Placenta previa

Placental
abruption
 Antepartum Hemorrhage

 Third-trimester bleeding
 Obstetric: Placental separation
 Placental Previa
 Placenta Abruption
 Uterine Rupture
 vasa previa : Fetal Vessel Rupture
 No obstetric: Acute vaginitis/cervicitis,
Cervical polyp, Cervical cancer, Trauma
 Placenta
previa
Definition

 Placenta previa:
The inferior edge of placenta load at the
lower uterine segment, or even reach the
internal cervical os after 28 weeks
gestation.
 Etiology
 High-risk group
 Age of gravida>35
 Multipara
 Pregnancy women used to tobacco or dope
 Multiple pregnancy
 Chronic HTN
 Damage of endometria
 Anomaly of placenta
 Cicatricial uterus due to cesarean section ,e.g.
Classification

 Classified according to the

relationship between the edge of
placenta and the internal cervical
os :
complete ( central ) placenta previa
partial placenta previa
marginal placenta previa

 Time to determine classification :

the last examination before managed
(1) complete placenta previa
(2) partial placenta previa
(3) marginal placenta previa
Classification

Types of placenta previa.

Clinical Features

 Painless 、recurrent vaginal

bleeding in the second or third
trimester of pregnancy
 Anemia,shock or even death
corresponded to the volume of
vaginal bleeding
 The uterus is usually soft and
relaxed
 Anomaly of fetal condition
Auxiliary examination

 B-ultrasound examination
 MRI
marginal placenta previa
Differential diagnosis

 Placental abruption
 Disruption of vasa previa
 Cervical polyp or erosion
 Cancer of cervix
 Complication of mother
and fetus

 Bleeding at or post partum

 Implantation of placenta
 Anemia and puerperal infection
 Premature delivery
Management
The management goals in women with
asymptomatic placenta previa are to:
●Determine whether the previa resolves
with increasing gestational age
●Reduce the risk of bleeding
●Reduce the risk of preterm birth
For pregnancies >16 weeks,
•If the placental edge is ≥2 cm from the internal os, the
placental location is reported as normal and follow-up
ultrasound for placental location is not indicated.
•If the placental edge is <2 cm from, but not covering,
the internal os, the placenta is labeled as low-lying. If
the placental edge covers the internal os, the placenta is
labeled a previa. For either diagnosis, follow-up
ultrasonography for placental location is performed at
32 weeks of gestation.
●At the 32-week follow-up ultrasound,
 If the placental edge is ≥2 cm from the internal os, the
placental location is reported as normal and follow-up
ultrasound for placental location is not indicated.

 If the placental edge is still <2 cm from the internal os

(low-lying) or covering the cervical os (previa), follow-
up transvaginal ultrasound is performed at 36 weeks.
 Transvaginal ultrasonography with color and pulsed
Doppler is recommended to rule out vasa previa, as
resolution of a low-lying placenta can be associated
with vasa previa
 advise women with placenta previa to avoid
 vaginal intercourse and exercise after 20 weeks of gestation (earlier if
they have experienced vaginal bleeding),
 overall physical activity in the third trimester. The rationale is that
these activities cause uterine contractions, which, in turn, provoke
bleeding.
 vaginal intercourse might cause direct trauma to the previa, resulting
in bleeding. There is no evidence to either support or refute these
recommendations. However, it is clear from anecdotal experience
that palpation of placenta previa through a partially dilated cervix can
result in severe hemorrhage.
Women should also be advised to seek immediate medical attention if
contractions or vaginal bleeding occur, given the potential for severe
bleeding and need for emergency cesarean delivery.
It is unclear whether asymptomatic women benefit
from hospitalization prior to delivery.
Findings from observational studies suggest that women with
placenta previa who have not experienced any antepartum bleeding
are at low risk of needing an emergency cesarean delivery These
women can generally be managed on an outpatient basis until
vaginal bleeding occurs or until admission for scheduled cesarean
birth.
However, patient-specific risk factors (eg, short cervical length,
ability to get to the hospital promptly in an emergency, home
support) need to be taken into account.
Delivery of pregnancies with uncomplicated
placenta previa should be accomplished at 360/7ths to
376/7ths weeks, without documentation of fetal lung
maturity by amniocentesis

