Introduce myself

 Chinese name: 董 迪 荣
 English name: Dong dirong
 Profession: Obstetrics and
Gynecology
 Work in: Zhongnan Hospital
of Wuhan University
If you are a doctor...

 Eg: 28GW, bedding

is soaked by an
impressive amount
of blood.
You

 How to diagnose ？

 How to treat ？

 How to explain ？
Causes of 763 pregnancy-related
maternal deaths due to hemorrhage
---------------------------------------------------------------
Causes of hemorrhage number(%)
---------------------------------------------------------------
Placental abruption 141(19)
Laceration/uterine rupture 125(16)
Uterine atony 115(15)
Coagulopathies 108(14)
Placental previa 50(7)
***
---------------------------------------------------------------
Williams Obstetrics 22nd edition, Page810
Placental previa

Dong dirong
Obstetric & Gynecological department of
Zhongnan Hospital of Wuhan University
We should understand

 Definition
 Classification
 Signs and symptoms
 Diagnosis
 treatment
什么叫子宫下段？ 宫底

宫腔

宫体
(Isthmus
uteri)
解剖学内口
宫颈管
组织学内口

宫颈阴道上部
宫颈外口

宫颈阴道部

（ 1 ）子宫冠状端面 （ 2 ）子宫矢状端面
(Lower uterine
segment)
The normal part that the
placenta adhere to
Definition

 In placenta previa, the placenta is

implanted in the lower uterine
segment and located over or very
near the internal os. It constitutes
an obstruction to descent of the
presenting part.
Placenta previa is

 Main cause of obstetrical

hemorrhage

 Incidence

0.24%-1.57% (our country)

Etiology
 Uncertain
 High risk factors
maternal age: >30 or <20 years old
multiparity: 85% - 90%
previous cesarean delivery: 5 times
previous placenta previa
smoking
Etiology
 Causes
1. Endometrial abnormality
Scared or poorly vascularized endometrium
in the corpus
Curettage, Delivery, CS and infection of
endometrium
2. Placental abnormality
Large placenta (multiple pregnancy),
succenturiate lobe ( 副胎盘 )
3. Delayed development of trophoblast
classification

 Total placenta previa

(Central placenta previa )
 Partial placenta previa
 Marginal placenta previa
Total placenta previa

The internal
os is covered
completely
by placenta
Partial placenta previa

The internal
os is covered
partialy by
placenta
Marginal placenta previa

The edge of
placenta is at
the margin of
the internal os
Low-iying
placenta

 The placenta lies

lower segment of
the uterus but
doesn’t attach
the edge of the The placenta, in the lower left
corner of the uterus in this
cervical os. illustration, nourishes the
developing baby and takes away
waste products. It is connected
to the baby by the umbilical cord.
Clinical findings
 Symptoms
 Painless hemorrhage
1. The most characteristic symptom
2. Time: during late pregnancy (usually after the
28th week) and delivery
3. Characteristics: sudden, painless, repeated and
profuse
4. Cause of bleeding: Mechanical separation of the
placenta from its implantation site, either during
the formation of the lower uterine segment, or
during effacement and dilatation of the cervix in
labor; Placentitis; Rupture of the veins in the
decidua basalis
Clinical findings
 Symptoms
 Anemia or shock
repeated bleeding→ anemia
heavy bleeding→ shock
 Abnormal fetal position
a high presenting part
breech presentation (often)
Clinical findings
Total placenta
previa
Partial placenta
Early(20-28wks) previa Marginal
Large amount placenta previa
Several times Between total
and marginal Late(37-40wks
or in labor )
Less bleeding

Bleeding time and volume

Clinical findings
 Signs
 The uterus is usually soft and relaxed.
 The infant position is oblique or
transverse in about 15% of cases.
 Fetal distress is not usually present
exercise
What is placenta previa ?
 How mang types of
placenta previa?
 And what they are?
What is total placenta previa?
What is marginal placenta previa?
What is the cause of
vaginal bleeding induced
by placenta previa?
4. Which is the most charicteristic
symptom of placenta previa?

 A. Painless vaginal bleeding

 B. Abdomen pain
 C. Palpitation
 D. Dizziness
 E. Dim eyesight
5. Which are the causes of
placenta previa?
 A. Endometrial abnormality
 B. Large placenta
 C. Succenturiate lobe
 D. Hypertensive disorder complicating
pregnancy
 E. Delayed development of
trophoblast
case
 Patient: 29 years old, G6P034GW ， Painless
vaginal bleeding for 1 hours.
 Clinical findings ：
BP100/70mmHg ， HR84/min ， fetal
position clear ， LSA ， FHR144/min ， once
menstrual amount of blood recently.
 Ultrasound ： placenta implanted on the
lower uterine segment, its edge touches the
margin of the internal cervical os.
questions

