Placenta Previa by HrIzv0f4

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									Placenta Previa
   R.L.
   33 y/o
   G4P3 (3002), PU 37 3/7 weeks AOG
   Married
   Filipino
   Roman Catholic




General Data
 scheduled Cesarean section



Reason for consult
 (-)   hypertension
 (-)   diabetes mellitus
 (-)   bronchial asthma
 (-)   thyroid disease

 No known allergies
 s/p LTCS IIIx (Ix for CPD)




Past Medical History
   nonsmoker and alcoholic beverage non-
    drinker




Personal and Social History
 (+) hypertension – father
 (+) bronchial asthma – mother
 (-) diabetes mellitus
 (-) cancer




Family History
   Menstrual History
        Menarche – 11 y/o
        Interval – regular, 28 days   LMP: October 25, 2009
        Duration – 2-3 days           PMP: Sptember 2009
        Amount – 3-4 ppd, fully-soaked
        Symptoms – (+) dysmenorrhea, day 1

   Sexual History
        Coitarche – 21 y/o; single sexual partner; (-)
    dyspareunia, postcoital bleeding; (-) history of STI

   Contraception Use: (+) use of OCPs x 2 months (2006); no
    IUDs
   Latest PAP smear was in June 2010: Normal results




Gynecologic History
G4P3 (3002)
 G1 (2000) – delivered to a live full term baby boy via
  primary LTCS for cephalopelvic disproportion attended
  by doctor – Fabella Hospital, BW 2kg, neonatal death
  x 10 days, neonatal sepsis secondary to meconium
  aspiration
 G2 (2001) – delivered to a live full term baby girl via
  repeat LTCS attended by doctor – SLMC
 G3 (2005) – delivered to a live full term baby boy via
  repeat LTCS attended by doctor – SLMC
 G4 – present pregnancy




Obstetric History
First Trimester          SecondTrimester        ThirdTrimester
•FPNCU (4 mos AOG)       •RPNCU                 •RPNCU
•(+) multivitamins,      •OGCT N                •(+) multivitamins,
ferrous sulfate, folic   •(+) multivitamins,    ferrous sulfate
acid                     ferrous sulfate        •No maternal illness
•No maternal illness     •No maternal illness
•Antenatal tests         •2 bleeding episodes
    •HbsAg               (see HPI)
    nonreactive
    •Blood type O+




Prenatal History
 4 months AOG  FPNCU
 5 months AOG  (+) vaginal bleeding,
  ~10 ppd fully soaked
    ◦ No hypogastric abdominal pain, no uterine
      contractions, no foul smelling vaginal
      discharge, no passage of meaty tissue, no
      fever
    ◦ Sought consult
    ◦ TVS: placenta previa totalis
    ◦ Prescribed Isoxilan tablet (Duvadilan) TID x 7
      days


History of Present Illness
   6 months  (+) vaginal bleeding, 5
    ppd/fully soaked
    ◦ Same associated signs and symptoms
    ◦ took Isoxilan tablet TID x 3 days (self-
      medicated)
    ◦ did not seek consult

   Few hours prior to admission  repeat
    TVS
    ◦ placenta previa totalis to consider placenta
      accreta
    ◦ scheduled Cesarean section
   General
    ◦ Denies fever or malaise
   HEENT
    ◦ Denies headache, blurring of vision, hearing
      problems, epistaxis, tooth or throat pain
   Pulmonary
    ◦ Denies cough or dyspnea
   Cardiovascular
    ◦ Denies palpitations or chest pain
   Gastrointestinal
    ◦ Denies diarrhea and constipation
    ◦ No nausea and vomiting, anorexia




