PLACENTA PREVIA. a disorder of Pregnancy

Placenta Previa

1. By: Prof. (Dr.) Geeta Chaudhary M.Sc (N), PhD PRESENTATION ON PLACENTA PREVIA

2. PLACENTA PREVIA

3. When the placenta is implanted partially or completely over the lower uterine segment , it is called placenta previa . INCIDENCE Placenta previa occurs approx. one in 250 births. It is one in 200 in india.One third of all antipartum hemorrhage occurs due to placenta previa . DEFINITION

4. The exact cause of placenta previa is not known.Following are the postulates theories : 1 Dropping down theory – The fertilized ovum drops down to lower uterine segment and poor reaction in the upper segment may be the cause. Multiple pregnancy ( hyperplacentosis ) CAUSES

5. Defective decidua – It results in spreading of chorionic villi over a wide area in uterine wall to get nourishment. During this process , not only placenta becomes membranous but encroaches onto lower segment. Previous lower segment cesarean delivery Uterine anomalies 5 Placental and cord abnormalities ( circumvallate placenta , battledore placenta , membranous placenta)

6. MULTIPARITY INCREASED MATERNAL AGE (>35 YEARS) HISTORY OF PREVIOUS C – SECTION TWIN PLACENTA PREVIOUS REPRODUCTIVE SURGERY EG. DILATATION AND CURRETAGE SMOKING AND DRUG ABUSE ETHNIC GROUPS EG. ASIAN WOMEN RISK FACTORS

7. CLASSIFICATION TYPE- I (low lying) TYPE – II (marginal) TYPE-III (Incomplete) TYPE - IV (Complete)

8. The major part of Placenta is attached to upper segment and only the lower margin but not upto os . TYPE – I (Low Lying)

9. The placenta reaches Margin of the internal Os but does not cover the Internal os . TYPE – II (Marginal)

10. The placenta covers The internal os Incompletely or Partially . TYPE – III (Partial Central)

11. The placenta covers The internal os even After it is fully Dilated . TYPE – IV (Central Or complete)

12. Mild degree placenta Major degree placenta Previa Previa (Type – I and II) ( Type – III and IV) CLINICAL TYPES

13. SYMPTOMS: Painless vaginal bleeding in 3 rd trimaster Bleeding is sudden,painless,recurrent without onset of labour The first bleeding is called ‘WARNING HEMORRHAGE’ Bleeding is bright red and amount varies CLINICAL FEATURES

14. SIGNS : General examination – Anemia and pallor.Shock may occur. Abdominal examination – Abdomen is soft,uterus is relaxed and non-tender FHS is normal and well auscultated Fetal head is floating Vulval examination – Only inspection is to be done to note whether the bleeding is still occuring or ceased.

15. The diagnosis of placenta previa is based on Clinical findings – Painless and recurrent bleeding. When labour starts and cervix dilates, profuse haemorrhage may occur. Abdominal examination - Displacement of presenting part Flaccidity of uterus DIAGNOSIS

16. Diagnostic procedures – MRI Placentography Ultrasound ( transabdominal and transvaginal ) Color doppler flow study – prominent venous flow in hypoechoic areas near cervix shows placenta previa . Conti..

17. MATERNAL - During pregnancy- APH Malpresentation Premature labour During Labour - Early rupture of membranes Cord prolapse Intra –partum haemorrhage slow dilatation of cervix COMPLICATIONS

18. Increased incidence of operative delivery Retained placenta Increased incidence of PPH During puerperium - P uerperial sepsis S ub involution Embolism Conti..

19. Low birth weight baby Fetal asphyxia IUD Congenital malformation like spina bifida Birth injuries FETAL COMPLICATIONS

20. MATERNAL – There has been a substantial reduction in maternal deaths in placenta previa throughout the globe. The contributing factors are early diagnosis, free availalbility of blood transfusion facilities, potent antibiotics and wider use of C-section with expert anaesthetist . PROGNOSIS –

21. The reduction in perinatal deaths is principally due to judicious extension of expectant treatment, thereby reducing the loss from prematurity FETAL –

22. Adequate antinatal care Antenatal diagnosis Significance of warning haemorrhage should not be ignored. Universal targetted scan of all pregnant women at 18 weeks can diagnose low lying placenta which can later become placenta previa . PREVENTION -

23. If the patient is at home - The patient is immediately put on bed Assess the amount of blood loss G ently examine the abdomen Auscultate the fetal heart sound If the patient is in hospital - MANAGEMENT Formulation of line of treatment Immediate Management

24. Expectant Management- Its aim is to continue pregnancy in gestation less than 37 weeks for fetal maturity. Requirements: availability of blood transfusion Facilities for C-section throughout 24 hours Treatment: Steroid therapy is given if pregnancy is less than 34 weeks Betamethasone is given Formulation of line of treatment:

25. Caesarean delivery is done Vaginal delivery may also be done where placenta edge is 2-3cm away from internal os . During this methergine 0.2mg is given IV with delivery of anterior shoulder. Indications Bleeding occurs at or after 37 weeks Patient is in labour Baby is dead. Active management:

26. All APH patients are to be admitted - General and abdominal examination - Clinical assessment of blood loss - check Hb %, haematocrit,ABO,Rh group - Resuscitation if necessary - Localisation of placenta SCHEME OF MANAGEMENT OF PLACENTA PREVIA :

27. - no active bleeding - bleeding continues - pregnancy<37weeks - pregnancy>37weeks - haemodynamically stable - patient in labour - FHS is good - FHS is normal - CTG- reactive fetus - fetal malformation - steroid therapy if 37 weeks duration<34 weeks EXPECTANT TREATEMENT ACTIVE INTERFERENCE

28. Ultrasonographic evidence Placental edge is 2-3cm placental edge within 2cm From cervical os of internal os Internal examination no internal examination In OT C-section A.R.M +- oxytocin Progression of labour no labour Vaginal delivery C-section

29. Dutta D.C,”Textbook of obstetrics” published by Hiralal Kohar,Pp - 241-251 Jacob Annamma,”A Comprehensive Textbook of Midwifery and Gyanecological Nursing” Edition-3 rd published by JAYPEE Pp- 285-288 Sharma J.B,”Midwifery and Gynaecological Nursing”, Published by Avichal publishing company,Pp-265-270 Basavanthappa BT,”Textbook of Midwifery and Reproductive Health Nursing”, Published by JAYPEE,Pp-521-524 BIBLIOGRAPHY:

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