Marginal placenta previa

Abnormal vaginal bleeding insecond half of pregnancyผศ.นพ.วัลลภ ปานพูนทรัพย์ภาควิชาสูติศาสตร์-นรีเวชวิทยาศูนย์การแพทย์สมเด็จพระเทพฯคณะแพทยศาสตร์ มศว.

Definition-Vaginal bleeding after 20 weeksgestational age (before delivery) maybe cause of maternal mortality andassociate with perinatal morbidity andmortalityIncidence5–10% of pregnancyprgmea.com

Obstetric cause-bloody show-placenta previa-placental abruption-uterine rupture-vasa previaprgmea.com

Gynecologic cause-cervicitis-cervical polyps-vaginal laceration, foreign bodies-varices-benign and malignant neoplasms of genitalorgansprgmea.com

Non obstetric-gynecologic causeHematologic diseases• Thrombocytopenia• Coagulopathy• Platelet dsyfunction• etc.prgmea.com

Placenta Previa

Definition and ClassificationThe placenta located over or very near theinternal os, classified as Total placenta previa Partial placenta previa Marginal placenta previa Low-lying placenta

Definition and Classification• Total placenta previa: the internal os iscovered completely by placenta• Partial placenta previa: the internal os ispartially covered by placenta• Marginal placenta previa: the edge of theplacenta is at the margin of the internal os• Low lying placenta: the placenta isimplanted in the lower uterine segment,theplacenta edge does not reach the internalos but is in close proximity to it

Etiology• defective vascularization of the decidua,inflammatory process or atrophic changes --multiparity- advancing age• previous cesarean delivery or uterine surgical scar• large placenta: multiple fetuses, erythroblastosis• others : smoking, cocaine use

Signs and symptoms-Painless hemorrhage usually nearthe end of the second trimester-Abnormal fetal presentationabout 1/3 of cases

Diagnosispainless bleedinguterus : soft, no tendernessfetus : may be in oblique or transverse liepresenting part not engagedUltrasonography - accuracy 95-98 %transvaginal ultrasound identifyinternal os better thantransabdominal ultrasound(double set up)

Fetal echoPlacentaBladderCervix

Management• Depend on severity of bleeding,gestational age, fetal maturity andfetal well-being• Principle of management– Hospitalization with hemodynamicstabilization– Obstetric evaluation– Do not PV or PR

Management Preterm fetus, good fetal well-being withno active bleeding• expectant, close observation• very sedentary lifestyle• avoidance of any intravaginal manipulation :vgdouch,PV,etc.• immediate availability of appropriate therapy

Management The fetus with poor fetal assessment ormore than 37 weeks gestation or severehemorrhage as to necessitate immediatedelivery of the fetus• Cesarean delivery: in most cases -transverse incisionor vertical uterine incision• Vaginal delivery: in cases of low-lying placenta ormarginal placenta previa

ComplicationMaternal- Postpartum hemorrhage- Infection- EmbolismFetus- Preterm (major cause ofperinatal death)- Intrauterine asphyxia- IUGR

Placental Abruption

Definition• The separation of the placenta from itssite of implantation in the uterus beforethe delivery of the fetus• abruption placentae, ablatio placentae,premature separation of the normallyimplanted placenta

Pathologyhemorrage from a decidual spiral artery into thedecidua basalis(the bleeding between the membranes anduterus,retroplacental hematoma )

Classification-acute placental abruption and chronicplacental abruptionor- external hemorrhage (revealedhemorrhage ~80-85%- no external hemorrage (concealedhemorrhage) ~15-20%- Mixed typeormarginal separation , partial separation,complete separation

Etiology• unknown

Risk factor• Prior abruption• hypertensive disorder in pregnancy• sudden decompression of the uterus: afteramniotomy, hydramnios• shortness of the umbilical cord: esp. inmultifetal pregnancy• uterine anomaly or tumor• pressure by the enlarged uterus on the inferiorvena cava• Increased age and parity• ethanol consumption, cigarette smoking, cocineuse, dietary deficiency• external trauma

PathologyLocal vascular injury in decidua basalisDecidual spiral artery rupture• (uterine venous pressure)Retroplacental hematomaSeparation of placenta

