Placenta praevia

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Placenta prvia
Classification and external resources ICD-10 ICD-9 MeSH O44., P02.0 641.0, 641.1 D010923

Placenta praevia (placenta previa AE) is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix [1]. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum haemorrhage (vaginal bleeding). It affects approximately 0.5% of all labours.

Contents
[hide]

1 Pathophysiology 2 Risk factors 3 Intervention 4 References 5 External links

[edit] Pathophysiology
No specific cause of placenta previa has yet been found but it is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection. In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a normal pregnancy the placenta does not overlie it, so there is no bleeding. If the placenta does overlie the lower segment, it may shear off and a small section may bleed. Women with placenta previa often present with painless, bright red vaginal bleeding. This bleeding often starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation.

Abdominal examination usually finds the uterus non-tender and relaxed. Leopold's Maneuvers may find the fetus in an oblique or breech position or lying transverse as a result of the abnormal position of the placenta. Praevia can be confirmed with an ultrasound. In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with an examination in the surgical theatre. The proper timing of an examination in theatre is important. If the woman is not bleeding severely she can be managed non-operatively until the 36th week. By this time the baby's chance of survival is as good as at full term. Placenta previa is classified according to the placement of the placenta:

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

Placenta previa is itself a risk factor of placenta accreta.

[edit] Risk factors

The following have been identified as risk factors for placenta praevia:

Previous placenta previa, caesarean delivery,[1] or abortion. Women who have had previous pregnancies, especially a large number of closely spaced pregnancies, are at higher risk. Women who are younger than 20 are at higher risk and women older than 30 are at increasing risk as they get older. Women with a large placentae from twins or erythroblastosis are at higher risk. Women who smoke or use cocaine may be at higher risk. Race is a controversial risk factor, with some studies finding that people from Asia and Africa are at higher risk and others finding no difference.

[edit] Intervention
An initial assessment to determine the status of the mother and fetus is required. 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. Immediate delivery of the fetus may be indicated if the fetus is mature or 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.

It is controversial if vaginal delivery or a Caesarean section is the safest method of delivery. In cases of fetal distress a Caesarean section is indicated. Caesarian section is contraindicated in cases of disseminated intravascular coagulation. A problem exists in places where a Caesarean section cannot be performed, due to the lack of a surgeon or equipment. In these cases the infant can be delivered vaginally. There are two ways of doing this with a placenta praevia:

The baby's head can be brought down to the placental site (if necessary with Willet's forceps or a vulsellum) and a weight attached to his scalp A leg can be brought down and the baby's buttocks used to compress the placental site

The goal of this type of delivery is to save the mother, and both methods will often kill the baby. These methods were used for many years before Caesarean section and saved the lives of both mothers and babies with this condition. The main risk with a vaginal delivery with a praevia is that as you are trying to bring down the head or a leg, you might separate more of the placenta and increase the bleeding. Placenta praevia increases the risk of puerperal sepsis and postpartum haemorrhage because the lower segment to which the placenta was attached contracts less well postdelivery.

Placenta Previa
By Robin Elise Weiss, LCCE, About.com Guide See More About:

pregnancy complications cesarean section preterm labor bleeding bedrest

LifeART (and/or) MediClip image copyright 2008 Wolters Kluwer Health, Inc.- Lippincott Williams & Wilkins. All rights reserved.

Sponsored Links
Calendar Monthly PregnancyFree online pregnancy calendar now with 'In Utero' images from GE!www.ivillage.com How To Get Pregnant FastI Stopped these common mistakes and got Pregnant almost immediately!TipsGettingPregnant.com New Method of IUIInnovative Method of insemination Successful,Painless,Cost effectivewww.iutpi.eu Pregnancy Ads Calendar Gender Pregnancy Pregnancy Week Baby Names Pregnancy Sign Pregnancy Due Date Placenta previa, the implantation of the placenta at least partially covering the cervix, occurs in about one in 200 pregnancies. There are actually three types of previa. Complete previa where the cervical os, the mouth of the uterus, is completely covered. Partial previa where just a portion of the cervix is covered by the placenta. And the marginal previa that extends just to the edge of the cervix. Diagnosing a previa is usually made when there is painless bleeding during the third trimester. If you are bleeding it is unwise to do a vaginal exam until an ultrasound has ruled out a placenta previa. However, there is a 10% false positive diagnosis rate, usually because of the bladder being over full. There is also a 7% false negative rate, typically caused from missing the previa that is located behind the baby's head. Other reasons to suspect a previa would sometimes be premature contractions, abnormal lie (breech, transverse, etc.), or the uterus measuring larger than you should according to dates. During second trimester ultrasounds, done in some places on a routine basis, will show that there are many more previas diagnosed at this stage. Typically at 16 weeks the placenta takes up 25-50% of the surface area. Also the third trimester brings a growth of this lower uterine segment, that out flanks the growth of the placenta. For these reasons, while 5% of pregnancies are diagnosed with complete previa in second trimester ultrasounds will see 90% of them resolved by term and while 45% of pregnancies are diagnosed with marginal previas will see 95% resolved at term. A follow up ultrasound will be done, and as noted above the vast majority of previas are not seen. True placenta previa at term is very serious. Complications for the baby include:

