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Whereas many women experience an uncomplicated pregnancy and childbirth, complication can develop at any point in the pregnancy, labor and delivery, or postpartum period. These complications can lead to serious illness, injury, and even death for the pregnant woman and her baby and place tremendous stress on the family.Antepartum Hemorrhage : Antepartum Hemorrhage Any bleeding occurring from the genital tract after the period of viability (28 weeks) but before birth of the baby is defined as placenta previa.Incidence: Incidence About 1 to 3.5 percent in hospital deliveries Does not contribute towards significant maternal mortality in most developed countries But still continues to cause maternal mortality and morbidity in the developing countries Foetal loss is also significantly highPlacenta Previa (Unavoidable Hemorrhage): Placenta Previa (Unavoidable Hemorrhage) Definition: Placenta praevia is a placenta that is implanted completely or partially over the lower uterine segment (LUS). It incites painless and causeless (no trauma, etc) bleeding.Definition – Cont’d: Definition – Cont’d Placenta that is situated wholly or partially within the lower segment at or after 28 weeks of gestation. A low implantation of the placenta in the uterus causing it to lie alongside or in front of the presenting part.Types/ Degrees of Placenta Praevia: Types/ Degrees of Placenta Praevia In present day practice, with the advent of ultrasound the distance of placental edge in centimeters form the internal os is also an important point in classifying placenta previa. A placental edge more than 2 cm from the cervical os is considered as normal attachment of placenta and hence, is not placenta previa. There are 4 grades or types of placenta praevia.Grade/ Type I (Lateral/Low Lying) : Grade/ Type I (Lateral/Low Lying) Grade/ Type I (Lateral/ Low lying) placenta just encroaches on the lower uterine segment but does not reach up to the internal os. Close to internal os (within 5 cm) The majority of the placenta is in the upper uterine segment. Vaginal delivery is possible Blood loss is usually mild and the mother and fetus remain in good conditionGrade/Type II (Marginal): : Grade/Type II (Marginal): The placenta reaches the internal os when closed, but does not cover it. It can be - Anterior - Posterior Vaginal delivery is possible, particularly if the placenta is anterior Blood loss is usually moderate, although the conditions of the mother and fetus can vary. Fetal hypoxia is more likely to be present than maternal shockPowerPoint Presentation: Type II posterior placenta previa is also known as ‘Dangerous Placenta Previa’ because: Major thickness of the placenta overlies the sacral promontory, thereby diminishing the antero-posterior diameter of the inlet and preventing engagement of the presenting part. When patient delivers vaginally, the placenta is likely to be compressed between the presenting part anteriorly and the sacral promontory leading of foetal hypoxia. There are greater chances of cord compression or cord prolapsed.Grade/ Type III (Partial/ Incomplete Central) : Grade/ Type III (Partial/ Incomplete Central) Covers the internal os partly when closed, but does not cover it fully when the internal os is completely dilated. Bleeding is likely to be severe, particularly when the lower segment stretches and the cervix begins to efface and dilate in late pregnancy. Vaginal delivery is inappropriate because the placenta precedes the fetus.Grade/ Type IV (Total/Complete/Central) : Grade/ Type IV (Total/Complete/Central) It covers the internal os completely even when the os is fully dilated. Torrential hemorrhage is very likely Caesarean section is essential in order to save the lives of the mother and fetus.TYPES OF PLACENTA PREVIA: TYPES OF PLACENTA PREVIACauses : Causes Generally Accepted Theories: Dropping down theory of zygote and its implantation in the lower uterine segment which normally implants in the upper segment. This could be as a result of poor decidual reaction in the upper uterine segment.Defective decidua basalis: Defective decidua basalis The placenta encroaches over a wide area in the uterine wall (especially seen in older patients, grand multipara, past history of manual removal of placenta, D & C or MTP or previous caesarean section)PowerPoint Presentation: Hyperplacentosis: Here a larger area is covered by the placenta, e.g. Multiple pregnancy, anemia, Rh Isoimmunisation. Persistence of chorion leave: This leads to formation of a capsular placenta, which encroaches on the LUS.PowerPoint Presentation: Association with placental and cord abnormalities like: Battledore placenta, membranous placenta, succenturiate lobe, multipartite placenta, velamentous cord insertion. Some ethnic groups are especially prone to placenta previaPowerPoint Presentation: Smoking and drug abuse (cocaine) increase the incidence of placenta previa. During smoking there is carbon monoxide