Placenta Previa

Supervised by:
dr. Pim Gonta, Sp.OG

Compiled by:
Sherynne Sulaiman

2013.061.081

Kent Pradana

2014.061.131

Emily

2014.061.132

Marsha Desica Arsanta

2014.061.136

Definition
After 28 pregnant weeks placental implantation over the cervical
ostium or in the lower uterine segment
It constitutes an obstruction of descent of the presenting part
Main cause of obstetrical hemorrhage (20%)
Incidence: 0.24%-1.57%

Epidemiology
US: occur in 0.3-0.5% of all US pregnancies
Incidence: 2.8 per 1000 live births
Prevalence rate of placenta previa = 4.0 per 1000
births:
USA-based studies (4.5 per 1000 births)
Foreign-based studies (3.7 per 1000 births)

Risk Factors & Associations

Prior cesarean delivery/myomectomy risks increase 1.5- to 5-fold
Prior myomectomy
Prior previa (4-8% recurrence risk)
Previous or recurrent abortion
Abnormal presentation
Advancing maternal age (>35 y)
Multiparity (5% in grand multiparous patients)
Multiple gestation

Risk Factors & Associations

Short interpregnancy interval
Previous uterine surgery, uterine insult or injury
Infertility treatment
Nonwhite ethnicity
Low socioeconomic status
Smoking
Cocaine use

Etiology
Endometrial abnormality
Scared or poorly vascularized endometrium in the corpus.
Curettage, Delivery, CS and infection of endometrium
Placental abnormality
Large placenta (multiple pregnancy), succenturiate lobe
Delayed development of trophoblast

Classification

Marginal
Placenta Previa

Partial Placenta
Previa

Complete
Placenta Previa

Symptoms
Painless vaginal bleeding
(70%)
Spontaneous,After coitus
The most characteristic
symptom
Late pregnancy (after the 28th
week) and delivery
Characteristics: sudden, painless
and profuse
Contractions
No symptoms
Routine ultrasound finding

Anemia or shock
Repeated bleeding anemia
Heavy bleeding shock
Abnormal fetal position
A high presenting part
Breech presentation (often)

Physical Findings
Bleeding on speculum exam
Cervical dilation
Abnormal position/lie
Non-reassuring fetal status
If significant bleeding:
Tachycardia
Postural hypertension
Shock

Diagnosis
History
Painless hemorrhage
At late pregnancy or delivery
History of curettage or Caesarean Section
Signs
Uterus is soft, relaxed and nontender.
Contraction may be palpated.
A high presenting part cant be pressed into the pelvic
inlet. Breech presentation
Fetal heart tones maybe disappear (shock or abruption)

Diagnosis
Speculum examination
Rule out local causes of bleeding, such as cervical erosion or polyp
or cancer.
Limited vaginal examination (seldom used)
Palpation of the vaginal fornices to learn if there is an intervening
bogginess between the fornix and presenting part.

Diagnosis
Ultrasound
Abdominal 95% accurate to detect
Transvaginal (TVUS) will detect almost all
Consider what placental location a TVUS may
find that was missed on abdominal
Transperineal accurate to localize placenta previa
MRI to visualize placental abnormality, including
previa
Check the placenta and membrane after
delivery

Differential Diagnosis
Placental Abruption
Vagina bleeding with pain,
tenderness of uterus.
Vasa Previa
In cases of velamentous cord
insertion fetal vessels cover
cervical os.
Abnormality of Cervix
Cervical erosion or polyp or cancer.

Treatments
Expectant therapy
Rest: keep the bed
Controlling the contraction:
MgSO4
Treatment of anemia
Preventing infection

Termination of pregnancy
Caesarean Section
Total placenta previa (36th
week), Partial placenta
previa (37th week) and
heavy bleeding with shock
Vaginal delivery
Marginal placenta previa
Vaginal bleeding is limited

MANAGEMENT
Depends on:
amount of uterine bleeding
duration of pregnancy and viability of the fetus
degree of placenta previa
presentation, position, and station of the fetus
gravidity and parity of the patient
status of the cervix

Management
Initial evaluation/diagnosis
Observe/admit to labor and delivery
IV access, routine (maybe serial) labs
Continuous electronic fetal monitoring
Continuous at least initally
May re-evaluate later if stable, no further bleeding
Delivery

Management
Less than 36 wks gestation - expectant management if stable,
reassuring
Bed rest (negotiable)
No vaginal exams (not negotiable)
Steroids for lung maturation (<32 wks)
Possible management at home after 1st bleed
70% will have recurrent vaginal bleeding before 36 completed weeks
Note: given stable
requiring emergent cesarean
maternal
and
reassuring
fetal
36+ weeks gestation
status, none of these
Cesarean delivery if positive fetal lung maturity by amniocentesis
management
guidelines
are
Delivery vs expectant management if fetal lung immaturity
absolute (this is why
Obstetrics is so much
Schedule cesarean delivery at 37 weeks
fun!)
Discussion/counseling regarding cesarean hysterectomy

Delivery
Cesarean Section delivery method of choice with placenta previa.
Most often, a transverse uterine incision is possible
Because of the poorly contractile nature of the lower uterine segment,
there maybe unconbtrollable hemorrhage following placental removal
Hypovolemic shock administration of IV fluids and blood before the
operation is started.

Vaginal Delivery
Vaginal delivery

marginal implantation

cephalic presentation.
+ limited vaginal bleeding
Oxytocin before amniotomy
Tamponade
Monitoring FHR

abnormalities CS

COMPLICATIONS

Puerperal infection and anemia are the most likely postoperative

complications.

PROGNOSIS
Meternal :Mortality has fallen << 1 in 1000
rapid recourse to cesarean section,
banked blood and
expertly administered anesthesia
Fetal: Perinatal mortality rate
placenta previa has declined to approximately 1%.
reduced if ideal obstetric and newborn care is given.

Thank You