placenta praevia associate professor iolanda elena blidaru md, phd

PLACENTA PRAEVIAPLACENTA PRAEVIA

Associate ProfessorAssociate Professor

Iolanda Elena BlidaruIolanda Elena Blidaru

Md, PhD.Md, PhD.


DefinitionDefinitionPPlacenta praevialacenta praevia = = placental insertion over placental insertion over or very near the internal os of the cervix (in or very near the internal os of the cervix (in the lower uterine segment including the the lower uterine segment including the zone of effacement and dilatation).zone of effacement and dilatation).

obstacle in front of the presenting partobstacle in front of the presenting partthe most frequent cause of third trimester the most frequent cause of third trimester bleedingbleeding


ClassificationClassification

Depending if the placenta covers the internal Depending if the placenta covers the internal cervical os completely or partially:cervical os completely or partially:

1.1. TotalTotal placenta praevia placenta praevia

2.2. PartialPartial placenta praevia placenta praevia

3.3. MarginalMarginal placenta praevia placenta praevia

4.4. Low-lyingLow-lying placenta placenta (laterally inserted (laterally inserted placenta) placenta)

PLACENTA PRAEVIAPLACENTA PRAEVIA TOTALIS TOTALIS

PLACENTA PRAEVIA PARTIALISPLACENTA PRAEVIA PARTIALIS

PLACENTA PRAEVIAPLACENTA PRAEVIA MARGINALISMARGINALIS


This classification is made on This classification is made on the basis of findings at the the basis of findings at the initial examination and may initial examination and may

change in labor or as change in labor or as pregnancy advances.pregnancy advances.


IncidenceIncidence

0.5% -1% of all births0.5% -1% of all birthsUS of early pregnancies - a large number of low-US of early pregnancies - a large number of low-lying pregnancies subsequently aborted.lying pregnancies subsequently aborted."placental migration" (US evaluation)"placental migration" (US evaluation) → as → as pregnancy advances, the lower uterine segment pregnancy advances, the lower uterine segment lengthens and the placenta is drawn upward with lengthens and the placenta is drawn upward with the enlarging uterus. the enlarging uterus.


Risk factorsRisk factors previous cesarean section (x 6)previous cesarean section (x 6) multiparity(x 2.6)multiparity(x 2.6)advancadvanceded age age previous D&Cprevious D&C smokingsmoking


EtiologyEtiologyinflammatory or atrophic changesinflammatory or atrophic changes of of the endometriumthe endometrium (endometritis, (endometritis, hypoplasia, submucous myomas, trauma)hypoplasia, submucous myomas, trauma) → → ddefective decidual vascularizationefective decidual vascularizationttwin pregnancywin pregnancy, with large placental bed, with large placental bedincreased surface of increased surface of thethe placenta placenta implanted in the lower uterine segment implanted in the lower uterine segment ((tissues → unappropriate for nidationtissues → unappropriate for nidation) )


PathogenesisPathogenesispainless bleedingpainless bleeding → → maternal blood + fetal maternal blood + fetal blood blood ((a little parta little part))..

MechanismsMechanisms::separation of the placenta from its separation of the placenta from its implantation siteimplantation siteformation of the lower uterine segment formation of the lower uterine segment effacement and dilatation of the cervix in laboreffacement and dilatation of the cervix in laborrupture of rupture of thethe venous lake in the decidua venous lake in the decidua basalisbasalis


Associated conditionsAssociated conditionsplacenta accreta → placenta accreta → abnormally firm abnormally firm adherence to the uterine walladherence to the uterine wall

placenta increta → placenta increta → placental villi invade placental villi invade the myometrium the myometrium

placenta percreta → placenta percreta → placental villi placental villi penetrate through the myometriumpenetrate through the myometrium


Clinical findingsClinical findingspainless bleeding (maternal origin)painless bleeding (maternal origin)slight or profuse hemorrhage slight or profuse hemorrhage the blood is bright redthe blood is bright redpostpartalpostpartal excessive hemorrhageexcessive hemorrhage →→

1.1. abnormal adherence,abnormal adherence,2.2. excessively large area of attachement, excessively large area of attachement, 3.3. the poorly contracted lower uterine segment,the poorly contracted lower uterine segment,4.4. lacerations in the cervix and lower segment.lacerations in the cervix and lower segment.

