placenta previa

Placenta PreviaPlacenta Previa

General DataGeneral Data

R.L.33 y/oG4P3 (3002), PU 37 3/7 weeks AOGMarriedFilipinoRoman Catholic

Reason for consultReason for consult

scheduled Cesarean section

Past Medical HistoryPast Medical History

(-) hypertension(-) diabetes mellitus(-) bronchial asthma (-) thyroid disease

No known allergiess/p LTCS IIIx (Ix for CPD)

Personal and Social HistoryPersonal and Social History

nonsmoker and alcoholic beverage non-drinker

Family HistoryFamily History

(+) hypertension – father (+) bronchial asthma – mother(-) diabetes mellitus (-) cancer

Gynecologic History Gynecologic History

Menstrual HistoryMenarche – 11 y/oInterval – regular, 28 days LMP: October 25,

2009Duration – 2-3 days PMP: Sptember 2009Amount – 3-4 ppd, fully-soakedSymptoms – (+) dysmenorrhea, day 1

Sexual HistoryCoitarche – 21 y/o; single sexual partner; (-)

dyspareunia, postcoital bleeding; (-) history of STI

Contraception Use: (+) use of OCPs x 2 months (2006); no IUDs

Latest PAP smear was in June 2010: Normal results

Obstetric HistoryObstetric History

G4P3 (3002)G1 (2000) – delivered to a live full term baby boy via

primary LTCS for cephalopelvic disproportion attended by doctor – Fabella Hospital, BW 2kg, neonatal death x 10 days, neonatal sepsis secondary to meconium aspiration

G2 (2001) – delivered to a live full term baby girl via repeat LTCS attended by doctor – SLMC

G3 (2005) – delivered to a live full term baby boy via repeat LTCS attended by doctor – SLMC

G4 – present pregnancy

Prenatal HistoryPrenatal History

First Trimester SecondTrimester ThirdTrimester

•FPNCU (4 mos AOG)•(+) multivitamins, ferrous sulfate, folic acid•No maternal illness•Antenatal tests

•HbsAg nonreactive•Blood type O+

•RPNCU•OGCT N•(+) multivitamins, ferrous sulfate•No maternal illness•2 bleeding episodes (see HPI)

•RPNCU•(+) multivitamins, ferrous sulfate•No maternal illness

History of Present IllnessHistory of Present Illness

4 months AOG FPNCU5 months AOG (+) vaginal bleeding,

~10 ppd fully soaked◦No hypogastric abdominal pain, no uterine

contractions, no foul smelling vaginal discharge, no passage of meaty tissue, no fever

◦Sought consult◦TVS: placenta previa totalis◦Prescribed Isoxilan tablet (Duvadilan) TID x 7

days

6 months (+) vaginal bleeding, 5 ppd/fully soaked◦Same associated signs and symptoms◦took Isoxilan tablet TID x 3 days (self-medicated)◦did not seek consult

Few hours prior to admission repeat TVS ◦placenta previa totalis to consider placenta

accreta◦scheduled Cesarean section

Review of SystemsReview of Systems

General◦Denies fever or malaise

HEENT◦Denies headache, blurring of vision, hearing

problems, epistaxis, tooth or throat painPulmonary

◦Denies cough or dyspneaCardiovascular

◦Denies palpitations or chest painGastrointestinal

◦Denies diarrhea and constipation◦No nausea and vomiting, anorexia

Urinary◦Denies dysuria, frequency, nocturia

Endocrine◦Denies polyuria, polydipsia, tremors

Hematopoietic◦Denies easy bruisability

Musculoskeletal◦Denies myalgia or arhtralgia

Neurologic/Psychiatric◦Denies change in sensorium or behavior

Physical ExaminationPhysical Examination

Conscious, coherent, not in cardio-respiratory distress, intermittently in pain

BP: 110/70mmHg CR: 80/min, regular RR: 20/min, regular T: 36.8oC

Skin: no suspicious lesionsHead: skull normocephalic, atraumaticEyes: pink palpebral conjunctivae,

anicteric scleraeNeck: supple neck, with no palpable neck

mass, no neck vein engorgement

Physical ExaminationPhysical Examination

Lungs: symmetrical chest expansion, no rib retractions, clear and equal breath sounds

Heart: adynamic precordium, normal rate, regular rhythm, no murmurs

Abdomen: globular abdomen, (+) midline scar; FH 33cm, EFW 3255g, FHT 140bpm; LM 1: breech LM 2: fetal back on maternal left LM 3: unengagedNon tender abdomen, no rigidity

Full and equal pulses, no cyanosis

Pelvic ExaminationPelvic Examination

External pelvic examination: no lesions, redness, excoriations, hyper/hypopigmentations

IE deferred

Salient FeaturesSalient Features

Subjective◦ 33 yoG4P3 (3002), PU 37

3/7 weeks AOG◦ (-) HPN, s/p LTCS IIIx (Ix

for CPD)◦ Non smoker◦ RPNCU since ~4mos AOG,

no maternal illnesses, with 2 episodes of vaginal bleeding in the 2nd trimester.

