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Placenta previa (PP)

I. Placenta previa (PP) is defined as the presence of placental tissue over or near the internal cervical os. PP can be classified into four types based on the location of the placenta relative to the cervical os: to the internal os.

complete or total previa, the placenta covers the entire cervical os; partial previa, the margin of the placenta covers part but not all of the internal os; marginal previa, the edge of the placenta lies adjacent to the internal os; low-lying placenta, placenta is located near (2 to 3 cm) but not directly adjacent

A. Epidemiology 1. the incidence of PP is 1 in 200 to 1 in 390 pregnancies over 20 weeks' gestational age). varies with parity, For nulliparous, the incidence is 0.2%, in grand multiparous, it may be as high as 5% 2. The most important risk factor for PP is a previous cesarean section. PP occurs in 1% of pregnancies after a cesarean section. The incidence after four or more cs increases to 10%

3. Other risk factors increasing maternal age after age 40), multiple gestation, and previous uterine curettage 4. the placenta covers the cervical os in 5% of pregnancies when examined at midpregnancy. The majority resolve as the uterus grows with gestational age. The upper third of the cervix develops into the lower uterine segment, and the placenta "migrates" away from the internal os.

B. Etiology. unknown. a. Endometrial scarring. b. A reduction in uteroplacental oxygen promotes need for an increase in the placental surface area that favors previa places.

2. Bleeding occur in association with the development of the lower uterine segment in the third trimester. Placental attachment is disrupted because this area gradually thins in preparation for labor.

the thinned lower uterine segment is unable to contract adequately to prevent blood flow from the open vessels.shearing action 3. Vaginal examination or intercourse may also cause separation of the placenta from the uterine wall.

C. Clinical Manifestations 1. 80% of affected patients present with painless vaginal bleeding Most commonly, the first episode is around 34 weeks of gestation; one-third of patients develop bleeding before 30 weeks

2. 30% patients develop bleeding after 36 weeks, 10% go to term without any bleeding The fluid is usually bright red, and the bleeding is acute in onset. 3. The number of bleeding episodes is unrelated to the degree of placenta previa or the prognosis for fetal survival.

4. pp is associated with a doubling of the rate of congenital malformations. a. CNS, GI tract, cardiovascular system, and respiratory system b. Pp is also associated with fetal malpresentation, preterm premature rupture of membranes, and intrauterine growth restriction.

c. Abnormal growth of the placenta into the uterus can result in one of the following 3 complications: i. Placenta Previa Accreta. The placenta adheres to the uterine wall without the usual intervening decidua basalis. The incidence in patients with previa who have not had previous uterine surgery is 4%. The risk is increased 25% in patients who have had a previous cs or uterine surgery

ii. Placenta Previa Increta. placenta invades myometrium. iii. Placenta Previa Percreta. The placenta penetrates the entire uterine wall growing into bladder or bowel.

D. Diagnosis 1. History. PP presents with acute onset of painless vaginal bleeding. A thorough history should be obtained from the patient, including obstetric and surgical history as well as documentation of previous ultrasound examinations. Other causes of vaginal bleeding must also be ruled out, such as placental abruption.

2. Vaginal sonography is the gold standard for diagnosis of previa Placental tissue has to be overlying or within 2 cm of the internal cervical os to make the diagnosis. The diagnosis may be missed by transabdominal scan, if the placenta lies in the posterior portion empty bladder may help in identifying anterior previas, and Trendelenburg positioning may be useful in diagnosing posterior previas.

3. Examination. IfPP is present, digital examination is contraindicated. a. A speculum examination can be used to evaluate the b. Maternal vital signs, abdominal exam, uterine tone, and fetal heart rate monitoring should be evaluated.

E. Management 1. Standard Management a. In the third trimester in a patient who is not bleeding, recommendations include ultrasound confirmation pelvic rest (nothing in the vagina, including intercourse or pelvic exams), explanation of warning signs and when to seek immediate medical attention, avoidance of exercise and strenuous activity, and fetal growth ultrasounds every 3 to 4 weeks. Fetal testing semiweekly

b. Standard management of symptomatic patients with PP hos-pitalization with hemodynamic stabilization and continuous maternal and fetal monitoring. Laboratory studies should be ordered Steroids should be given to promote lung maturity for gestations between 24 and 34 weeks. Rho(D) immunoglobulin should be administered to Rh-neg-ative mothers.

2. Term Gestation, Maternal and Fetal Hemodynamic Stability. At this point, management depends on placental location. a. Complete Previa. Patients with complete previa at term require cesarean section.

b. Partial, Marginal Previa. These patients may deliver vaginally; a double setup in the operating room is recommended. The patient should be prepared and draped for cesarean section. An anesthesiologist and the operating room team should be present. If at any point maternal or fetal

stability is compromised, urgent cesarean section is indicated.

3. Term Gestation, Maternal and Fetal Hemodynamic Instability. The first priority is to stabilize the mother with fluid resuscitation and administration of blood products, if necessary.

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