Miscarriage

Miscarriage is a pregnancy that ends spontaneously before 24 weeks’

gestation.

ABORTION
Definition:
Termination of pregnancy before viability of the foetus i.e. before 28 weeks (in
Britain) and before 20weeks or if the foetal weight is less than 500 gm ( in
USA and Australia).
When the abortion occurs spontaneously, the term “miscarriage" is often
used.
Incidence: about 15% of all pregnancies.
Aetiology:
1) Chromosomal abnormalities: cause at least 50% of early abortions e.g. trisomy,
monsomy X (XO) and triploidy.
2) Blighted ovum (anembryonic gestational sac): where there is no visible foetal
tissues in the sac.
3) Maternal infections : e.g. listeria monocytogenes, mycoplasma hominis,
ureaplasma urealyticum, cytomegalovirus and toxoplasma gondii which causes
abortion if there is acute infection early in pregnancy. Acute fever for
whatever the cause can induce abortion.
4) Trauma: external to the abdomen or during abdominal or pelvic operations.
5) Endocrine causes:
A. Progesterone deficiency ( causes abortion between 8-12 weeks).
B. Diabetes mellitus.
C. Hyperthyroidism.
6) Drugs and environmental causes: e.g. quinine , ergots, severe purgatives,
tobacco, alcohol, arsenic, lead, formaldehyde, benzene and radiation.
7) Maternal anoxia and malnutrition.
8) Overdistension of the uterus: e.g. acute hydramnios.
9) Immunological causes:
a. Systemic lupus erythematosus.
b. Antiphospholipid antibodies that are directed against platelets and
vascular endothelium leading to thrombosis, placental destruction and
abortion.
 c. Histocompatibility between the mother and father and in turn the
foetus. It is assumed that histoincompatibility particularly in human
leucocyte antigen (HLA- DR locus) is essential for stimulation of the
immune system to produce blocking factors which prevent rejection of
the foetus.
10) Ageing sperm or ovum.
11) Uterine defects e.g. Septum , Asherman's syndrome (intrauterine adhesions)
and submucous myomas.
12) Nervous, psychological conditions and over fatigue.
13) Idiopathic.
Mechanism of Abortion:
a. Up to 8 weeks:The gestational sac tends to be expelled complete and
the decidua is shed thereafter.
b. From 8-12 weeks: The decidua capsularis ruptures and the embryo is
expelled either entire or after rupture of the amnion.
c. After 12 weeks: The placenta is completely formed and the process of
abortion is like a miniature labour. It is more common for the foetus to
be expelled but for the placenta to be retained due to firmer
attachment to the uterine wall.

Types of Abortion
(A) Threatened Abortion:
Clinical picture:
 Symptoms and signs of pregnancy coincide with its duration.
 Vaginal bleeding slight or mild, bright red in colour originating from
the
 choriodecidual interface.
 Pain is absent or slight.
 Cervix is closed.
 Pregnancy test is positive.
 Ultrasonography shows a living foetus.
Prognosis:
If the blood loss is less than a normal menstrual flow and is not accompanied
by pain of uterine contraction there is a reasonable chance for continuing
pregnancy. This occurs in 50% of cases while other half will proceed to
inevitable or missed abortion.
Treatment:
 Rest in bed until one week after stoppage of bleeding.
 No intercourse as it may disturb pregnancy by the mechanical effect
and the effect of semen prostaglandins on the uterus.
  Sedatives: if the patient is anxious.
 Treatment of controversy:
 Progestogens: e.g. hydroxy progesterone caproate (Primulot depot)
 250 mg IM twice weekly is given by some if there is evidence of
progesterone deficiency. However, low plasma progesterone level is an
indication of pregnancy failure. Progestogens may cause retention of
the dead ovum leads to missed abortion.
 Gonadotrophins may be of benefit in cases of luteal phase deficiency
and those get pregnant with ovulatory drugs.
 Sympathomimetics, antiprostaglandins and folic acid were used but of
no proven beneficial effect.
(B) Inevitable Abortion:
Clinical picture:
 Symptoms and signs of pregnancy coincide with its duration.
 Vaginal bleeding is excessive and may accompanied with clots.
 Pain is colicky felt in the suprapubic region radiating to the back.
 The internal os of the cervix is dilated and products of conception may
be felt through it.
 Rupture of membranes between 12-28 weeks is a sign of the
inevitability of abortion.

