MANAGEMENT OF PLACENTA

PRAEVIA
PREVENTION
Adequate antenatal care
Antenatal diagnosis with ultra sound at 20
weeks and repeat at 34 weeks to confirm
diagnosis
Warning hemorrhage should not be ignored
Color flow doppler USG in placenta praevia is
indicated to detect any placenta accreta

AT HOME
Immediate bed rest
Asses blood loss
a)Inspection of clothings soaked with blood
b)Note the pulse ,BP ,degree of anemia
Quick but gentle abdominal examination
Vaginal examination must NOT be done
TRANSFER TO HOSPITAL
I.V Dextrose saline drip should be started and is
kept running during transport
Patient should be accompanied by two or three
persons fit for donation of blood if necessary
ADMISSION TO HOSPITAL
All the cases of Antepartum hemorrhage should
be admitted
REASONS:
a)All the cases of Antepartum hemorrhage
should be regarded as due to placenta praevia
unless proved other wise
b)The bleeding may reoccur
TREATMENT ON ADMISSION
Immediate attention
Formulation of the line of treatment
IMMEDIATE ATTENTION
ASSESS:
1. Amount of blood loss
2.Blood samples are taken for grouping and
estimation of haemoglobin
3.Infusion of normal saline
4.Gentle abdominal palpation for uterine tenderness
and auscultation to note fetal heart
5.Inspection of vulva to note active bleeding
Confirmation of diagnosis from history,examination
and with SONOGRAPHIC EXAMINATION


Formulation of line of treatment
It depends upon:
Duration of pregnancy
Fetal and maternal status
Extent of hemorrhage
EXPECTANT TREATMENT
AIM:
To continue pregnancy for fetal maturity without
compromising maternal health

VITAL PREREQUISITES:
1.Blood for transfusion
2.Facilities for cesarean section should be
available through out 24 hours

Selection of cases:
1.Mother in good health status
2.Duration of pregnancy less than 37 weeks
3.Active vaginal bleeding is absent
4.Fetal well being is assured (USG)

Conduct of expectant treatment
1.Bed rest
2.Investigation like hemoglobin estimation, blood
grouping and urine for protein are done
3.Periodic inspection of vulval pads
4.Suppelementary hematinics
5.Speculum examination to exclude local lesions
for bleeding
6.Use of tocolytics if associated with uterine
contractions

Preterm delivery is done in conditions such as:
1.Reccurence of brisk hemorrhage and which is
continuing
2.Fetus is dead
3.Fetus is congenitally malformed on investigation
Steroid therapy is indicated when the duration
of pregnancy is less than 34 weeks .
Betamethasone reduces the risk of respiratory
distress of new born
ACTIVE MANAGEMENT(DELIVERY)
INDICATIONS:
1.Bleeding occurs at or after 37 weeks of
pregnancy
2.Patient is in labour
3.Patient is exsanguinated on admission
4.Bleeding is continuing and of moderate degree
5.The baby is dead or congenitally deformed
DEFINITIVE MANAGEMENT(DELIVERY)
CESAREAN DELIVERY where placental edge is
within 2cms from internal os.Wider use of
cesarean section reduces maternal risk and
improves fetal salvage
VAGINAL DEIVERY where placental edge s 2-
3cms away from internal os.

VAGINAL EXAMINATION
It should be done with a double set up
arrangement in OT keeping everything ready for
C-section
CONTRAINDICATIONS:
1.Patient in exsanguinated state
2.Major degree of placenta praevia
3.Associated complicating factors like
malprsesentation,elderly primi gravidae etc


LOW RUPTRE OF MEMBRANES:
It is done using long kochers forceps in less
degree of placenta praevia

Finger is reinserted to exclude cord prolapse
PRECAUTIONS DURING VAGINAL
DELIVERY
Restore blood volume
Methergin 0.2 mg given intravenously with the
delivery of anterior shoulder to prevent blood
loss in third stage
Proper examination of cervix soon following
delivery to detect any evidences of tear
Babys blood hemoglobin level is checked and if
needed blood transfusion is done
GENERAL REMARKS IN CESAREAN
SECTION
TYPE-LOWER SEGMENT
CLASSICAL
LOWER UTERINE CESARIAN SECTION:
Advantages :conservant technique
2. decision to preserve or remove the
uterus can easily be made
3.placenta accreta if accidentally met
can also be tackled effectively


Disadvantages:
1.Whole blood shuld be made available
2.Engorged vessels may bleed profusely when they
are cut
3.Anteriorly situated placenta,the placenta may
have to be cut or seperated to deliver the baby
4.Fetal exsanguination
Claasical cessaren section
Advantages:
1.Operation can be done more quickly
2.Baby is delivered without disturbing the
placenta ,no fetal exsanguination
Drawbacks:
1.Lower segment over which placenta is implanted
cannot be visualised and difficult to control
bleeding
Practical guide to lower segment
approach
To make infraumbilical longitudnal incision
To tackle placenta lying underneath the incision
After the placenta is expelled out the lower
segment should be inspected for any oozing
point which is over sewed if needed
Tight intrauterine pack for hemostasis
Atonic uterus
Isthmic cervical apposition suture
Babys blood hemoglobin levelis to be checked at
birth
Thank you