. The rationale behind this recommendation is that

the risks associated with continuing the pregnancy
(severe bleeding, emergency unscheduled delivery)
are greater than the risks associated with prematurity
at this gestational age
ACUTE CARE OF BLEEDING PLACENTA
PREVIA —
 should be admitted to the Labor and
Delivery Unit for maternal and fetal
monitoring.
The major goals in managing these pregnancies
are:
●Achieve and/or maintain maternal
hemodynamic stability
●Determine if cesarean delivery is indicated
Assessment
Maternal :
 cardiac monitor and automated blood pressure cuff to
monitor maternal heart rate and blood pressure
 . Urine output is evaluated hourly with a Foley catheter
attached to an urometer.
Fetal :
 The fetal heart rate should be monitored. The presence
of fetal hypoxia or anemia may result in category 2 or 3
fetal heart rate tracings
Laboratory —
●At a minimum, blood should be sent for baseline
complete blood count and type and antibody screen.
The blood bank should be notified that a patient
with placenta previa has been admitted.
●When bleeding is heavy or increasing, delivery is
likely, or difficulty in procuring compatible blood is
anticipated, we advise cross-matching two to four
units of packed red blood cells.
 Massive blood loss or suspicion of coexistent abruption should
prompt evaluation for coagulopathy: fibrinogen level, activated
partial thromboplastin time, prothrombin time.
 A crude clotting test can be performed at the bedside by placing 5
mL of the patient's blood in a tube with no anticoagulant for 10
minutes . Failure to clot within this time or dissolution of an initial
clot implies impairment of coagulation, and is suggestive of a low
fibrinogen level. Prolonged oozing from needle puncture sites also
suggests coagulopathy

 A Kleihauer-Betke test on a specimen of vaginal blood can

diagnose fetal bleeding from disruption of fetal vessels in
placental villi, vasa previa, or a velamentous cord; however,
the fetal bleeding typically results in fetal demise or a
nonreassuring fetal heart rate tracing necessitating
emergency delivery
Intravenous access and crystalloid —
One or two large bore intravenous lines are inserted and
crystalloid (Ringers lactate or normal saline) is infused to
achieve/maintain hemodynamic stability and adequate urine
output (at least 30 mL/hour)
Transfusion —
. A reasonable approach is to begin red cell
transfusions in hypotensive patients whose
blood pressure fails to improve after two liters
of crystalloid have been rapidly infused.
Tocolysis
— to reduce or eliminate uterine contractions,
which may promote placental separation and
bleeding.
this therapy may prolong pregnancy and result
in an increase in birthweight, without causing
adverse effects on the mother or fetus
If tocolytics are used, indomethacin has an
inhibitory effect on platelet function and thus
should be avoided in women with placenta
previa due to the risk of increased blood loss.
Magnesium sulfate —
for neuroprotection in patients with preterm
(24 to 32 weeks) placenta previa in whom a
decision has been made to deliver within 24
hours, but not emergently.
Antenatal corticosteroids —
should be administered to symptomatic women
between 23 and 34 weeks of gestation to
enhance fetal pulmonary maturity.
do not administer steroids to asymptomatic
women or to those whose first bleed is after 34
weeks of gestation
Indications for delivery —
Cesarean delivery is indicated if any of the following occur:
●A nonreassuring fetal heart rate tracing unresponsive
resuscitative measures.
●Life-threatening refractory maternal hemorrhage
●Significant vaginal bleeding after 34 weeks of gestation
Management of placenta previa after acute
bleeding
After the patient has been stabilized, we take the following
approach with the goal of prolonging the pregnancy.

Inpatient versus outpatient management —

Symptomatic women often remain hospitalized from their
initial or second significant bleeding episode until delivery.
discharge selected women with placenta previa whose
bleeding has stopped for a minimum of 48 hours and who
have no other pregnancy complications, although the safety
and efficacy of this approach has not been established
candidates for outpatient care should:
●Be able to return to the hospital within 20 minutes

●Be reliable and able to maintain bed rest at home.

●Understand the risks entailed by outpatient management.
●Have an adult companion available 24 hours/day who can
immediately transport the woman to the hospital if there is light
bleeding or call an ambulance for severe bleeding.
Correction of anemia —
Iron supplementation may be needed for optimal
correction of anemia.
Stool softeners and a high-fiber diet help to minimize
constipation and avoid excess straining that might
precipitate bleeding
Anti-D immune globulin
. Readministration is not necessary if delivery or
rebleeding occurs within three weeks of
administration, unless a large fetomaternal
hemorrhage is detected
Fetal assessment

—
There is no proven value of nonstress testing or
performing a biophysical profile in pregnancies
with asymptomatic placenta and no evidence of
uteroplacental insufficiency (eg, preeclampsia,
fetal growth restriction, oligohydramnios) or
other indications for antepartum fetal
assessment.
active vaginal bleeding is an indication for fetal
monitoring
Cerclage —
Cervical cerclage has been used in an attempt to
minimize early development of the lower uterine
segment, which is thought to promote placental
separation. However, the efficacy of this approach
is unproven
presence of a stable placenta previa is not a
contraindication to cerclage placement when indicated
for cervical insufficiency.
Preterm premature rupture of membranes