production leading to tissue hypoxia causing compensatory placental hypertrophy which encroaches on the lower uterine segment.Predisposing Factors : Predisposing Factors Grand multiparity Increasing maternal age(2 to 3 times higher in women over 35 years) Multiple pregnancies Rhesus negative blood group of the pregnant women and rhesus positive husband Previous lower segment caesarean section Previous spontaneous or induced miscarriages and curettage Preview history of placenta praeviaPredisposing Factors – Cont’d : Predisposing Factors – Cont’d More common in some ethnic groups, e.g. women of Asian origin. More common in mothers who smoke during pregnancy or consume cocaine during pregnancy. Foetal malpresentations may be the cause or effect of placenta previa Uterine anomalies may predispose to low implantation of the placenta as well as malpresentation. Uterine scars: scars from previous surgical procedures, for example myomectomy, submucous fibroids, TCRE (transcervical resection of the endometrium)Clinical Features: Clinical Features Symptoms Bleeding per vaginum Pain in abdomen: - Absent unless spontaneous labour ensuresClinical Features – cont’d: Clinical Features – cont’d General Examination: Pallor May or may not be in shock depending on the amount of bleeding Per-Abdomen Examination: Abdomen is soft The uterus is relaxed and non-tender, corresponding to the period of amenorrhoea Malpresentation are often associated Foetal parts are easily felt and FHS may be normal.PowerPoint Presentation: Presenting part is floating. “Stalworthy’s sign” may be seen in type II b placenta previa Per-Speculum: Placental tissue may be seen if the os is open Per-Vaginum: A pervaginal examination is not to be done in a case of PH, unless placenta previa is ruled out because it may provoke serious bleeding which may be life-threatening If USG is not available for diagnosis then a double set up vaginal examination can be done on OT table with all preparation for immediate caesarean section..Diagnosis-Clinical : Diagnosis-Clinical High index of suspicion should be kept if there is foetal malpresentation or even slight per-vaginal bleeding is noticed in the late pregnancy, or if predisposing factors are present. If ultrasound is not available, a diagnosis can be established by PV examination in OT with readiness for immediate surgery, by direct visualization during caesarean section and examination of placenta following delivery.Investigations: Investigations USG MRI: Helpful to diagnose placenta accrete and percreta Radiography Radioactive isotopes study (Technetium scanning) Arteriography Soft tissue placentography Thermography Transabdominal imagingInvestigations for management : Investigations for management Hemoglobin, PCV Blood group VDRL Urine IF Rh Negative-coomb’s test Kleihauer-Betke test Pap SmearDifferential Diagnosis : Differential Diagnosis Placenta previa is differentiated from premature separation of a normally situated placenta (Abruption Placenta). Vasa previa unsupported umbilical vessels in velamentous placenta, lie below the presenting part and run across the cervical os. Local Cervical Lesions (Polyps, carcinoma) Circumvallate placentaPrognosis : Prognosis Maternal: Substantial reduction of maternal deaths in placenta previa throughout the globe Reduction of maternal deaths from placenta previa to less than 1% or even to zero in some centres. The ultimate causes of death are hemorrhage and shock The morbidity is somewhat raised due to hemorrhage and operative deliveryFetal : Fetal The reduction of deaths is principally due to judicious extension of expectant treatment thereby reducing the loss form prematurity, liberal use of caesarean section which greatly lessens the loss form anoxia and improvement in the neonatal care unit. Still the perinatal mortality ranges from 10-25%. Causes of death are prematurity, asphyxia and congenital malformation.Management : Management Early Detection: Adequate antenatal care Antenatal diagnosis Significance of ‘warning hemorrhage should not be ignored or underestimated Family planning and limitation of births Transfer to hospital in timePowerPoint Presentation: The management of placenta previa depends on: The amount of bleeding The condition of mother and fetus The location of the placenta The stage of pregnancyComplications - Maternal: Complications - Maternal Long hospital stay Due to hemorrhagic shock & hypotension, e.g. Adult respiratory failure, renal cortical necrosis PROM, preterm labour, cord prolapsed More operative interference due to CS and emergency surgery Risk of sensitization in Rh negative patient DIC Problems specific to placenta previa are: Placenta accreta Uterine atony and PPHFetal Complications: Fetal Complications Prematurity Asphyxia Birth trauma Fetal malpresentations Fetal abnormality (Eg. Spina bifida) Foetal hypovolemia Perinatal mortality ranges from 7-25%PowerPoint Presentation: THANK YOU You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.