Management of Type II Placenta Previa

Management of Type II Placenta Previa

Dr. Geetha Balsarkar,Dr. Geetha Balsarkar,Associate Professor and Unit incharge,Associate Professor and Unit incharge,Nowrosjee Wadia Maternity Hospital,Nowrosjee Wadia Maternity Hospital,

Seth G.S. Medical college, Parel , MumbaiSeth G.S. Medical college, Parel , MumbaiJoint Asst. Secretary to the Editor,Joint Asst. Secretary to the Editor,

Journal of Obstetrics and Gynecology of India,Journal of Obstetrics and Gynecology of India,Secretary, AMWI, Mumbai branchSecretary, AMWI, Mumbai branch

Dr. Geetha Balsarkar,Dr. Geetha Balsarkar,Associate Professor and Unit incharge,Associate Professor and Unit incharge,Nowrosjee Wadia Maternity Hospital,Nowrosjee Wadia Maternity Hospital,

Seth G.S. Medical college, Parel , MumbaiSeth G.S. Medical college, Parel , MumbaiJoint Asst. Secretary to the Editor,Joint Asst. Secretary to the Editor,

Journal of Obstetrics and Gynecology of India,Journal of Obstetrics and Gynecology of India,Secretary, AMWI, Mumbai branchSecretary, AMWI, Mumbai branch

http://en.wikipedia.org/wiki/File:Placenta_Previa.jpg

ClassificationClassification Type I or low lying: The placenta encroaches the lower

segment of the uterus but does not infringe on the cervical os

Type II or marginal: The placenta touches, but does not cover, the top of the cervix.

Type III or partial: The placenta partially covers the top of the cervix

Type IV or complete: The placenta completely covers the top of the cervix

Type I or low lying: The placenta encroaches the lower segment of the uterus but does not infringe on the cervical os

Type II or marginal: The placenta touches, but does not cover, the top of the cervix.

Type III or partial: The placenta partially covers the top of the cervix

Type IV or complete: The placenta completely covers the top of the cervix

DiagnosisDiagnosis DO NOT DIAGNOSE via vaginal exam!

(Exception-”double setup”) Ultrasound is the easiest, most reliable

way to diagnose (95-98+% accuracy) False positive- ultrasound with distended bladder Transvaginal or transperineal often superior to

transabdominal methods

DO NOT DIAGNOSE via vaginal exam!

(Exception-”double setup”) Ultrasound is the easiest, most reliable

way to diagnose (95-98+% accuracy) False positive- ultrasound with distended bladder Transvaginal or transperineal often superior to

transabdominal methods

MigrationMigration Clinically important bleeding is not likely before

24-26 weeks gestation The clinically important diagnosis of placenta previa

is therefore a late second or early third trimester diagnosis

Migration is a misnomer- the placental attachment does not change, the relative growth of the lower segment does

Clinically important bleeding is not likely before 24-26 weeks gestation

The clinically important diagnosis of placenta previa is therefore a late second or early third trimester diagnosis

Migration is a misnomer- the placental attachment does not change, the relative growth of the lower segment does

InterventionIntervention Although mothers used to be treated in the hospital

from the first bleeding episode until birth, it is now considered safe to treat placenta praevia on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the fetus are in distress.

Bedrest probably indicated Antenatal testing probably indicated

Although mothers used to be treated in the hospital from the first bleeding episode until birth, it is now considered safe to treat placenta praevia on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the fetus are in distress.

Bedrest probably indicated Antenatal testing probably indicated

McCafee regime of expectant management

McCafee regime of expectant management

EvaluationEvaluation Evaluation for possibility of accreta needs to be

considered Consideration for RHIG in rh negative patients with

bleeding Episodic AFS testing with bleeding events Vigilance regarding fetal growth Follow up ultrasound if indicated

Evaluation for possibility of accreta needs to be considered

Consideration for RHIG in rh negative patients with bleeding

Episodic AFS testing with bleeding events Vigilance regarding fetal growth Follow up ultrasound if indicated

Associated conditionsAssociated conditions Abnormal presentation (placenta raises presenting

part) Oblique lie Transverse lie Placental abruption Placenta accreta (especially if prior ceserean section) Postpartum hemorrhage

Abnormal presentation (placenta raises presenting part)

Oblique lie Transverse lie Placental abruption Placenta accreta (especially if prior ceserean section) Postpartum hemorrhage

Think AccretaThink Accreta

Previous cesarean scars

Previous myomectomy scars

Twins or multiple gestation

Grand multipara

Previous cesarean scars

Previous myomectomy scars

Twins or multiple gestation

Grand multipara

CounselingCounseling

Risk of severe life-threatening hemorrhage

Risk of fetal death

Risk of maternal death

Blood transfusion may be necessary

Hysterectomy may be needed to control bleeding

Risk of severe life-threatening hemorrhage

Risk of fetal death

Risk of maternal death

Blood transfusion may be necessary

Hysterectomy may be needed to control bleeding

Conservative measuresConservative measures If the bleeding is not life threatening or, if initially

severe but begins to settle, then there is a place for conservative measures

If the fetus is still preterm and the bleeding is under control, a policy of conservative management should be followed, at least until fetal maturity is achieved.

If the bleeding is not life threatening or, if initially severe but begins to settle, then there is a place for conservative measures

If the fetus is still preterm and the bleeding is under control, a policy of conservative management should be followed, at least until fetal maturity is achieved.

Management ProtocolManagement Protocol

Late pregnancy bleeding Ceserean delivery indications

37 weeks or Unstable: Heavy bleed, hypotension,

fetal distress

Late pregnancy bleeding Ceserean delivery indications

37 weeks or Unstable: Heavy bleed, hypotension,

fetal distress

DeliveryDelivery

Delivery should depend upon type of previa

– Complete previa = c/section

– Low lying = (probable attempted vaginaldelivery

– Marginal/partial = (it depends!)

Consider “double setup” for uncertain cases

Delivery should depend upon type of previa

– Complete previa = c/section

– Low lying = (probable attempted vaginaldelivery

– Marginal/partial = (it depends!)

Consider “double setup” for uncertain cases

DeliveryDelivery Immediate delivery of the fetus may be indicated if

the fetus is mature If the fetus or mother are in distress. Blood volume replacement (to maintain blood

pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary in a bleeding episode

Immediate delivery of the fetus may be indicated if the fetus is mature

If the fetus or mother are in distress. Blood volume replacement (to maintain blood

pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary in a bleeding episode

Vaginal deliveryVaginal delivery Tertiary center

Blood crossmatched and ready

Fetal monitoring

Gentle PV examination ???? To assess progess of

labour

Everything ready for LSCS

Tertiary center

Blood crossmatched and ready

Fetal monitoring

Gentle PV examination ???? To assess progess of

labour

Everything ready for LSCS

Thank youThank you