— Antepartum decidual hemorrhage is a major

risk factor for preterm premature rupture of
membranes (PPROM). PPROM can occur despite
the presence of a complete placenta previa. In
these cases, each condition is managed
independently
Delivery
Timing — depends on the patient’s status.
Delivery of patients with stable (no bleeding or minimal bleeding)
placenta previa should be accomplished at 36 to 37 weeks, without
documentation of fetal lung maturity by amniocentesis
'Delivery is indicated emergently if any of the following occur
vaginal bleeding with a nonreassuring fetal heart rate tracing
unresponsive to resuscitative measures
●Life-threatening refractory maternal hemorrhage
●Labor
In women with moderate vaginal bleeding >34 weeks or
progressively increasing frequency or volume of bleeding
after cessation of an initial bleed, we deliver the patient if she
has previously received a course of betamethasone anytime
during the pregnancy.
If she is clinically stable and has not received a course of
betamethasone because her first bleed occurred after 34
weeks, we perform an amniocentesis and deliver the fetus if
pulmonary indices are mature. Management of women with
immature indices in this setting is controversial, and is
ultimately a decision based on clinical judgment. We would
give a course of betamethasone and then perform cesarean
delivery in 48 hours, based on limited data that even late in
gestation neonatal respiratory problems may be reduced with
steroid use
Previa —
A cesarean delivery in complete placenta previa and a viable fetus.
Vaginal delivery may be considered in rare circumstances, such as in the presence of a
fetal demise or a previable fetus, as long as the mother remains hemodynamically
stable.
When the placenta reaches the internal os but does not cross it, it has been
hypothesized that vaginal delivery can occasionally be performed because the fetal
head tamponades the adjacent placenta, thus preventing hemorrhage. These
pregnancies remain at high risk of intrapartum hemorrhage; therefore, we suggest
scheduled cesarean delivery to minimize the risk of emergent delivery and need for
transfusion.
Low placenta —placenta is more than 20 mm from the internal os, so a trial of labor is
appropriate if there are no other contraindications to vaginal birth

When this distance is between 1 and 20 mm, the rate of cesarean delivery ranges from
40 to 90 percent, so management of these patients is more controversialfrom the
internal os.
Placental abruption
Definition

Placental abruption: placenta in normal site

strip from the uterine parietal partially or
completely before the fetus expulsion,after
20 weeks gestation or in the delivery
procedure.

Incidence rate: 1% of total pregnancies

Etiology

 HTN, preeclampsia, thrombophilia

 Previous abruption
 Iron deficiency anemia
 Mechanical agent
 Others: Age of gravida>35,multipara,
tobacco,dope
Classification

 Classify according to severity degree:

Light type ＜1/3
Severe type ＞1/3; ＞ 1/2, Dead fetus
Clinical Features
 Abruptly,persistent abdominal pain with
vaginal bleeding
 Back pain
 Maternal compromise/ shock(Volume of
vaginal bleeding not correspond to patient
condition)
 Anomaly of fetal condition
 The uterus touched hard with pain
 The size of uterus is bigger than it should be
in that gestation age
Auxiliary examination

 Diagnotic examination :
B-ultrasound examination
Placenta examination post partum
Sonography
Differential diagnosis

 Placental previa
 Uterus rupture
 Complications

 DIC,dysfunction of coagulation
 Post partum hemorrhagic/shock
 Amniotic fluid embolism
 Acute renal failure
 Fetal death
Management
Pregnant women with symptoms of
abruption
 should be evaluated promptly on a labor and
delivery unit to establish the diagnosis,
 assess maternal and fetal status, and initiate
appropriate management.
The following actions are reasonable initial
interventions:
● continuous fetal heart rate monitoring,
●Place one wide-bore intravenous line; two if the
patient presents with signs of moderate or severe
abruption, such as moderate to heavy bleeding,
hypotension, tachysystole, uterine hypertonicity and
tenderness, coagulopathy, or an abnormal fetal heart
rate. Administer crystalloid, preferably Lactated
Ringer's, to maintain urine output above 30 mL/hour
Closely monitor the mother's hemodynamic status (heart
rate, blood pressure, urine output, blood loss).
●Draw blood for a CBC, PL, BGRH, fibrinogen, PT,
APTT, cr,ALT,AST.

notify the blood bank so blood replacement products (red

cells, fresh frozen plasma, cryoprecipitate, platelets) will be
readily available, if needed, and repeat the blood count and
coagulation studies.
Transfusion goals are:
-Maintain hematocrit at 25 to 30 percent or greater

