant manaement if fetallun immaturity

*chedule cesarean delivery at !C weeks

Note:

ivensta&(ematerna(

andreassurin4eta(status,none o4t'ese

manaementuide(inesarea&so(ute0t'is is 'O&stetri-s

is so mu-'4un<2

Placenta previa accreta is found, hemostasis may necessitatea total h sterectom '

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Treatments

E6pe-tant t'erap-est: keep the &ed+ontrollin the contraction: *? .reatment of anemia

Preventin infection

Termination o4 prenan-Caesarean Se-tionVaina( de(iver

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De(iverCesarean Se-tion 

delivery method ofchoice with placentaprevia'

 .otal placenta previa(!Dth week), Partialplacenta previa (!Cthweek) and heavy&leedin with shock

#ypovolemic shock  administration of 6 Fuidsand &lood &efore theoperation is started'

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Vaina( De(iver

ainal delivery marinal implantation

cephalic presentation'

G limited vainal &leedin

?3ytocin &efore amniotomy .amponade

onitorin #- a&normalities +*

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CO+PLICATIONS

Puerperal infection and anemia are the most likely

postoperative complications'

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PROGNOSIS

eternal :ortality has fallen BB 1 in 1$$$rapid recourse to cesarean section,&anked &lood and

e3pertly administered anesthesiaetal: Perinatal mortality rateplacenta previa has declined to appro3imately

1%'

reduced if ideal o&stetric and new&orn care isiven'

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