PLACENTA PREVIA

INTRODUCTION
Placenta previa is a condition in which the placenta
implants in the lower portion of the uterus partially or
wholly.
The low lying allows the lost blood to escape
uninterrupted therefore a retroplacental clot is not
formed. And for this reason, pain is not a feature of
placenta previa.
The incidence at term is approximately 1 in 200 births.
Although the etiology remains unclear, some risk factors
implicate previous decidual damage and/or large placental
surface area as causes.
CONT’D
During routine second-trimester ultrasound, the placenta is
observed to cover the cervical os in 5–20% of pregnancies.
However, differential growth of the uterus and placenta
throughout gestation results in realignment of the placenta
with respect to the internal cervical os.
By term, more than 90% of early placenta previas convert to
a normal location.
Conversion to normal location is less common in centrally
located complete placenta previa.
Placenta praevia has been associated with increased
maternal and perinatal morbidity and mortality.
TYPES
 TYPE 1 PLACENTA PREVIA
In this type, majority of the placenta is in the upper
uterine segment.
Blood loss is usually minimal and the mother and
foetus remain in good condition.
Vaginal birth is possible
TYPES CONT’D
TYPE 2 PLACENTA PREVIA
Here the placenta is partially located at the lower
uterine segment near the internal os (marginal)
There is moderate blood loss, though the condition of
the mother and foetus varies.
Foetal hypoxia is more likely to be present than
maternal shock.
Vaginal birth is possible, particularly if the placenta is
anteriorly located.
TYPES CONT’D
TYPE 3 PLACENTA PREVIA
In this type, the placenta is located over the internal
os but not centrally.
Bleeding is likely to be severe, most especially when
the lower segment stretches and the cervix begins to
efface and dilate in late pregnancy.
Vaginal birth is inappropriate because the placenta
precedes the foetus.
TYPES CONT’D
TYPE 4 PLACENTA PREVIA
Here the placenta completely covers internal cervical
os or centrally located and torrential haemorrhage is
very likely.
C/S is essential to save the lives of the mother and
foetus.
Risk Factors for Placenta Previa
 Endometrial scarring
Previous placenta praevia
Previous cesarean section
Abortion
Multiparity
CONT’D
 Impeded endometrial vascularization
Advance maternal age
Diabetes or hypertension
Cigarette smoking
Uterine anomalies/fibroids/endometritis
Erythroblastosis fetalis
 Increased placental mass
Large placenta
Multiple gestation
Clinical presentation

Placenta praevia is characterized by painless vaginal bleeding

in the late second or third trimester.
However, uterine pain and/or contractions do not preclude
the diagnosis in a woman who presents with vaginal bleeding.
In many cases, placenta previa remains asymptomatic
throughout pregnancy.
Colour of blood is bright red denoting fresh bleeding
A retroplacental clot is not formed
Degree of shock correlates with the amount of blood loss
On abdominal examination, the lie of the foetus is oblique or
transverse with high head in a primi near term
CONT’D
Preterm delivery and complications of prematurity are
the most common sources of perinatal morbidity,
occurring in nearly two-thirds of cases.
Blood product replacement is necessary in one-third
to one-half of cases.
Majority of placenta praevia cases are associated with
placenta accreta.
Diagnosis

Placenta previa is most often diagnosed by routine

sonography.
In other cases, the initial diagnosis is made at the time
of presentation for vaginal bleeding during the second
half of pregnancy.
Trans-abdominal ultrasound may confirm the
suspicion of placenta praevia.
A vaginal exam is contraindicated
MANAGEMENT
The management of placenta praevia depends on:
 The amount of bleeding
 Condition of the mother and foetus
 Location of the placenta
 Stage of the pregnancy
CONSERVATIVE MANAGEMENT
This is appropriate if bleeding slight and the mother
and foetus are stable.
The woman is kept in the hospital until bleeding stops
Speculum examination will help to rule out incidental
causes.
If the placenta encroaches into the lower segment,
further bleeding is inevitable.
Therefore the woman is required to remain in the
hospital or close to the hospital for the rest of the
pregnancy.
CONT’D
Placental function is monitored by means of feotal kick or
CTG.
USS is repeated at intervals in order to observe the position
of the placenta in relation to the cervical Os
Foetal growth is monitored. This is because placental
perfusion across the lower segment is less efficient
compared to fundally situated placenta and so IUGR may
occur.
 ACTIVE MANAGEMENT
This is regardless of the location of the placenta.
It involves C/S in case of severe vaginal bleeding
Emergency Medical Management

Cesarean delivery is necessary when either maternal or

fetal status is compromised as a result of excessive vaginal
bleeding.
Cesarean birth is necessary in practically all women with
placenta praevia because the placenta is at the cervix, and
labor and cervical dilation results in placental hemorrhage
Vaginal delivery may be attempted with a low-lying
placenta if one can proceed with an emergency cesarean
birth if needed.
Blood is transfused as needed.
Management of placenta previa
without hemorrhage