Treatment:
 Any attempt to maintain pregnancy is useless.
 Resuscitation and ergometrine 0.5 mg is given by IM or IV route to
induce tetanic uterine contraction and stop bleeding.
o If pregnancy is less than 12 weeks: Termination is done by
vaginal evacuation and curettage or suction evacuation under
general anaesthesia.
o If pregnancy is more than 12 weeks:
 Oxytocin is given by intravenous drip to expel the uterine
contents.
 If the placenta is retained it is removed under general
anaesthesia.
Cervical abortion: is a variety of inevitable abortion in which the products
of conception has been separated from the uterine cavity but retained in the
cervical canal causing its distension.
Clinical picture:
o The patient complains of considerable bleeding and severe lower
abdominal pain referred to the back.
 o On examination, the products of conception is felt through the
dilated cervix.
Treatment:
Under anaesthesia, the cervix is dilated, contents is removed and cavity is
curetted to remove the decidua.
C) Incomplete Abortion:
Retention of a part of the products of conception inside the uterus. It may be
the whole or part of the placenta which is retained.
Clinical picture:
 The patient usually noticed the passage of a part of the conception
products.
 Bleeding is continuous.
 On examination, the uterus is less than the period of amenorrhoea but
still large in size. The cervix is opened and retained contents may be
felt through it.
 Ultrasonography: shows the retained contents.
Treatment:
 Resuscitation and ergometrine 0.5 mg is given by IM or IV route to
induce tetanic uterine contraction and stop bleeding.
o If pregnancy is less than 12 weeks: Termination is done by
vaginal evacuation and curettage or suction evacuation under
general anaesthesia.
o If pregnancy is more than 12 weeks:
 Oxytocin is given by intravenous drip to expel the uterine
contents.
 If the placenta is retained it is removed under general
anaesthesia.
(D) Complete Abortion:
All products of conception have been expelled from the uterus.
Clinical picture:
 The bleeding is slight and gradually diminishes.
 The pain ceases.
 The cervix is closed.
 The uterus is slightly larger than normal.
 Ultrasound : shows empty cavity.
(E) Missed Abortion:
Retention of dead products of conception for 4 weeks or more.
Carneous mole is a special variety of missed abortion in which the dead ovum
in early pregnancy is surrounded by clotted blood.
Clinical picture:
(A) Symptoms:
 Symptoms of threatened abortion may or may not be developed.
 Regression of pregnancy symptoms as nausea, vomiting and breast
Symptoms.
 The abdomen does not increase and may even decrease in size.
 The foetal movements are not felt or ceases if previously present.
 Milk secretion may start particularly in second trimester abortion
 Because of the decline in oestrogens secretion that were normally
blocking the action of prolactin on the breasts.
 A dark brown vaginal discharge may occur ( prune juice discharge).
(B) Signs:
 The uterus fails to grow or even decreases in size and becomes firmer.
 The cervix is closed.
 The foetal heart sounds cannot be heard by the doptone.

Investigations:
 Pregnancy test becomes negative within two weeks from the ovum
death, but it may remain positive for a longer period due to persistent
living chorionic villi.
 Ultrasound shows either a collapsed gestational sac, absent foetal heart
movement or foetal movement.

