placenta praevia associate professor iolanda elena blidaru md, phd
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PLACENTA PRAEVIAPLACENTA PRAEVIA
Associate ProfessorAssociate Professor
Iolanda Elena BlidaruIolanda Elena Blidaru
Md, PhD.Md, PhD.
PLACENTA PRAEVIAPLACENTA PRAEVIA
DefinitionDefinitionPPlacenta praevialacenta praevia = = placental insertion over placental insertion over or very near the internal os of the cervix (in or very near the internal os of the cervix (in the lower uterine segment including the the lower uterine segment including the zone of effacement and dilatation).zone of effacement and dilatation).
obstacle in front of the presenting partobstacle in front of the presenting partthe most frequent cause of third trimester the most frequent cause of third trimester bleedingbleeding
PLACENTA PRAEVIAPLACENTA PRAEVIA
ClassificationClassification
Depending if the placenta covers the internal Depending if the placenta covers the internal cervical os completely or partially:cervical os completely or partially:
1.1. TotalTotal placenta praevia placenta praevia
2.2. PartialPartial placenta praevia placenta praevia
3.3. MarginalMarginal placenta praevia placenta praevia
4.4. Low-lyingLow-lying placenta placenta (laterally inserted (laterally inserted placenta) placenta)
PLACENTA PRAEVIAPLACENTA PRAEVIA
This classification is made on This classification is made on the basis of findings at the the basis of findings at the initial examination and may initial examination and may
change in labor or as change in labor or as pregnancy advances.pregnancy advances.
PLACENTA PRAEVIAPLACENTA PRAEVIA
IncidenceIncidence
0.5% -1% of all births0.5% -1% of all birthsUS of early pregnancies - a large number of low-US of early pregnancies - a large number of low-lying pregnancies subsequently aborted.lying pregnancies subsequently aborted."placental migration" (US evaluation)"placental migration" (US evaluation) → as → as pregnancy advances, the lower uterine segment pregnancy advances, the lower uterine segment lengthens and the placenta is drawn upward with lengthens and the placenta is drawn upward with the enlarging uterus. the enlarging uterus.
PLACENTA PRAEVIAPLACENTA PRAEVIA
Risk factorsRisk factors previous cesarean section (x 6)previous cesarean section (x 6) multiparity(x 2.6)multiparity(x 2.6)advancadvanceded age age previous D&Cprevious D&C smokingsmoking
PLACENTA PRAEVIAPLACENTA PRAEVIA
EtiologyEtiologyinflammatory or atrophic changesinflammatory or atrophic changes of of the endometriumthe endometrium (endometritis, (endometritis, hypoplasia, submucous myomas, trauma)hypoplasia, submucous myomas, trauma) → → ddefective decidual vascularizationefective decidual vascularizationttwin pregnancywin pregnancy, with large placental bed, with large placental bedincreased surface of increased surface of thethe placenta placenta implanted in the lower uterine segment implanted in the lower uterine segment ((tissues → unappropriate for nidationtissues → unappropriate for nidation) )
PLACENTA PRAEVIAPLACENTA PRAEVIA
PathogenesisPathogenesispainless bleedingpainless bleeding → → maternal blood + fetal maternal blood + fetal blood blood ((a little parta little part))..
MechanismsMechanisms::separation of the placenta from its separation of the placenta from its implantation siteimplantation siteformation of the lower uterine segment formation of the lower uterine segment effacement and dilatation of the cervix in laboreffacement and dilatation of the cervix in laborrupture of rupture of thethe venous lake in the decidua venous lake in the decidua basalisbasalis
PLACENTA PRAEVIAPLACENTA PRAEVIA
Associated conditionsAssociated conditionsplacenta accreta → placenta accreta → abnormally firm abnormally firm adherence to the uterine walladherence to the uterine wall
placenta increta → placenta increta → placental villi invade placental villi invade the myometrium the myometrium
placenta percreta → placenta percreta → placental villi placental villi penetrate through the myometriumpenetrate through the myometrium
PLACENTA PRAEVIAPLACENTA PRAEVIA
Clinical findingsClinical findingspainless bleeding (maternal origin)painless bleeding (maternal origin)slight or profuse hemorrhage slight or profuse hemorrhage the blood is bright redthe blood is bright redpostpartalpostpartal excessive hemorrhageexcessive hemorrhage →→
1.1. abnormal adherence,abnormal adherence,2.2. excessively large area of attachement, excessively large area of attachement, 3.3. the poorly contracted lower uterine segment,the poorly contracted lower uterine segment,4.4. lacerations in the cervix and lower segment.lacerations in the cervix and lower segment.