Problems for the baby, secondary to acute blood loss Intrauterine growth restriction (IUGR) due to poor placental perfusion Increased incidence of congenital anomalies

Risks for the mother include:

Life-threatening hemorrhage Cesarean delivery Increased risk of postpartum hemorrhage Increased risk placenta accreta (Placenta accreta is where the placenta attaches directly to the uterine muscle.)

Placenta previa, once diagnosed, will usually mean bed rest for the mother, frequently in the hospital. Depending on the gestational age steroid shots may be given to help mature the baby's lungs. If the bleeding cannot be controlled immediate cesarean delivery is usually done, regardless of the length of the pregnancy. Some marginal previas can be delivered without cesarean surgery, the other types of placenta previa preclude vaginal delivery. There are a few predisposing factors. The following can increase your risk for placenta previa:

Advanced maternal age Increased parity (number of pregnancies) Previous uterine surgery, including cesarean section (regardless of incision type)

Placenta previa can be a very scary diagnosis for all involved. The period of time from the diagnosis to the delivery are often periods of great worry and fear. There are support groups for bedrested mothers and even some for mothers with placenta previa. They are available to help you through this period of time.

Introduction
Background
Placenta previa is an obstetric complication that occurs in the second and third trimesters of pregnancy. It may cause serious morbidity and mortality to both the fetus and the mother. It is one of the leading causes of vaginal bleeding in the second and third trimesters.

Placenta previa is generally defined as the implantation of the placenta over or near the internal os of the cervix.

Total placenta previa occurs when the internal cervical os is completely covered by the placenta. Partial placenta previa occurs when the internal os is partially covered by the placenta.

Marginal placenta previa occurs when the placenta is at the margin of the internal os. Low-lying placenta previa occurs when the placenta is implanted in the lower uterine segment. In this variation, the edge of the placenta is near the internal os but does not reach it. A recent study concluded that more than two thirds of women with a distance of more than 10 mm from the placental edge to cervical os have vaginal delivery without an increased risk of hemorrhage.1

Pathophysiology
The exact etiology of placenta previa is unknown. The condition may be multifactorial and is postulated to be related to multiparity, multiple gestations, advanced maternal age, previous cesarean delivery,2 previous abortion, and possibly, smoking. Unlike first trimester bleeding, second and third trimester bleeding is usually secondary to abnormal placental implantation.

Frequency

United States
Placenta previa complicates approximately 5 of 1,000 deliveries and has a mortality rate of 0.03%. Data recorded from 1989-1997 indicated placenta previa occurs in 2.8 per 1000 live births in the United States.

Mortality/Morbidity
The maternal mortality rate secondary to placenta previa is approximately 0.03%. Babies born to women with placenta previa tend to weigh less than babies born to women without placenta previa. The risk of neonatal mortality is higher for placenta previa babies compared with pregnancies without placenta previa. The great majority of deaths are related to uterine bleeding and the complication of disseminated intravascular coagulopathy. In early pregnancy, a partial previa can often self-correct as the uterus enlarges and the placental site moves cephalad.

Race
Significance of race is somewhat controversial. Some studies suggest an increased risk of placenta previa among blacks and Asians, whereas other studies cite no difference.

Age
Women older than 30 years are 3 times more likely to have placenta previa than women younger than 20 years.

Clinical
History
Placenta previa is one of the leading causes of vaginal bleeding.

Vaginal bleeding is apt to occur suddenly during the third trimester. Bleeding is usually bright red and painless. Some degree of uterine irritability is present in about 20% of the cases. Initial bleeding is not usually profuse enough to cause death; it spontaneously ceases, only to recur later. The first bleed occurs (on average) at 27-32 weeks' gestation. Contractions may or may not occur simultaneously with the bleeding.