Complications:
 Disseminated intravascular coagulation (DIC) may occur if the dead
conceptus is retained for more than 4 weeks.
  Superadded infection.
Treatment:
The dead conceptus is expelled spontaneously in the majority of cases.
Evacuation of the uterus is indicated in the following conditions:
 spontaneous expulsion does not occur within four weeks,
 there is bleeding,
 Infection or DIC developed or ,
 Patient is anxious. Although some gynaecologists advise evacuation of
the uterus once sure diagnosis of missed abortion is made.
Evacuation is carried out as following:
 If the uterine size is less than 12 weeks’ gestation: vaginal or suction
evacuation is done
 If the uterine size is more than 12 weeks' gestation : evacuation can be
done by
a. Prostaglandins: given intravaginally (PGE2), intravenously, intra-or
extraamniotic (PGF2 a).
b. Oxytocin infusion.
c. Combination: starting with prostaglandin and completed with
oxytocin.
d. Hysterotomy: is rarely indicated in 2nd trimester missed abortion if
the medical induction fails initially and after repetition few days
later.

(F) Septic Abortion:

It is any type of abortion, usually criminal abortion, complicated by infection.
Microbiology:
E.Coli,bacteroids, anaerobic streptococci, clostridia, streptococci and
staphylococci are among the most causative organisms.
Clinical picture:
General examination:
o Pyrexia and tachycardia.
o Rigors suggest bacteraemia.
o A subnormal temperature with tachycardia is ominous and
mostly seen with gas forming organisms.
o Malaise, sweating , headache, and joint pain.
o Jaundice and /or haematuria is an ominous sign, indicating
haemolysis due to chemicals used in criminal abortion or
haemolytic infection as clostridium welchii.
Abdominal examination:
  Suprapubic pain and tenderness.
 Abdominal rigidity and distension indicates peritonitis.
Local examination:
o Offensive vaginal discharge. Minimal inoffensive vaginal
discharge is often associated with severe cases.
o Uterus is tender.
o Products of conception may be felt.
o Local trauma may be detected.
o Fullness and tenderness of Douglas pouch indicates pelvic
abscess which will be associated with diarrhoea.
Complications:
 Endotoxic ( septic ) shock may develop
 acute renal failure and
 DIC.
Treatment:
 Isolate the patient. Bed rest in semi-sitting position.
 An intravenous line is established for therapy. In case of shock a central
venous pressure (CVP) line to aid in the control of fluid and blood
transfusion is added
 Observation for vital signs: pulse, temperature and blood pressure as
well as fluid intake and urinary output.

 A cervico-vaginal swab is taken for culture (aerobic and anaerobic) and

sensitivity,
 Antibiotic therapy: Ampicillin or cephalosporin ( as a broad spectrum)
+gentamycin (for gram -ve organisms) + metronidazole (for anaerobic
infection)are given by intravenous route while awaiting the results of
the bacteriological culture. Another regimen to cover the different
causative organism is clindamycin + gentamycin.
 Fluid therapy: e.g. glucose 5% normal saline and/or lactated ringer
solutions can be given as long as there is no manifestations of acute
renal failure particularly the urinary output is more than 30 ml/hour.
 Blood transfusion: is given if CVP is low (normal: 8-12 cm water). It is of
importance also to correct anaemia coagulation defects andinfection.
 Anti-gas gangrene (in Cl.welchii) and antitetanic serum (in Cl. tetani).
 Oxytocin infusion: to control bleeding and enhances expulsion of the
retained products.
 Surgical evacuation of the uterus can be done after 6 hours of
commencing IV therapy but may be earlier in case of severe bleeding
or deteriorating condition in spite of the previous therapy.
 . Hysterectomy may be needed in endotoxic shock not responding to
treatment particularly due to gas gangrene (Cl. welchii).

(G) Therapeutic Abortion:

Abortion induced for a medical indication.

(H) Criminal Abortion:

Illegal abortion induced for a non-medical indication.