PLACENTA PRAEVIAPLACENTA PRAEVIADiagnosisDiagnosis
abdominal examination: abdominal examination: ababnormal fetal normal fetal presentation (presentation (transverse lie, breech transverse lie, breech presentation), the presenting part is high above presentation), the presenting part is high above the inlet and deviated anteriorly or laterally the inlet and deviated anteriorly or laterally
FHR - normalFHR - normal
If cervical os dilated → cautious inspectionIf cervical os dilated → cautious inspection
digital examination is never permitted digital examination is never permitted unless unless at term pregnancy, in an operating room with all at term pregnancy, in an operating room with all the preparations for immediate cesarean section; the preparations for immediate cesarean section; the examination can cause life-threatening the examination can cause life-threatening hemorrhage.hemorrhage.
PLACENTA PRAEVIAPLACENTA PRAEVIA
DiagnosisDiagnosisSonographySonography
transabdominal US transabdominal US (96% accuracy)(96% accuracy)transvaginal UStransvaginal US transperineal UStransperineal US
PLACENTA PRAEVIAPLACENTA PRAEVIA
Differential diagnosisDifferential diagnosisCervical bleedingCervical bleeding → benign / malignant → benign / malignant lesionslesions
Endouterine bleedingEndouterine bleeding: : premature separation of the normally premature separation of the normally
implanted placenta, implanted placenta, rupture of umbilical cord vessels,rupture of umbilical cord vessels,premature labor. premature labor.
PLACENTA PRAEVIAPLACENTA PRAEVIA
DELIVERY MODEDELIVERY MODEPractically all Practically all women do need women do need cesarean sectioncesarean section..
PLACENTA PRAEVIAPLACENTA PRAEVIACONDUCT AT THE CONDUCT AT THE DELIVERY DELIVERY
Several clinical situations:Several clinical situations: 1. The patient is in labor → 1. The patient is in labor → cesareancesarean sectionsection 2. The fetus is mature and the bleeding does not stop 2. The fetus is mature and the bleeding does not stop
→ → cesarean sectioncesarean section 3. The fetus is preterm and there is no indication for 3. The fetus is preterm and there is no indication for
delivery → delivery → observeobserve 4. The bleeding is so severe, despite the fetus 4. The bleeding is so severe, despite the fetus
immaturity → immaturity → cesarean sectioncesarean section 5. Total placenta praevia with dead fetus 5. Total placenta praevia with dead fetus →→ cesareancesarean
sectionsection (the bleeding cannot be controlled). (the bleeding cannot be controlled).
PLACENTA PRAEVIAPLACENTA PRAEVIACONDUCT AT THE CONDUCT AT THE DELIVERYDELIVERY
If If placenta praevia + accretaplacenta praevia + accreta, other methods of , other methods of
hemostasis:hemostasis:
oversewing the implantation siteoversewing the implantation site
bilateral uterine / inernal iliac artery ligationbilateral uterine / inernal iliac artery ligation
packing the lower uterine segment with gauzepacking the lower uterine segment with gauze
total abdominal hysterectomytotal abdominal hysterectomy..
PLACENTA PRAEVIAPLACENTA PRAEVIA
CONDUCT AT THE CONDUCT AT THE DELIVERYDELIVERYVaginal deliveryVaginal delivery may be possible in: may be possible in:
a multipara with a soft, effaced and partially a multipara with a soft, effaced and partially dilated cervix + a minor degree of anterior dilated cervix + a minor degree of anterior placenta praevia + ruptured membranesplacenta praevia + ruptured membranes
if the fetus is dead, the cervix is soft and effaced, if the fetus is dead, the cervix is soft and effaced, only an edge of placenta can be felt and bleeding only an edge of placenta can be felt and bleeding is minimalis minimal
before the 28th week, when the baby has little before the 28th week, when the baby has little chance of survivingchance of surviving
PLACENTA PRAEVIAPLACENTA PRAEVIA
ADDITIONAL TREATMENTADDITIONAL TREATMENT
adequate transfusionadequate transfusion
prophilactic treatment of thrombo-prophilactic treatment of thrombo-embolism / infectious complicationsembolism / infectious complications
anti-D Iganti-D Ig
bed restbed rest
PLACENTA PRAEVIAPLACENTA PRAEVIA
PrognosisPrognosis
MaternalMaternalFetal / NeonatalFetal / NeonatalThe perinatal mortality rate The perinatal mortality rate →→ 15-20% (10 times>) 15-20% (10 times>)Causes: Causes: • prematurity (a major cause) prematurity (a major cause) • IUGRIUGR• intrauterine anoxia (placental separation, prolapsed cord)intrauterine anoxia (placental separation, prolapsed cord)• respiratory distress syndromerespiratory distress syndrome• exsanguination exsanguination • fetal malformationsfetal malformations
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