management of placenta previa

1. Management of preterm labour in Placenta previa and Abruptio Placentae NAVEENA.R.L’09. Management of preterm labour in Placenta previa and Abruptio placentae NAVEENA.R.L. 09

2. PLACENTA PREVIA It is a condition in which the placenta is located over or very near the internal os . Four degrees: Total placenta previa . Partial placenta previa . Marginal placenta previa . Low lying placenta.

3. CLINICAL FEATURES SYMPTOMS: Painless bleeding. Causeless bleeding. Recurrent bleeding.

4. SIGNS: Tachycardia or hypotension Anemia Uterus relaxed.Fetal parts easily felt. -Vaginal examination must not be done. DIAGNOSIS: Transvaginal sonography .

5. Management of preterm labour in placenta previa Diagnosis should be confirmed. Admit the patient. Management depends on, quantity of bleeding. overall physical condition of the mother. Overall fetus condition and fetal maturity.

6. Expectant line of management: Macafee -Johnson’s regime Aim is to continue pregnancy for fetal lungs to mature without compromising maternal health. VITAL PREREQUISITES : Availability of blood transfusion. Facilities for caesarean section should be available 24 hrs.

7. Cases suitable for expectant management: Mother is in good health: Hb >10 gm%; haematocrit >30%. Duration of pregnancy <37 weeks. No active vaginal bleeding. Fetal wellbeing assured by USG.

8. Conduct of expectant treatment: Bed rest. Hb %, blood grouping, Urine protein. Fetal surveillance with USG. Blood transfusion to correct anemia. Tocolytics - Given if vaginal bleeding is associated with uterine contractions. Corticosteroids to improve fetal lung maturity and reduce respiratory distress. Rh immunoglobulin given to all Rh negative mothers.

9. Termination of expectant treatment: It is carried upto 37 weeks of pregnancy and then the baby becomes sufficiently mature after which pregnancy is terminated .

10. Preterm delivery may have to be done in conditions such as, Recurrence of brisk haemorrhage which is continuing. Fetus is dead. Congenitally malformed fetus found on investigation. However,there is a risk of IUGR with expectant management. When an early delivery is needed fetal amniocentesis is done to find out whether the fetal lungs are ready to breathe well.

11. Active line of management: LOWER SEGMENT CAESAREAN DELIVERY- done for all women with sonographic evidence of placenta previa where placental edge is within 2 cm from internal os . VAGINAL DELIVERY : when placenta edge is clearly 2-3 cm away from internal os .

12. ABRUPTIO PLACENTAE It refers to a condition where antepartum heamorrhage occurs due to premature seperation of a normally situated placenta. TYPES: Concealed: Blood is retained within the uterine cavity and is not visible exernally.Retroplacental clot present. Revealed: In this the blood collected due to placental seperation escapes by dissecting under the membranes and seen externally if memabranes are ruptured.Blood stained liquor may occur. Mixed

13. TYPES:

14. Clinical features: Abdominal pain and bleeding PV. Signs : Features of PIH. Shock. Uterine height may or may not correspond to the period of amenorrhea. Uterine tenderness and difficulty in palpating fetal parts in concealed variety. Fetal heart may be normal,abnormal or absent. Uterine contractions.

15. Bleeding is almost always maternal. Clinical Classification : Grade 0 - No clinical features,diagnosed after delivery after seeing retroplacental clot. Grade 1 - Slight vaginal bleeding, Uterine tenderness minimal or absent,BP and fibrinogen level unaffected,FHS good. Grade 3 - Mild to moderate vaginal bleeding,uterine tenderness,maternal pulse increased,BP maintained,fibrinogen decreased,Fetal distress. Grade 4 -Severe bleeding,tender uterus,Fetal death,Associated coagulation defect or anuria .

16. COUVELAIRE UTERUS or uteroplacental apoplexy includes severe forms of placental seperation with widespread extravasation of blood into uterine musculature.

17. Management:

18. ACTIVE MANAGEMENT is the main mode of managing Abruptio placentae . In Expectant management: Risk of sudden seperation of placenta and fetal death.So it is not done.

19. SEVERE CASES : Immediate delivery of the fetus is indicated either by vaginal delivery or ceasarean section. So, once abruption sets in,it is difficult to prevent preterm labour .

20. Vaginal delivery indicated when, Limited placental abruption. FHR is reassuring. Continuous electronic fetal monitoring available. Placental abruption with a dead fetus. If patient is not in labour and bleeding continues deliver by , Induction of labour by low rupture of membranes. Caesarean section.

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