Review of Systems
   Urinary
    ◦ Denies dysuria, frequency, nocturia
   Endocrine
    ◦ Denies polyuria, polydipsia, tremors
   Hematopoietic
    ◦ Denies easy bruisability
   Musculoskeletal
    ◦ Denies myalgia or arhtralgia
   Neurologic/Psychiatric
    ◦ Denies change in sensorium or behavior
   Conscious, coherent, not in cardio-
    respiratory distress, intermittently in pain
   BP: 110/70mmHg CR: 80/min, regular
    RR: 20/min, regular T: 36.8oC
   Skin: no suspicious lesions
   Head: skull normocephalic, atraumatic
   Eyes: pink palpebral conjunctivae,
    anicteric sclerae
   Neck: supple neck, with no palpable neck
    mass, no neck vein engorgement


Physical Examination
   Lungs: symmetrical chest expansion, no rib
    retractions, clear and equal breath sounds
   Heart: adynamic precordium, normal rate,
    regular rhythm, no murmurs
   Abdomen: globular abdomen, (+) midline
    scar; FH 33cm, EFW 3255g, FHT 140bpm; LM
    1: breech LM 2: fetal back on maternal left
    LM 3: unengaged
     Non tender abdomen, no rigidity
   Full and equal pulses, no cyanosis




Physical Examination
 External pelvic examination: no lesions,
  redness, excoriations,
  hyper/hypopigmentations
 IE deferred




Pelvic Examination
   Subjective                         ~5 mos (+) vaginal
    ◦ 33 yoG4P3 (3002), PU 37           bleeding, ~300 mL
      3/7 weeks AOG                     ◦ No hypogastric abdominal
                                          pain, no uterine contractions,
    ◦ (-) HPN, s/p LTCS IIIx (Ix          no foul smelling vaginal
      for CPD)                            discharge, no passage of
    ◦ Non smoker                          meaty tissue, no fever
    ◦ RPNCU since ~4mos AOG,            ◦ TVS: placenta previa
      no maternal illnesses, with       ◦ Isoxilan tablet (Duvadilan)
      2 episodes of vaginal               TID x 7 days
      bleeding in the 2nd               ◦ (+) vaginal bleed ~150ml @
      trimester.                          6 mos AOG
                                       Few hours PTA, TVS was
                                        done which showed:
                                        ◦ Placenta previa totalis t/c
                                          placenta accreta  scheduled
                                          CS


Salient Features
   Objective                  ◦ Abdomen: globular
     Conscious, coherent,       abdomen, (+) midline
      not in cardio-             scar; FH 33cm, EFW
      respiratory distress,      3255g, FHT 140bpm;
      intermittently in pain     LM 1: breech LM 2:
     BP: 110/70mmHg             fetal back on
      CR: 80/min, regular        maternal left LM 3:
      RR: 20/min, regular        unengaged
      T: 36.8oC                  No abdominal
                                  tenderness, no
                                  rigidity




Salient Features
G4P3(3002) PU 37 3/7 weeks AOG,
 cephalic, not in labor, placenta previa
 totalis, t/c placenta accreta previous LTCS
 IIIx (Ix for cephalopelvic disproportion)




Clinical Impression
 Placenta Previa
 Abruptio Placenta
 Spontaneous Abortion
 Cervicitis




Differential Diagnosis
Placenta Previa
             Placenta Previa is a
               condition where the
               placenta lies low in
               the uterus and
               partially or
               completely covers
               the cervix.




DEFINITION
   Total placenta previa
    ◦ the internal os is covered completely by placenta
   Partial placenta previa
    ◦ the internal os is partially covered by placenta
   Marginal placenta previa
    ◦ the edge of the placenta is at the margin of the internal os
   Low-lying placenta
    ◦ the placenta is implanted in the lower uterine segment such
      that the placental edge does not reach the internal os, but
      is in close proximity to it
   Vasa previa
    ◦ the fetal vessels course through membranes and present at
      the cervical os (uncommon, associated with higher rate of
      fetal death




Four degrees of abnormalities
Placentaprevia affects about 1 in 200
pregnant women (Iyasu et al., 1993).