-Maintain platelet count ≥75,000/microL

-Maintain fibrinogen ≥100 mg/dL.
-Maintain a prothrombin and partial thromboplastin time
less than 1.5 times control
Administer standard medications to
women likely to deliver:
magnesium sulfate for neuroprotection for
pregnancies <32 weeks of gestation,
antenatal corticosteroids for pregnancies
<34 weeks of gestation,
and group B streptococcus prophylaxis
according to local guidelines.
SUBSEQUENT MANAGEMENT BASED ON THE
CLINICAL SETTING

— The most important factors impacting the

decision to deliver a patient with placental abruption
versus expectant management are:
●Fetal and maternal status, which reflect the severity
of the abruption
●Gestational age
Dead fetus —
The optimal route of delivery in these cases minimizes the risk
of maternal morbidity or mortality.
Blood and blood product replacement is often necessary and
expeditious delivery is desirable because the frequency of
coagulopathy and continuous heavy bleeding is much higher in
abruptions in which fetal death has occurred. Placental separation
is often greater than 50 percent.
Unstable mother —

Cesarean delivery is often the best option when

vaginal delivery is not imminent and rapid
Stable mother —
Vaginal delivery is preferable. These patients
are often contracting vigorously, so
amniotomy may be all that is required to
expedite delivery. Oxytocin is administered,
if needed to induce or augment labor.
Nonreassuring fetal status
 Category III tracing

 Category II tracing - .
Reassuring fetal status —
If the fetal heart rate pattern (category I tracing)
or biophysical profile score is reassuring, then
the decision to deliver versus expectant
management depends on both maternal
hemodynamic status and gestational age.
Less than 34 weeks of gestation
— When the fetus and mother are both stable and there is
no evidence of ongoing major blood loss or coagulopathy,
conservative management with the aim of delivering a
more mature fetus is the main goal before 34 weeks of
gestation
Administer corticosteroids
Tocolytic ???
●Antenatal fetal assessment –
NST.BPP, at least weekly.
 also perform serial sonographic estimation of fetal weight
to assess growth since these fetuses are at risk of developing
growth restriction over time
●Hospitalization –
until the bleeding has subsided for at least 48 hours, fetal heart rate
tracings and ultrasound examinations are reassuring, and the
patient is asymptomatic.
At that point, discharge may be considered. Importantly, the
patient should be counseled to return immediately if she has
further bleeding, contractions, decreased fetal movement, or
abdominal pain.
In patients with sonographic evidence of a large hematoma, we
believe it is prudent to keep the patient in the hospital for a
longer period for close monitoring.
●
Delivery –
at 37 to 38 weeks

Delivery before 37
, fetal growth restriction,
preeclampsia,
premature rupture of membranes,
nonreassuring fetal assessment,
recurrent abruption with maternal instability
Placental abruption occurring in the second trimester
carries an especially poor prognosis when accompanied
by oligohydramnios

( routinely : send placenta for pathology

Abnd ABG umblical cord )
36 weeks to term gestation —
deliver all pregnancies with acute abruption at ≥36
weeks of gestation
Vaginal delivery is preferable, if there are no obstetrical
indications for cesarean delivery (eg, malpresentation,
prior cesarean). With a clinically significant abruption,
the patient is often contracting vigorously, but if she is
not in active labor, then amniotomy and administration of
oxytocin frequently result in rapid delivery
COUVELAIRE UTERUS —
In severe abruptions, blood may extravasate into
the myometrium (called a Couvelaire uterus), and
this can be seen at cesarean.
The Couvelaire uterus is atonic and prone to
postpartum hemorrhage.
, these women are at high risk for requiring
hysterectomy
POSTPARTUM CARE —
Postpartum, we administer an intravenous oxytocin
infusion as the first-line uterotonic agent.
Maternal vital signs, blood loss, urine output, uterine
size and consistency, and laboratory results
(hemoglobin/hematocrit, coagulation studies) are
monitored closely to ensure that bleeding has been
controlled and that coagulopathy (if present) is resolving,
and to guide replacement of fluids and blood products, as
needed.
MANAGEMENT OF FUTURE PREGNANCIES
Recurrence risk —
Placental abruption resulting from trauma is not likely to recur in the absence of
recurrent trauma, so these women can be reassured
Timing of delivery —
For most patients with an abruption in a prior pregnancy who have no bleeding,
growth restriction, or preeclampsia, we provide routine prenatal care until
spontaneous labor ensues or perform a repeat cesarean delivery at 39 to 40 weeks
of gestation. We deliver all patients with a history of abruption by 400/7ths weeks
For patients who have had a prior perinatal death or more than one prior abruption,
we offer late preterm or early term delivery at 36 to 37 weeks after documentation
of fetal lung maturity. (lamellar body count, and deliver if the count is above
50,000 per microliter; alternatively, a lecithin/sphingomyelin ratio may be
performed.)
If fetal lung maturity tests indicate immaturity, we delay delivery until 39 weeks
as long as the patient is stable.