Download - Placenta Previa
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Placenta PreviaPlacenta Previa
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General DataGeneral Data
R.L.33 y/oG4P3 (3002), PU 37 3/7 weeks AOGMarriedFilipinoRoman Catholic
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Reason for consultReason for consult
scheduled Cesarean section
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Past Medical HistoryPast Medical History
(-) hypertension(-) diabetes mellitus(-) bronchial asthma (-) thyroid disease
No known allergiess/p LTCS IIIx (Ix for CPD)
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Personal and Social HistoryPersonal and Social History
nonsmoker and alcoholic beverage non-drinker
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Family HistoryFamily History
(+) hypertension – father (+) bronchial asthma – mother(-) diabetes mellitus (-) cancer
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Pelvic ExaminationPelvic Examination
External pelvic examination: no lesions, redness, excoriations, hyper/hypopigmentations
IE deferred
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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
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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
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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)
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Differential DiagnosisDifferential Diagnosis
Placenta PreviaAbruptio Placenta Spontaneous Abortion Cervicitis
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Placenta PreviaPlacenta Previa
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DEFINITIONDEFINITION
Placenta Previa is a condition where the placenta lies low in the uterus and partially or completely covers the cervix.
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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
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IncidenceIncidence
Placenta previa affects about 1 in 200 pregnant women (Iyasu et al., 1993).
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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)
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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.
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Placenta accreta -- Abnormal adherence of the placenta to the myometrial wall, with absence of decidua basalis.
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Placenta increta--placenta attaches deep into the uterine wall and penetrates into the uterine muscle, but does not penetrate the uterine serosa
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Placenta percreta-- Placental villi penetrate myometrium and through to uterine serosa.
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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
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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.
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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.
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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%.
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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.
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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.
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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.
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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.
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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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Thank YouThank You