Ectopic pregnancy
Definition
An ectopic pregnancy (EP) is defined as the implantation of a pregnancy
outside the normal uterine cavity. Over 98% implant in the Fallopian tube.
Rarely, ectopic pregnancies can implant in the interstitium of the tube,
ovary, cervix, abdominal cavity or in caesarean section scars. A heterotopic
pregnancy is the simultaneous development of two pregnancies: one
within and one outside the uterine cavity.
 Aetiology
The following risk factors have been implicated:
(A) Mechanical factors: May prevent or retard the passage of the fertilised
ovum into the uterine cavity. These may result from:
1- Previous inflammatory disease: It is the commonest risk factor. Ectopic
pregnancy may occur due to:
 Destruction of tubal ciliated epithelium resulting in reduction or
loss of the ciliary current.
 Intratubal adhesions resulting in partial tubal obstruction.
 Peritubal adhesions resulting in restricted tubal motility.
2- Previous pelvic surgery: Particularly reconstructive tubal surgery.
3- Developmental abnormalities: as diverticulae, accessory ostia and tubal
hypoplasia.
4- Adjacent tumours: especially in the broad ligament resulting in
distortion, stretching or partial obstruction of the tube.
5- Previous ectopic pregnancy: where conservative treatment was carried
out.
6- Intrauterine contraceptive device: due to its effect on tubal motility or
increased incidence of PID.
(B) Premature implantation:
Premature implantation of the fertilised ovum in the tube may occur due
to :
1. Premature shedding of the zona pellucida: from the fertilised ovum.
2. Transperitoneal migration of the fertilised ovum to the contralateral
tube: this long journey leads to advanced development of the ovum
that it becomes ready for implantation when it reaches the tube.
This was proved by presence of the corpus luteum in the
contralateral ovary in 50% of ectopic pregnancy.
3. Presence of ectopic endometrium in the tube.
Clinical Picture
General symptoms:
1- Short period of amenorrhoea: usually does not exceed 8-10 weeks. This
may be lacking if the ectopic pregnancy is disturbed before the next
menstruation. This may occur particularly with ectopic pregnancy in the
interstitial portion of the tube.
2- Pain: is present in almost every case and precedes vaginal bleeding. It may
be:
A. Aching due to tubal distension.
B. Colicky in tubal abortion.
C. Stabbing in tubal rupture.
 D. Shoulder pain if blood accumulates under the diaphragm.
E. Bladder and rectal irritability in pelvic haematocele.

3- Vaginal bleeding:
Due to shedding of the decidua. It is usually slight and follows the pain.
General signs:
General examination:
Breast signs of pregnancy.
Abdominal examination: Lower abdominal tenderness and rigidity especially
on one side may be present.
Vaginal examination:
o Bluish vagina and bluish soft cervix.
o Uterus is slightly enlarged and soft.
o Marked pain in one iliac fossa on moving the cervix from side to
side.
o Ill-defined tender mass may be detected in one adnexa in which
arterial pulsation may be felt.
The other manifestations depend upon the clinical variety of the ectopic
pregnancy:

Investigations
The following are useful investigations for the diagnosis of EP. Nonetheless,
again, it is fundamentally important to assess the woman clinically (‘ABC’,
abdominopelvic examination) in conjunction with the results of investigations
to manage the patient.
• TVUSS: identification of an intrauterine pregnancy (intrauterine gestation sac,
yolk sac +/− fetal pole) on TVUSS effectively excludes the possibility of an EP
in most patients except in those patients with rare heterotopic pregnancy. A
TVUSS showing an empty uterus with an adnexal mass has a sensitivity of
90% and specificity of 95% in the diagnosis of EP. The presence of moderate
to significant free fluid during TVUSS is suggestive of a ruptured EP.
• Serum hCG: the serum hCG level almost doubles every 48 hours in a
normally developing intrauterine pregnancy. In patients with EP, the rise of
hCG is often suboptimal. However, hCG levels can vary widely in individuals
and thus consecutive measurements 48 hours apart are often required for
comparison purposes.
• Haemoglobin and ‘Group and Save’ (or cross-match if patient is severely
compromised):
• Measure to assess degree of intra-abdominal bleeding and rhesus status.
Management
An EP can be managed using an expectant, medical or a surgical approach,
depending on clinical presentation and patient choice.
Expectant management
Expectant management is based on the assumption that a significant
proportion of all EPs will resolve without any treatment. This option is suitable
for patients who are haemodynamically stable and asymptomatic (and remain
so). The patient requires serial hCG measurements until levels are
undetectable.
Medical management
Intramuscular methotrexate is a treatment option for patients with minimal
symptoms, an adnexal mass <40 mm in diameter and a current serum hCG
concentration under 3,000 IU/l. Methotrexate is a folic acid antagonist that
inhibits deoxyribonucleic acid (DNA) synthesis, particularly affecting
trophoblastic cells.
The dose of methotrexate is calculated based on the patient’s body surface
area and is 50 mg/m2. After methotrexate treatment serum hCG is usually
routinely measured on days 4, 7 and 11, then weekly thereafter until
undetectable (levels need to fall by 15% between day 4 and 7, and continue
to fall with treatment). Medical treatment should therefore only be offered if
facilities are present for regular followup visits. The few contraindications to
medical treatment include:
1. chronic liver, renal orhaematological disorder;
2. active infection;
3. immunodeficiency; and
4. breastfeeding.
There are also known side-effects such as stomatitis, conjunctivitis,
gastrointestinal upset and photosensitive skin reaction, and about two-thirds
of patients will suffer from non-specific abdominal pain. It is important to
advise women to avoid sexual intercourse during treatment and to avoid
conceiving for 3 months after methotrexate treatment because of the risk of
teratogenicity. It is also important to advise them to avoid alcohol and
prolonged exposure to sunlight during treatment.
Surgical management
The standard surgical treatment approach is laparoscopy (Figure 5.3).
Laparotomy is reserved for severely compromised patients or where there are
no endoscopic facilities. The operation of choice is removal of the Fallopian
tube and the EP within (salpingectomy), or in some cases a small opening can
be made over the site of the EP and the EP extracted via this opening
(salpingostomy). Salpingostomy is recommended only if the contralateral tube
is absent or visibly damaged, and it is associated with a higher rate of
subsequent EP. Pregnancy rates subsequently remain high if the contralateral
tube is normal because the oocyte can be picked up by the ipsilateral or
contralateral tube.
Anti-D administration
All rhesus-negative women who have a surgical procedure to manage an EP
or miscarriage should be offered anti-D immunoglobulin at a dose of 50 μg
(250 IU) as soon as possible and within 72 hours of the surgery.

Hydatidiform (Vesicular) Mole

It is a benign neoplasm of the chorionic villi.
Incidence: 1:2000 pregnancies in United States and Europe, but 10 times
more in Asia. The incidence is higher toward the beginning and more toward
the end of the childbearing period. It is 10 times more in women over 45
years old.
Pathology:
The uterus is distended by thin walled, translucent, grape-like vesicles of
different sizes. These are degenerated chorionic villi filled with fluid.
There is no vasculature in the chorionic villi leads to early death and
absorption of the embryo.
There is trophoblastic proliferation, with mitotic activity affecting both
syncytial and cytotrophoblastic layers. This causes excessive secretion of
hCG,chorionic thyrotrophin and progesterone. On the other hand, oestrogen
production is low due to absence of the foetal supply of precursors.
High hCG causes multiple theca lutein cysts in the ovaries in about 50% of
cases. It also results in exaggeration of the normal early pregnancy symptoms
and signs.
Types of mole:
(i) Complete mole:
o The whole conceptus is transformed into a mass of vesicles.
o No embryo is present.
o It is the result of fertilisation of anucleated ovum ( has no
chromosomes) with a sperm which will duplicate giving rise to
46 chromosomes of paternal origin only.
(ii) Partial mole:
o A part of trophoblastic tissue only shows molar changes.
o There is a foetus or at least an amniotic sac.
o It is the result of fertilisation of an ovum by 2 sperms so the
chromosomal number is 69 chromosomes.
DIAGNOSIS:
(A) Symptoms:
1. Amenorrhoea: usually of short period (2-3 months).
2. Exaggerated symptoms of pregnancy especially vomiting.
3. Vaginal bleeding which is usually dark brown and may be associated with
passage of vesicles.
4. Abdominal pain : may be ,
- dull-aching due to rapid distension of the uterus,
- colicky due to starting expulsion,
- Sudden and severe due to perforating mole.