The diagnosis and Classification of

placenta previa.
Diagnosis
 low-lying not
placenta in maybe
early plcenta
pregnancy previa

 low-lying
placenta in
the second
plcenta
half of previa
pregnancy
Diagnosis

 History
1. Sudden, Painless vaginal bleeding

2. At late pregnancy or delivery

3. History of curettage or CS
Diagnosis
 Signs
 Abdominal examenation
1) Uterus is soft, relaxed and nontender
2) Contraction may be palpated
3) A high presenting part can’t be pressed
into the pelvic inlet; Breech presentation
4) Fetal heart tones maybe disappear
(shock or abruption)
Diagnosis
 Signs
 Speculum examination ( 窥阴检查 )
Rule out local causes of bleeding, such
as cervical erosion or polyp or cancer.
Diagnosis
 Signs
 vaginal examination is limited
Palpation of the vaginal fornices to
learn if there is an intervening
bogginess between the fornix and
presenting part, but it is dangerous
 Rectal examination is also useless
and dangerous
Accessory examinations
 Ultrasonography
 transabdominal or transvaginal:
1. The most useful diagnostic method:
95%
2. Not make the diagnosis at the mid
pregnancy
Marginal placenta previa
Total Placenta Previa
Partial Placental Previa
（ Crucial triangle ）
Total Placental Previa
Accessory examinations

 Check the placenta

and membrane
after delivery
<7cm
Accessory examinations

 Magnetic
resonance
imaging
(MRI)
Differential Diagnosis
 Placental abruption
vagina bleeding with pain, tenderness
of uterus.
 Vasa previa
 Abnormality of cervix
cervical erosion or polyp or cancer
Complications
 Maternal complications
 Hypovolemic shock, consumptive
coagulopathy and death.
 Placenta Increta or percreta
 Anemia
 infection
 Fetal complications
 prematurity (infant is less than 36 weeks
gestation)
 Fetal blood loss or hemorrhage during
labor or CS
Treatment
 Women with a placenta previa may be
considered as follows:
1.Those in whom the fetus is preterm and there
is no indication for delivery
2.Those in whom the fetus is resonably mature
3.Those in labor
4.Those in whom hemorrhage is so severe as to
mandate delivery despite fetal immaturity
Treatment

Principle
 Inhibit contraction
 Stop bleeding
 Correct anemia
 Prevent infection
Expectant therapy

 Indications:
Expectant Therapy is
appropriate when the mother
is stable (the bleeding is
minor) and the fetus is
immature (<34wks).
Expectant therapy
 Methods:
Rest: keep the bed
No vaginal examintion
Controlling the contraction: MgSO4
Glucocorticoids for lung mature
Treatment of anemia
Preventing infection
Termination of Pregnancy
 Cesarean section: It has proven to
be the most important factor in reducing
maternal and infant death rates
1) Indications: total placenta previa (36th
week), Partial placenta previa (37th week) and
heavy bleeding with shock
2) Preventing postpartum hemorrhage:
pitocin and PG
3) Hysterectomy: Placenta accreta or
uncontroled bleeding
Termination of Pregnancy

 Vaginal delivery
Marginal placenta previa:
Spotting vaginal bleeding

Vaginal bleeding is limited

Prevention
 Control the birth well, promote contraception.
 prevent the prolificacy, avoid the multiple
dilation and curettage, reduce the endometrium
damage or infection.
 Strengthen the management and propaganda of
pregnant woman. To gestational hemorrhage,
regardless its volume, must go to see a doctor,
achieve the prompt diagnosis, correct
treatment.
Important contents
 Definition: the placenta is implanted in the
lower uterine segment and located over or
very near the internal os.
 Classification: Total placenta previa,
Partial placenta previa, Marginal placenta
previa
 The charicteristic symptom: painless,
sudden, repeated and profuse vaginal bleeing
Important contents
 Diagnosis: sepecific history, charicteristic
symptoms, ultrasounic examination
 Complications:
maternal (Placenta percreta,Anemia,infection)
fetal (prematurity, fetal blood loss)
 Treatment: expectant therapy, C-section is the
important method of termination of Pregnancy
1.About the treatment of the
placenta previa, which one is
faulse?

 The treatmental principle is to stop bleeding and supply the

blood volume
 According to the pregnant weeks, the type of placenta
previa, the volume of blood, whether be in shock or not to
decide whether to use the expectant therapy
 The decision should be made according to the number of
birth, the fetal position, whether the baby survive or not
 According to the relationship between placenta and internal
os, ultrasound diagnoses the type of placenta previa
 No matter the cervical os opening or not, artificial broken of
membrane will never be permitted
2.If a patient is suspected of
placenta previa,which examination
should be choose at first?

 A. Vaginal or rectal examination

 B. Ultracound
 C. MRI
 D. Cross-match blood
 E. Abdominal examination
3. To total placenta previa, which is the
best way of termination of pregnancy?

 A. Vaginal delivery
 B. Vaginal delivery first, then C-section
 C. C-section
 D. Observation
 E. C-section first, then Vaginal delivery
4. Which are the complication
of placenta previa to the
mother?

 A. Shock
 B. Anemia
 C. Placenta percreta
 D. Infection
 E. Ectopic pregnancy
 Case 1
 Patient: 29 years old, G6P034GW ， Painless vaginal
bleeding for 1 hours.
 Clinical findings ： BP100/70mmHg ， HR84/min ， fetal position
clear ， LSA ， FHR144/min ， once menstrual amount of blood
recently.

 Ultrasound ： placenta implanted on the lower uterine

segment, 2.5cm to the internal cervical os.
Question

1. What is the therapy of this patient?

2. What is the expectant methods?

Case 2
 Basic Case:

A 25-year-old primigravida at 32

weeks’ gestation comes to the

maternity unit with painless bright-red

vaginal bleeding
Case 2
Thank You