Post on 26-Mar-2015
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
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