~5 mos (+) vaginal bleeding, ~300 mL◦ No hypogastric abdominal pain,

no uterine contractions, no foul smelling vaginal discharge, no passage of meaty tissue, no fever

◦ TVS: placenta previa◦ Isoxilan tablet (Duvadilan) TID

x 7 days◦ (+) vaginal bleed ~150ml @ 6

mos AOG Few hours PTA, TVS was

done which showed:◦ Placenta previa totalis t/c

placenta accreta scheduled CS

Salient FeaturesSalient Features

ObjectiveConscious, coherent,

not in cardio-respiratory distress, intermittently in pain

BP: 110/70mmHg CR: 80/min, regular RR: 20/min, regular T: 36.8oC

◦Abdomen: globular abdomen, (+) midline scar; FH 33cm, EFW 3255g, FHT 140bpm; LM 1: breech LM 2: fetal back on maternal left LM 3: unengaged No abdominal

tenderness, no rigidity

Clinical ImpressionClinical Impression

G4P3(3002) PU 37 3/7 weeks AOG, cephalic, not in labor, placenta previa totalis, t/c placenta accreta previous LTCS IIIx (Ix for cephalopelvic disproportion)

Differential DiagnosisDifferential Diagnosis

Placenta PreviaAbruptio Placenta Spontaneous Abortion Cervicitis

Placenta PreviaPlacenta Previa

DEFINITIONDEFINITION

Placenta Previa is a condition where the placenta lies low in the uterus and partially or completely covers the cervix.

Four degrees of abnormalitiesFour degrees of abnormalities

Total placenta previa◦ the internal os is covered completely by placenta

Partial placenta previa◦ the internal os is partially covered by placenta

Marginal placenta previa◦ the edge of the placenta is at the margin of the internal os

Low-lying placenta◦ the placenta is implanted in the lower uterine segment such

that the placental edge does not reach the internal os, but is in close proximity to it

Vasa previa◦ the fetal vessels course through membranes and present at

the cervical os (uncommon, associated with higher rate of fetal death

IncidenceIncidence

Placenta previa affects about 1 in 200 pregnant women (Iyasu et al., 1993).

Risk FactorsRisk Factors

Placenta previa is more common in women who have had one or more of the following:

◦Increasing maternal age

◦Multiparity

◦Prior cesarean delivery

◦Surgery on the uterus

◦Smoking

◦Multiple gestation (larger surface area of the placenta)

Placenta Previa is associated Placenta Previa is associated with:with:

Placenta accreta, placenta increta or placenta percreta◦Secondary to the poorly developed decidua on

the lower uterine segment.

Placenta accreta -- Abnormal adherence of the placenta to the myometrial wall, with absence of decidua basalis.

Placenta increta--placenta attaches deep into the uterine wall and penetrates into the uterine muscle, but does not penetrate the uterine serosa

Placenta percreta-- Placental villi penetrate myometrium and through to uterine serosa.

Clinical Findings:Clinical Findings:

Painless hemorrhage (most characteristic)◦Due to tearing of placental attachments during the

formation of the LUS or during cervical dilatation

◦Bleeding occurs at the implantation site as the uterus is unable to contract adequately and stop the flow of blood from the open vessels.

◦Hemorrhage persists after delivery because of the LUS contracts poorly so it cannot constrict the torn vessels. May also be due to lacerations in the cervix and LUS following manual removal of adherent placenta

PathophysiologyPathophysiology

Placental implantation is initiated by the embryo adhering in the lower uterus.

With placental attachment and growth, the developing placenta may cover the cervical os.

However, it is thought that a defective decidual vascularization occurs over the cervix, possibly secondary to inflammatory or atrophic changes.

DiagnosisDiagnosis

Diagnosis can seldom be established by clinical examination unless a finger is passed thru the cervix the placenta is palpated. Such examination is never permissible because even the gentlest examination may cause torrential hemorrhage.

◦Such examination is rarely necessary since placental location can be obtained by sonography.

Imaging StudiesImaging Studies

•The most useful and inexpensive study is transvaginal ultrasonography that provides >95% accuracy in identifying a placenta previa•An alternative would be transabdominal ultrasonography that can be 95% accurate; however, the false-positive and false-negative rates can range from 2-25%.

Imaging StudiesImaging Studies

MRI may be used for planning the delivery in that it may help identify placenta accreta, placenta increta, or placenta percreta. These invasive placental abnormalities are more common (eg, placenta accrete occurs in up to 0.2% of pregnancies) due to the increase in cesarean deliveries, advancing maternal age, hypertensive disease, smoking, and placenta previa cases.

Imaging StudiesImaging Studies

MRI is no more sensitive in diagnosing placenta accreta that ultrasonography, but it may be superior for the posterior placenta accreta or the more invasive increta and percreta.

ManagementManagement

Preterm fetus but with no active bleeding:◦Close observation◦In some cases, prolonged hospitalization is

ideal but the patient is discharged after bleeding has stopped and fetus is assessed to be healthy.

◦If bleeding persists, preparation for immediate surgery is indicated.

ManagementManagement

Additionally, tocolytics may also be considered in cases of minimal bleeding and extreme prematurity to administer antenatal corticosteroids. If more than one episode of bleeding occurs during gestation (at viability or >24 wk), the clinician should consider hospitalization until delivery given the increased potential for placental abruption and fetal demise.

ManagementManagement

Cesarean delivery is necessary in practically all cases of placenta previa.

Poorly contractile nature of the LUS there may be uncontrollable hemorrhage following placental removal.◦Oversew the implantation site with 0-chromic

sutures◦Bilateral uterine artery ligation or internal iliac

artery ligation◦Tightly packing the LUS with gauze◦If bleeding persists hysterectomy

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