Physical

Profuse hemorrhage Hypotension Tachycardia Soft and nontender uterus Normal fetal heart tones (usually) Vaginal and rectal examinations o Do not perform these examinations in the ED because they may provoke uncontrollable bleeding. o Perform examinations in the operating room under double set-up conditions (ie, ready for emergent cesarean delivery).

Causes

Prior uterine insult or injury Risk factors o Prior placenta previa (4-8%) o First subsequent pregnancy following a cesarean delivery o Multiparity (5% in grand multiparous patients) o Advanced maternal age o Multiple gestations o Prior induced abortion o Smoking

Other Problems to Be Considered

Vasa previa Infection Vaginal bleeding

Lower genital tract lesions Bloody show

Workup
Laboratory Studies
The following studies are indicated in placenta previa:

Beta-human chorionic gonadotropin (beta-hCG) subunit Rh compatibility Fibrin split products (FSP) and fibrinogen levels Prothrombin time (PT)/activated partial thromboplastin time (aPTT) Type and hold for at least 4 units CBC count Apt test to determine fetal origin of blood (as in the case of vasa previa) Wright stain applied to a slide smear of vaginal blood, looking for nucleated RBCs, not adult blood Lecithin/sphingomyelin (L/S) ratio for fetal maturity, if needed

Imaging Studies

Transabdominal ultrasonography o A simple, precise, and safe method to visualize the placenta, this ultrasonography has an accuracy of 93-98%. o False-positive results can occur secondary to focal uterine contractions or bladder distention. Transvaginal ultrasonography o Recent studies have shown that the transvaginal method is safer and more accurate than the transabdominal method. Transvaginal ultrasonography is also considered more accurate than transabdominal ultrasonography. In one study, 26% of placental localization diagnosed by transabdominal ultrasonography was later changed using transvaginal ultrasonography. o The angle between the transvaginal probe and the cervical canal is such that the probe does not enter the cervical canal. Some advocate insertion of the probe no more than 3 cm for visualization of the placenta. Transperineal ultrasonography: Transperineal ultrasonography has been suggested as an alternate method, especially when instrumentation of the vaginal canal with a probe is a concern. A recent study suggests that transperineal ultrasonography may compliment transabdominal ultrasonography and help eliminate falsepositive results using the transabdominal method alone. MRI: MRI has been suggested as a safe and alternate method and may be useful in determining the presence of placenta accreta. A large trial determining the efficacy and safety of the use of MRI during pregnancy has not been performed, and further investigation is required.

Other Tests

Kleihauer-Betke test, if concerned about fetal-maternal transfusion Bedside clot test

Procedures

If the location of the placenta is unknown and sonography is not available, a double set-up bimanual examination under anesthesia (EUA) may be performed in the operating room.

What is placenta previa?

If you have placenta previa, it means that your placenta is lying unusually low in your uterus, next to or covering your cervix. The placenta is the pancake-shaped organ normally located near the top of the uterus that supplies your baby with nutrients through the umbilical cord. Placenta previa is not usually a problem early in pregnancy. But if it persists into later pregnancy, it can cause bleeding, which may require you to deliver early and can lead to other complications. If you have placenta previa when it's time to deliver your baby, you'll need to have a c-section. If the placenta covers the cervix completely, it's called a complete or total previa. If it's right on the border of the cervix, it's called a marginal previa. (You may also hear the term "partial previa," which refers to a placenta that covers part of the cervical opening once the cervix starts to dilate.) If the edge of the placenta is within 2 centimeters of the cervix but not bordering it, it's called a low-lying placenta. The location of your placenta will be checked during your midpregnancy ultrasound exam.

What happens if I'm diagnosed with placenta previa?

It depends on how far along you are in pregnancy. Don't panic if your second trimester ultrasound shows that you have placenta previa. As your pregnancy progresses, your placenta is likely to "migrate" farther from your cervix and no longer be a problem. (Since the placenta is implanted in the uterus, it doesn't actually move, but it can end up

farther from your cervix as your uterus expands. Also, as the placenta itself grows, it's likely to grow toward the richer blood supply in the upper part of the uterus.) Only about 10 percent of women who have placenta previa noted on ultrasound at midpregnancy still have it when they deliver their baby. A placenta that completely covers the cervix is more likely to stay that way than one that's bordering it (marginal) or nearby (low-lying). Even if previa is discovered later in pregnancy, the placenta may still move away from the cervix (although the later it's found, the less likely this is to happen). You'll have a follow-up ultrasound early in your third trimester to check on the location of your placenta. If you have any vaginal bleeding in the meantime, an ultrasound will be done then to find out what's going on.