B) Signs:
General examination:
1. Pre-eclampsia develops in 20% of cases, usually before 20 weeks’
gestation.
2. Hyperthyroidism develops in 10% of cases manifested by enlarged
thyroid gland, tachycardia and elevated plasma thyroxin level.
3. Breast signs of pregnancy.
Abdominal examination:
1. The uterus is larger than the period of amenorrhoea in 50% of cases,
corresponds to it in 25% and smaller in 25% with inactive or dead
mole.
2. The uterus is doughy in consistency
3. Foetal parts and heart sound cannot be detected except in partial mole.
Local examination
1. Passage of vesicles (sure sign).
2. Bilateral ovarian cysts (5-20 cm) in 50% of cases.
(C) Investigations:
1. Urine pregnancy test: is positive in high dilution. 1/200 is highly
suggestive, 1/500 is surely diagnostic. In normal pregnancy it is positive
in dilutions up to 1/100.
2. Serum b -hCG level: is highly elevated ( > 100.000 mIU/m1).
3. Ultrasonography reveals:
 The characteristic intrauterine " snow storm" appearance,
 no identifiable foetus,
 bilateral ovarian cysts may be detected.
4. X-ray : shows no foetal skeleton.

Treatment:
o As soon as the diagnosis of vesicular mole is established the
uterus should be evacuated.
o The selected method depends on the size of the uterus, whether
partial expulsion has already occur or not, the patient's age and
fertility desire.
o Cross - matched blood should be available before starting.
(I) Suction evacuation:
o It is carried out under general anaesthesia, but not that which
relax the uterus as halothane as it may induce severe bleeding.
 o An infusion of 20 units oxytocin in 500 m1 of 5% glucose should
be maintained throughout the procedure.
o Dilatation of the cervix is done up to a Hegar's number equal to
the period of amenorrhoea in weeks e.g. No. 10 Hegar for 10
weeks’ amenorrhoea. The suction canula used will be of the
same size also.
o - A suction canula which may be metal or a disposable plastic
(preferred) is introduced into the uterine cavity.
o - The canula is connected to a suction pump adjusted at
negative pressure of 300-500 mmHg according to the duration
of pregnancy.
o - Although some recommended a gentle sharp curettage to the
uterus after evacuation, it is preferable to wait one week for fear
of uterine perforation.
(II)Hysterotomy:
 It may be needed for evacuation of a large mole to minimise and
facilitate control of bleeding.
(III) Hysterectomy:
 It should be cosidered in women over 40 years who have completed
their family for fear of developing choriocarcinoma.
IV) Medical induction:
 Oxytocins and / or prostaglandins may be used to encourage expulsion
of the mole but must always be followed by surgical evacuation.