Placenta praevia diagnosed by routine second-trimester

sonography is managed expectantly.
The patient can be reassured that the likelihood of spontaneous
resolution is greater than 90%.
It is reasonable to recommend avoidance of strenuous activity,
but further limitations probably are not necessary early in
pregnancy.
Placental location should be re-evaluated at 28–30 weeks.
If placenta praevia persists, the patient should be cautioned that
rigorous activity and/or intercourse might provoke bleeding.
If complete placenta praevia persists beyond 32–34 weeks,
resolution by term is unlikely.
CONT’D
Cesarean delivery should be scheduled at a gestational age that will
maximize the likelihood of fetal maturity and minimize the risk of
hemorrhage that may result from the normal onset of uterine
contractions.
 In the asymptomatic patient, amniocentesis should be considered at
34–36 weeks to assess fetal pulmonary maturity.
 If the test result is consistent with pulmonary maturity, delivery is
indicated.
 If the test suggests pulmonary immaturity, decisions regarding
corticosteroid administration and delivery timing must be
individualized, taking into account such factors as obstetric history,
gestational age, fetal status, amniotic fluid volume and uterine
activity.
Management of placenta previa
with hemorrhage

The management of placenta praevia complicated by

acute hemorrhage is directed at optimizing the
outcomes of the mother and the fetus.
In many cases, bleeding resolves spontaneously and
the patient may be managed expectantly.
In other cases, severe haemorrhage may require
intervention.
Expectant management

If the initial episode of bleeding resolves, the mother

and fetus remain stable, and the fetus is premature, a
period of expectant management may be appropriate.
Bed rest usually is prescribed, antenatal
corticosteroids are administered to accelerate fetal
maturation, Rh immune globulin is given if indicated,
and blood product availability is confirmed.
 If the woman remains stable for a period of days after
an initial episode of bleeding, continued
hospitalization is unnecessary.
CONT’D
Preparations should be made prior to delivery to
ensure adequate venous access and ready availability
of blood products and uterotonic agents.
Informed consent should include the possibility of
hysterectomy and blood transfusion.
Nursing Actions

Nursing actions are related to maternal fetal status and the

amount of vaginal bleeding and include:
Explain interventions, treatments, and procedure and plan of
care.
Inform the patient and family of maternal and fetal status.
Reassure the patient and her family.
Perform the initial assessment:
Evaluation of color, character, and amount of vaginal bleeding
Arrangement for ultrasound to determine placental location
Determination of fetal gestational age and fetal lung maturity
CONT’D
Assessment of vital signs for increased pulse and
respiratory rate and falling blood pressure every 5 to 15
minutes if active bleeding.
The woman can have up to a 40% maternal blood loss
before exhibiting hemorrhagic hemodynamic changes
in the blood pressure and pulse.
Monitor vaginal bleeding and uterine activity.
Ensure bedrest with bathroom privileges.
Maintain IV access with large-bore IV in case blood
replacement therapy is needed.
CONT’D
Ensure availability of blood.
Assess FHR and UCs.
Give corticosteroids to accelerate fetal lung maturity, if
indicated.
Monitor lab values including CBC, platelets, and
clotting studies.
Notify the physician of any of the following:
Onset or increase in vaginal bleeding
Blood pressure less than 90/60 mm Hg; pulse less than
60 or more than 120 bpm
CONT’D
Respirations less than 14 or more than 26 breaths/min
Temperature greater than 100.4°F (38°C)
Urine output less than 30 mL/hr
Saturated oxygen less than 95%
Decreased level of consciousness
Onset or increase in uterine activity
Non-reassuring fetal status
Anticipate a cesarean birth.
Risks for the Woman
Haemorrhagic and hypovolaemic shock related to
excessive blood loss.
Because of the large volume of maternal blood flow to
the uteroplacental unit at term, unresolved bleeding
can result in maternal exsanguinations in 10 minutes.
Anemia
Potential Rh sensitization as Rh-negative women can
become sensitized during any antepartum bleeding
episode.
CONT’D
PPH
Placenta Accreta up to 15% of women
Maternal death
Air embolism when sinuses in the foetal bed is broken
Risks for the Foetus/Newborn

Disruption of uteroplacental blood flow can result in

progressive deterioration of fetal status, and the
degree of fetal compromise is related to the total
volume of maternal blood loss fetal blood flow.
Blood loss, hypoxia, anoxia, and death related to
maternal hemorrhage may occur.
Fetal anemia may develop due to maternal blood loss.
Neonatal morbidity and mortality is related primarily
to preterm birth.
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