Incidence
Placentaprevia is more common in women
who have had one or more of the following:
  ◦Increasing maternal age
  ◦Multiparity
  ◦Prior cesarean delivery
  ◦Surgery on the uterus
  ◦Smoking
  ◦Multiple gestation (larger surface area of the
  placenta)



Risk Factors
   Placenta accreta, placenta increta or
    placenta percreta
    ◦ Secondary to the poorly developed decidua on
      the lower uterine segment.




Placenta Previa is associated with:
   Placenta accreta --
    Abnormal
    adherence of the
    placenta to the
    myometrial wall,
    with absence of
    decidua basalis.
   Placenta increta--
    placenta attaches
    deep into the
    uterine wall and
    penetrates into the
    uterine muscle, but
    does not penetrate
    the uterine serosa
   Placenta percreta--
    Placental villi
    penetrate
    myometrium and
    through to uterine
    serosa.
   Painless hemorrhage (most characteristic)
    ◦ Due to tearing of placental attachments during the
      formation of the LUS or during cervical dilatation

    ◦ Bleeding occurs at the implantation site as the
      uterus is unable to contract adequately and stop
      the flow of blood from the open vessels.

    ◦ Hemorrhage persists after delivery because of the
      LUS contracts poorly so it cannot constrict the torn
      vessels. May also be due to lacerations in the cervix
      and LUS following manual removal of adherent
      placenta




Clinical Findings:
Pathophysiology
   Placental implantation is initiated by
    the embryo adhering in the lower
    uterus.
With placental attachment and growth, the
developing placenta may cover the cervical
os.
However,  it is thought that a defective
decidual vascularization occurs over the
cervix, possibly secondary to inflammatory
or atrophic changes.
Diagnosis  can seldom be established by
clinical examination unless a finger is passed
thru the cervix the placenta is palpated.
Such examination is never permissible
because even the gentlest examination may
cause torrential hemorrhage.
 ◦Such examination is rarely necessary since
 placental location can be obtained by sonography.




Diagnosis
•The most useful and inexpensive study is
transvaginal ultrasonography that provides
>95% accuracy in identifying a placenta
previa
•An alternative would be transabdominal
ultrasonography that can be 95% accurate;
however, the false-positive and false-
negative rates can range from 2-25%.




Imaging Studies
MRI may be used for planning the delivery in
that it may help identify placenta accreta,
placenta increta, or placenta percreta. These
invasive placental abnormalities are more
common (eg, placenta accrete occurs in up
to 0.2% of pregnancies) due to the increase
in cesarean deliveries, advancing maternal
age, hypertensive disease, smoking, and
placenta previa cases.



Imaging Studies
MRI is no more sensitive in diagnosing
placenta accreta that ultrasonography, but it
may be superior for the posterior placenta
accreta or the more invasive increta and
percreta.




Imaging Studies
   Preterm fetus but with no active bleeding:
    ◦ Close observation
    ◦ In some cases, prolonged hospitalization is
      ideal but the patient is discharged after
      bleeding has stopped and fetus is assessed to
      be healthy.
    ◦ If bleeding persists, preparation for immediate
      surgery is indicated.



Management
   Additionally, tocolytics may also be
    considered in cases of minimal bleeding
    and extreme prematurity to administer
    antenatal corticosteroids. If more than
    one episode of bleeding occurs during
    gestation (at viability or >24 wk), the
    clinician should consider hospitalization
    until delivery given the increased potential
    for placental abruption and fetal demise.



Management
   Cesarean delivery is necessary in practically
    all cases of placenta previa.
   Poorly contractile nature of the LUS there
    may be uncontrollable hemorrhage following
    placental removal.
    ◦ Oversew the implantation site with 0-chromic
      sutures
    ◦ Bilateral uterine artery ligation or internal iliac
      artery ligation
    ◦ Tightly packing the LUS with gauze
    ◦ If bleeding persists  hysterectomy




Management
Thank You

								
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