Follow up:
 As choriocarcinoma may complicate the vesicular mole after its
evacuation, detection of serum ß-hCG by radioimmunoassay for 2 years
is essential.
 Detection is done every;
 2 weeks after evacuation to ensure regression of b –hCG level then,
 Every month for one year then,
 Every 3 months for another year.
 Persistent high level indicates remnants of molar tissues which
necessitate chemotherapy ( methotrexate) with or without curettage.
Hysterectomy is indicated if women had enough children.
 Rising hCG, level after disappearance means developing of
choriocarcinoma or a new pregnancy. So combined contraceptive pills
should be used for prevention of pregnancy which can be misleading.
  It is expected that urine pregnancy test is negative 4 weeks after
evacuation and serum b -hCG is undetectable 4 months after
evacuation.
 Early features suggesting residual molar tissue include;
 recurrent or persistent vaginal bleeding,
 amenorrhoea,
 failure of uterine involution,
 Persistence of ovarian enlargement.
Complications:
1. Haemorrhage.
2. Infection due to absence of the amniotic sac.
3. Perforation of the uterus.
4. Pregnancy induced hypertension
5. Hyperthyroidism.
6. Subsequent development of choriocarcinoma
Bleeding in Late Pregnancy (Antepartum Haemorrhage)
Definition

It is bleeding from the genital tract after the 28th week of pregnancy and before the
end of the second stage of labour.

Classification

(A ) Placental site bleeding : (62%)

 Placenta praevia (22%) : Bleeding from separation of a placenta wholly or

partially implanted in the lower uterine segment.
 Abruptio placentae (30%) : Premature separation of a normally implanted
placenta.
 Marginal separation (10%)ý: Bleeding from the edge of a normally implanted
placenta.

(B) Non-placental site bleeding: (28%)

 Vasa praevia : Bleeding from ruptured foetal vessels.

 Rupture uterus. 3-Bloody show.
 Cervical ectopy , polyp or cancer.
 Vaginal varicosity.

PLACENTA PRAEVIA

Definition
The placenta is partialy or totally attached to the lower uterine segment.

Incidence: 0.5% of pregnancies. It is more common in multiparas and in twin

pregnancy due to the large size of the placenta.

Aetiology

Not well known but may be due to:

 Low implantation of the blastocyst.

 Development of the chorionic villi in the decidua capsularis leading to
attachement to the lower uterine segment.
 Large placenta as in twin pregnancy.

Degrees (types)

1. First degree ( Type I = P.P. lateralis = low-lying placenta):- The lower edge
of the placenta reaches the lower uterine segment but not the internal os.
2. Second degree ( Type II= P.P. marginalis): The lower edge of the placenta
reaches the margin of the internal os but does not cover it.
3. Third - degree ( Type III= P.P. incomplete centralis): The placenta covers the
internal os when it is closed or partially dilated but not when it is fully dilated.
4. Fourth - degree ( Type IV = P.P. complete centralis): The placenta covers the
interanl os completely whether the cervix is partially or fully dilated.

N.B. Placenta praevia marginalis posterior is of bad prognosis than marginalis

anterior because: It encroaches on the true conjugate diameter delaying engagement
of the head. Engagement of the head will compress the placenta against the sacrum,
causing foetal asphyxia.
Mechanism of bleeding

Progressive stretching of the lower uterine segment normally occurs during the 3rd
trimester and labour, but the inelastic placenta cannot stretch with it. This leads to
inevitable separation of a part of the placenta with unavoidable bleeding. The closer
to term, the greater is the amount of bleeding.

Diagnosis

Symptoms:

Causeless, painless and recurrent bright-red vaginal bleeding;

 It is causeless, but may follow sexual intercourse or vaginal examination.

 It is painless, but may be associated with labour pains .
 It is recurrent, but may occur once in slight placenta praevia lateralis.

Fortunately, the first attack usually not severe.

Signs:

General examination:
 The general condition of the patient depends upon the amount of blood loss. Shock
develops if there is acute severe blood loss and anaemia develops if there is
recurrent slight blood loss.

Abdominal examination:

The uterus is corresponding to the period of amenorrhoea, relaxed and not tender.

The foetal parts and heart sound (FHS) can be easily detected.

Malpresentations, particularly transverse and oblique lie and breech presentation are
more common as well as non-engagement of the head. This is because the lower
uterine segment is occupied by the placenta.

