Management of Placenta

Praevia
By
Dr Dambo
• INTRODUCTION
• HISTORY TAKING
• PHYSICAL EXAMINATION
• INVESTIGATIONS
• DIAGNOSIS
• TREATMENT
• COMPLICATIONS
• PROGNOSIS
• CONCLUSION
 Introduction
Maternal and fetal morbidity and mortality
from placenta praevia are considerable
and are associated with high demands on
health resources. Consensus views as to
how we should manage these cases,
especially in the face of a rising incidence
of placenta praevia and its complications
are therefore considered important.
 History
• Vaginal bleeding
– It is apt to occur suddenly during the third trimester.
– Bleeding is usually bright red and painless. Some
degree of uterine irritability is present in about 20% of
the cases.
– Initial bleeding is not usually profuse enough to cause
death; it spontaneously ceases, only to recur later.
– The first bleed occurs (on average) at 27-32 weeks'
gestation.
– Contractions may or may not occur simultaneously
– with the bleeding
High presenting part.
 Physical Examination
• Pallor
• Hypotension
• Tachycardia
• Soft and nontender uterus
• Normal fetal heart tones (usually)
• Vaginal bleeding -Bright red
-Spotting
-Profuse –with clots
– Blood loss usually not extensive to produce shock
– Do not perform digital vaginal examination because it
may provoke uncontrollable bleeding.
 Investigations
• FBC+differentials
• Rh compatibility if needed
• Fibrin split products (FSP) and fibrinogen levels
• Prothrombin time (PT)/activated partial
thromboplastin time (aPTT)
• Type and hold for at least 4 units
• Apt test to determine fetal origin of blood (as in
the case of vasa previa)
• Lecithin/sphingomyelin (L/S) ratio for fetal
maturity, if needed
 Investigations contd
• Transabdominal ultrasonography
– A simple, precise, and safe method to visualize the
placenta, this ultrasonography has an accuracy of 93-
98%.
– False-positive results can occur secondary to focal
uterine contractions or bladder distention.
• Transvaginal ultrasonography
– Recent studies have shown that the transvaginal
method is safer and more accurate than the
transabdominal method. Transvaginal ultrasound is
also considered more accurate than transabdominal
ultrasound. The angle between the transvaginal probe
and the cervical canal is such that the probe does not
enter the cervical canal. Some advocate insertion of
the probe no more than 3 cm for visualization of the
placenta.
 Investigations contd
• Magnetic Resonance Imaging (MRI)
-It is a very accurate method of
diagnosing PP
-It is available only in few centres
-It is an expensive investigation
• Soft tissue placentography, compression
radiography, isotopic placentography,
arterial placentography,
 DIAGNOSIS
• Transvaginal ultrasonography
• If the location of the placenta is unknown
and sonography is not available, a double
set-up bimanual examination under
anesthesia (EUA) may be performed in
the operating room.
 Treatment
• It depends on the gestational age
• The extent of haemorrhage
• Type of placenta praevia
 Treatment contd
• Expectant management -The
aim is to allow the pregnancy to continue to a
point at which the baby is unlikely to encounter
major complications of immaturity after delivery.
• This policy was introduce by Macafee in 1945 at
Royal Maternity Hospital Belfast it involves:-
1, From the
time of diagnosis, the woman was advised to
remain in hospital.
2,Blood was to be constantly available for
immediate transfusion.
3,Facilities were to be available for
immediate caesarean section.
4,Anaemia was to be identified and
corrected, if necessary by repeated blood
transfusion, because of the likelyhood of
further haemorrhage
This policy was introduce to reduce the
perinatal mortality associated with PP
Normal Saline IVF
• With current anxieties about the risk of
viral infections after blood transfusion,
autologous blood donation can be
considered.
• It is likely to be of limited value in women
with PP
• Because bleeding occurs mainly as a
result of placental detachment from
lengthening lower uterine segement and
dilating cervix, cervical cerclage has been
advocated. Not backed up by sufficient
evidence
• Also the use of tocolytic drugs to prevent
premature labour may be indicated to
prolong pregnancy at least up to 36weeks.
• Although it is controversial. Due to the
side effects of tocolytic drugs.
• While on admission patient should be
closely monitored.
• Despite repeated blood transfusions and
patient is deteriorating, pregnancy is
terminated.
• If GA if between 28-34wks corticosteriods
is given to promote fetal lung maturity.
This is given 24hours before termination.
 ACTIVE MANAGEMENT
Vaginal delivery
-Reserve for patients with minor degree
PP
-Arm
-oxytocin drip.
Caesarean section
-choice for major degree PP
-resuscitation before surgery.
-It can end up in caesarean hysterectomy
-At least 2 units of blood crossmatched.
 Complications
Maternal
-haemorrhage
-shock
-placenter accreta
-death
Fetal
-prematurity
-IUGR
-Congenital anomalies
-Fetal anemia and Rh isoimmunization
• -fetal death
 Prognosis
With the abandonment of double set up,
the use of caesarean section, use of
banked blood and expertly administered
anesthesia, the overall maternal and
perinatal mortality and morbidity has
fallen. Although premature labour,
placenter seperation cord accidents an
uncontrollable haemorrhage cannot be
avoided.
 Conclussion
• Placenta previa is a disease that occur with
increasing frequency in current obstetric practice.
Ultrasonography has greatly improved the ability
to diagnose this condition antenatally.
Improvements in antibiotic therapy, neonatal
intensive care, and blood component therapy
have decreased the previously high maternal and
fetal morbidity and mortality rates. However, this
disease will pose a risk to the mother and fetus.
Counseling and preparation for the problems that
may ensue will greatly benefit the patient and the
obstetrician.