Signs and symptoms* may be no clinical symptoms in early stage* profuse external bleeding per vagina* uterine tenderness, rapid uterine contractionor tetanic uterine contraction

Signs and symptoms* Hypotension, Shock out of proportion to theamount of hemorrhage* Fetal heart rate decelerations or no FHRbeen heard

Clinical findings• Classical : pain, uterine tenderness andrigidity, fetal distress or absent fetalheart sound (Decreased short-termvariability, increased baseline uterinetone, uterine hyperstimulation, andworsening variable decelerations)• Vaginal bleeding, shock• Shock not relate to vaginal bleeding• Idiopathic preterm labor

Clinical findings• Vaginal bleeding 78%• Uterine tenderness or back pain 66%• Fetal distress 60%• Preterm labor 22%• High frequency contraction, hypertonus 17%• Dead fetus 15%

Laboratory findings• Hct decrease• Thrombocytopenia• Hypofibrinogenemia (fibrinogen20 ug/ml• Abnormal coagulogram

Ultrasound findings• Retroplacental hematoma• Exclude placenta previaDifferential diagnosis• Placenta previa• Rupture of the uterus

Complication* - Comsumptive coagulopathy:hypofibrinogenemia(less than 150 mg/dlof plasma), elevated levels offibrinogen-fibrin degradation products,decrease of coagulation factors* - Renal failure may be from impaired renalperfusion* - Uteroplacental Apoplexy (CouvelaireUterus) : extravasations of blood intothe uterine musculature and beneath theuterine serosa* - feto-maternal hemorrhage* - Post-partum hemorrhage* - Death of the fetus

Uteroplacental Apoplexy(Couvelaire Uterus)

Managementbbb-evaluation for fetal well-being, maternalcirculation status-intense therapy with blood, coagulationfactor,plus electrolyte solution in case of seriousmaternal hemorrhage-prompt delivery (may be very close observationcoupled with facilities for immediate interventionin mild cases)

Route of delivery• Cesarean section- Fetal distress,unfavorable cervix- Uncontrol bleeding• Vaginal delivery with induction oflabor by oxytocin infusion andamniotomy- Dead fetus with control bleeding- Favorable cervix, rapid progress oflabor, stable maternalhemodynamic, no fetal distress

prognosis• Fetal mortality rate 60-80 %• Maternal mortality rate 1-5 %

Rupture of the uterusRupture of the uterus

Rupture of the uterus• Complete uterinerupture• Incomplete uterinerupture(uterine dehiscence)

Predisposing factors• Uterine injury or abnormality duringcurrent pregnancy– before deliverypersistent, intense, spontaneous contractions oruterine hyperstimulationexternal versionuterine overdistension: hydramnios– During deliveryobstructed laborinternal versiondifficult forceps deliverybreech extraction

Predisposing factors• Others:- placenta increta or percreta- previous surgery involving themyometrium: cesarean section- congenital anomaly- grand multiparity- coincidental uterine trauma

How to diagnosis-uterine scar-suprapubic pain and tenderness-vaginal bleeding-cessation of uterine contractions-pathological retraction ring (Bandl’ring)-disappearance of fetal heart sound-recession of the presenting part (lossof station)-easily palpated fetus-hypovolemic shock with hemoperitoneum

management-hemodynamic stabilization-emergency surgery:repair wound with or without internaliliac ligation or hysterectomy dependon maternal condition pathology ofthe uterus, need of child-bearing)

complication• amniotic fluid embolism• hypovolemic shock• DIC• ureteral injury• postoperative infection

prognosis• Perinatal mortality rate 40-70%• Maternal mortality rate 5-40%

Rupture of vasa previaThank you for your attention

vasa previa- incidence 1:3000 – 1:5000 pregnancies- associated with- velamentous insertion (fetalvessels in the membranes cross theregion of the cervical os)- Marginal cord insertion- Bilobed or succenturiate-lobedplacenta

vasa previaHow to diagnosis- palpate or directly visualize fetalvessel in the membrane overlying thepresenting part of the fetus- ultrasonography : color doppler-Lab : fetal blood- bloody amniotic fluid duringamniotomy with FHR change

management-immedate vaginal delivery orcesarean sectionPrognosis-Fetal death 60-70%

Thank you for your attention