Vaginal examination

Speculum examination to exclude local lesions is only permissible when placenta

praevia has been excluded by ultrasound.

P/V is indicated only if active treatment is initiated. This may provoke a severe attack
of bleeding so it should be done with the following precautions:

 In the operating room,

 under general anaesthesia,
 cross- matched blood is in hand,
 Operating theatre is ready for immediate caesarean section.

Investigations:

 Ultrasound:

It is the most simple, precise and safe method for placental localization. A partially
full bladder is necessary to identify the lower edge of the placenta. If it is less than 3
cm from the margin of the internal os , it is diagnosed as placenta praevia.

 Rh compatibility test.
 Complete blood cell (CBC) count.
 Blood grouping
Treatment

At home:

 Arrange for immediate trasfer to the hospital.

  No vaginal examination and no vaginal pack, only a sterile vulval pad is
applied.
 No oral intake as anaesthesia may be required.
 Antishock measures as pethidine IM, fluids and blood transfusion may
begiven in the way to the hospital if bleeding is severe.

At Hospital:

Assessment of the patient's condition, general and abdominal examination and

resuscitation if needed.

At least 2 unites of cross matched blood should be available.

Ultrasonography for:

Differentiation between abruptio placentae (retroplacental haematoma in a normally

implanted placenta), marginal bleeding (separation of the margine of a normally
implanted placenta) and placenta praevia ( in the lower uterine segment), assessment
of foetal viability age, position and presentation.

Then management is carried out as following:

(I) If the patient is not in labour:

Look to the amount of bleeding;

If the bleeding is severe, continue antishock measures and do immediate caesarean

section . If the bleeding is slight , look to the gestational age;

If completed 37 weeks (36 weeks by some authors) or more, pregnancy is terminated

by induction of labour or caesarean section (see later). At this time, the foetus is
mature and the mother will be in a risk of severe haemorrhage as term approaches.

If less than 37 weeks (36 weeks by others), conservative treatment is indicated till the
end of 37 (or 36) weeks but not more.

Conservative treatment:

 The patient is kept hospitalized with bed rest and observation till delivery.
 Anaemia should be corrected if present.
 Observation of foetal wellbeing.
 Anti-D immunoglobulin is given for the Rh-negative mother.

(II) If the patient is in labour:

Vaginal examination is done under the previously mentioned precautions. According
to the findings, the patient will be delivered either vaginally by amniotomy +
oxytocin or by caesarean section.

Vaginal delivery is allowed if the following findings are fulfilled:

 Placenta praevia is lateralis or marginalis anterior,

 bleeding is slight,
 vertex presentation,
 Adequate pelvis with no soft tissue obstruction.
 partialy dilated cervix to allow amniotomy.

Caesarean section is indicated in :

 Placenta praevia centralis whether complete or incomplete even if the foetus

is dead.
 Placenta praevia marginalis posterior.
 Severe bleeding.
 Presentation other than vertex.
 Other obstetric indications as contracted pelvis, cord prolapse and elderly
primigravida.

Complications of Placenta Praevia:

(A) Maternal:
Maternal mortality rate is 0.2%.

(I) During pregnancy:

a. Abortion.
b. Preterm labour.
c. Antepartum haemorrhage.

(4) Malpresentation and non-engagement.

(II) During labour:

a. Premature rupture of membranes.

b. Cord prolapse.
c. Inertia.
d. Obstructed labour.
e. Postpartum haemorrhage.
f. Retained placenta.
 g. Placenta accreta due to deficient decidual reaction in the lower
segment allows deep penetration of chorionic villi. This may
necessitate hysterectomy.
h. Lacerations of lower uterine segment due to increased vascularity and
friability.
i. Air embolism due to low placental site.

(B) Foetal:

Foetal mortality rate is 20 %.

a. Prematurity.
b. Asphyxia.
c. Malformations (2%).