PLACENTA PRAEVIAPLACENTA PRAEVIADiagnosisDiagnosis

abdominal examination: abdominal examination: ababnormal fetal normal fetal presentation (presentation (transverse lie, breech transverse lie, breech presentation), the presenting part is high above presentation), the presenting part is high above the inlet and deviated anteriorly or laterally the inlet and deviated anteriorly or laterally

FHR - normalFHR - normal

If cervical os dilated → cautious inspectionIf cervical os dilated → cautious inspection

digital examination is never permitted digital examination is never permitted unless unless at term pregnancy, in an operating room with all at term pregnancy, in an operating room with all the preparations for immediate cesarean section; the preparations for immediate cesarean section; the examination can cause life-threatening the examination can cause life-threatening hemorrhage.hemorrhage.


DiagnosisDiagnosisSonographySonography

transabdominal US transabdominal US (96% accuracy)(96% accuracy)transvaginal UStransvaginal US transperineal UStransperineal US


Differential diagnosisDifferential diagnosisCervical bleedingCervical bleeding → benign / malignant → benign / malignant lesionslesions

Endouterine bleedingEndouterine bleeding: : premature separation of the normally premature separation of the normally

implanted placenta, implanted placenta, rupture of umbilical cord vessels,rupture of umbilical cord vessels,premature labor. premature labor.


DELIVERY MODEDELIVERY MODEPractically all Practically all women do need women do need cesarean sectioncesarean section..

PLACENTA PRAEVIAPLACENTA PRAEVIACONDUCT AT THE CONDUCT AT THE DELIVERY DELIVERY

Several clinical situations:Several clinical situations: 1. The patient is in labor → 1. The patient is in labor → cesareancesarean sectionsection 2. The fetus is mature and the bleeding does not stop 2. The fetus is mature and the bleeding does not stop

→ → cesarean sectioncesarean section 3. The fetus is preterm and there is no indication for 3. The fetus is preterm and there is no indication for

delivery → delivery → observeobserve 4. The bleeding is so severe, despite the fetus 4. The bleeding is so severe, despite the fetus

immaturity → immaturity → cesarean sectioncesarean section 5. Total placenta praevia with dead fetus 5. Total placenta praevia with dead fetus →→ cesareancesarean

sectionsection (the bleeding cannot be controlled). (the bleeding cannot be controlled).

PLACENTA PRAEVIAPLACENTA PRAEVIACONDUCT AT THE CONDUCT AT THE DELIVERYDELIVERY

If If placenta praevia + accretaplacenta praevia + accreta, other methods of , other methods of

hemostasis:hemostasis:

oversewing the implantation siteoversewing the implantation site

bilateral uterine / inernal iliac artery ligationbilateral uterine / inernal iliac artery ligation

packing the lower uterine segment with gauzepacking the lower uterine segment with gauze

total abdominal hysterectomytotal abdominal hysterectomy..


CONDUCT AT THE CONDUCT AT THE DELIVERYDELIVERYVaginal deliveryVaginal delivery may be possible in: may be possible in:

a multipara with a soft, effaced and partially a multipara with a soft, effaced and partially dilated cervix + a minor degree of anterior dilated cervix + a minor degree of anterior placenta praevia + ruptured membranesplacenta praevia + ruptured membranes

if the fetus is dead, the cervix is soft and effaced, if the fetus is dead, the cervix is soft and effaced, only an edge of placenta can be felt and bleeding only an edge of placenta can be felt and bleeding is minimalis minimal

before the 28th week, when the baby has little before the 28th week, when the baby has little chance of survivingchance of surviving


ADDITIONAL TREATMENTADDITIONAL TREATMENT

adequate transfusionadequate transfusion

prophilactic treatment of thrombo-prophilactic treatment of thrombo-embolism / infectious complicationsembolism / infectious complications

anti-D Iganti-D Ig

bed restbed rest


PrognosisPrognosis

MaternalMaternalFetal / NeonatalFetal / NeonatalThe perinatal mortality rate The perinatal mortality rate →→ 15-20% (10 times>) 15-20% (10 times>)Causes: Causes: • prematurity (a major cause) prematurity (a major cause) • IUGRIUGR• intrauterine anoxia (placental separation, prolapsed cord)intrauterine anoxia (placental separation, prolapsed cord)• respiratory distress syndromerespiratory distress syndrome• exsanguination exsanguination • fetal malformationsfetal malformations

placenta praevia associate professor iolanda elena blidaru md, phd

Documents

placenta praevia slide

placenta praevia totalis

total placenta praevia

partial placenta praevia

marginal placenta praevia

placenta praevia incidence

inserted placenta slide

lowlying placenta