Mudaliar

and
Menon’s
Clinical
Obstetric
s
13TH EDITION
 Chapter
23
PLACENT
A PREVIA

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 Placenta previa is defined as the
presence of placenta over or adjacent
to the internal os of the cervix.
The fertilised ovum is implanted
very close to the internal os of the
cervix so that the placenta develops
in the lower segment, covering it
either completely or partially.
DEFINITION
Complicates about 0.5% of
deliveries.
The incidence of placenta previa
reported by the Institute of
Obstetrics and Gynecology, Chennai,
between 2001 and 2010 was 0.63%.

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Type I: Low-lying placenta or lateral placenta
In this type, the placenta’s edge does not
actually reach the internal os but is in close
proximity to it

TYPE
Type II: Marginal placenta
Here, the edge of the placenta is at the
margin of the internal os but does not cover
it

Type III: Partial placenta previa

Here, the internal os is covered by the
S
placenta, but only partially , when the cervix
is dilated.

Type IV: Total placenta previa/complete or central

placenta previa
Here, the internal os is covered completely
by the placenta even when the cervix is fully
dilated

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 •All posterior placenta previa and types III and IV
anterior placenta previa are considered major
degrees
•Type II posterior is considered dangerous

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 Placenta previa

USG
CLASSIFICATIO
Low-lying placenta
N OF
PLACENTA
PREVIA Normally located placenta, the
placental edge is located >2 cm from
the cervical os

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 Previous uterine surgery
Previous placenta previa (6-8-fold risk)
Uterine curettage
Advanced age
CAUSES OF Multiparity
PLACENTA
PREVIA Multiple pregnancy
Living at high altitudes
Smoking and drug abuse

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 The formation of the lower uterine
segment and dilatation of the internal os
invariably result in the tearing of placental
attachments.
CAUSES OF The bleeding is augmented by the
BLEEDING IN inability of the myometrial fibres of the
PLACENTA lower uterine segment to contract and
thereby constrict the torn vessels.
PREVIA
This bleeding is called inevitable or
unavoidable bleeding.

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Symptoms
 Painless bleeding, spontaneous and not related to any activity
 Bleeding may stop spontaneously but tends to recur
 The first bleeding usually occurs at the end of the second trimester, in the third trimester or during
labour
Signs
 Tachycardia or hypotension
 The woman is anemic which is proportionate to the amount of bleeding
 Abdominal palpation:
◦ Uterus is relaxed, non-tender
◦ The size of the uterus corresponds to the period of amenorrhea
◦ Abnormal lie or presentation and no difficulty in palpating fetal parts
◦ The fetal heartbeat is usually present if bleeding is not excessive
◦ In cases of posterior placenta previa, Stallworthy’s sign can be elicited

Clinical features
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 USG
In all women diagnosed with
placenta previa, colour
Doppler USG should be
carried out to rule out
placenta accreta.
It is also useful to rule out
vasa previa when the
umbilical cord is noted in the
lower segment
USG picture showing
placenta in the lower uterine
segment.

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MAGNETIC RESONANCE IMAGING (MRI)
MRI is not routinely used for the diagnosis of placenta previa.
However, it is useful in obese women, in cases of posterior placenta previa or when
adherent placenta is suspected.

MIGRATION OF PLACENTA
Commonly seen when a low-lying placenta or marginal placenta is reported.
This is due to the differential growth of the upper and lower segment as pregnancy
advances.

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 Heavy bleeding leading to shock.
The risk of adherent placenta (placenta accrete,
increta and percreta)
PPH
Chronic repeated hemorrhage may lead to IUGR
COMPLICATIONS
Acute fetal distress or even fetal death
OF PLACENTA
PREVIA: Preterm labour
Maternal mortality--in the presence of adherent
placenta

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 Admit the patient
Start two IV lines with large-bore cannulae (size 14 or 16)
Infuse NS/RL rapidly until blood transfusion is available
Collect blood samples for Hb and hematocrit, blood
grouping and typing and cross-matching and coagulation
profile
Monitor vitals
Continuous bladder drainage
MANAGEMEN
T OF History and clinical examination, presence or absence of
bleeding noted
PLACENTA Fetal heart monitoring
PREVIA
Vaginal examination should never be performed in
suspected cases of placenta previa
A speculum examination may be required after 48 hours,
after bleeding stops, to rule out cervical pathology
The woman is given a clean diaper, and vaginal bleeding is
monitored
Urgent USG is carried out to confirm placenta previa and
fetal well-being

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Expectant Line of Management:
Mcafee-Johnson’s Regimen
Prerequisites for conservative Prerequisites for active management:
management:
Gestation is 37 weeks or more
Hemodynamically stable
Fetus is dead/in case of major
Bleeding: Not ongoing and should stop
malformation of the fetus
early
Bleeding is profuse and/or recurrent
The fetus: Good condition and gestational
age <36 weeks Hemodynamically unstable
The woman should not be in labour Woman in labour
Facilities for emergency cesarean section
and blood transfusion should be readily
available

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Conservative management is Expectant management:
discontinued, and pregnancy is Bed rest
terminated in the following Monitor maternal and fetal conditions
scenarios: Correct anemia , cross match blood
 Recurrent bleeding, leading to Antenatal steroids for lung maturity
hemodynamic instability in the Elective cesarean section at 36–-37 weeks
woman
 Fetal distress or fetal death
 Suspicion of IUGR
 Rupture of membranes
 The pregnancy has reached term
 The woman goes into labour

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 The lower segment section is the choice in all
varieties of placenta previa.
When the placenta is anterior, large vessels may be
seen over the lower segment. These vessels can be
tied off before performing the lower segment
MODE OF operation.
The other way is the Ward technique/a low vertical
DELIVER or classical cesarean.

Y Profuse hemorrhage may occur from the placenta

site – purse-string sutures/Cho’s sutures maybe
required.
Uncontrollable hemorrhage: Bilateral internal iliac
ligation or even total hysterectomy.
Adherent placenta: Uterine artery embolisation.

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 Two IV lines with NS and/or RL.
Blood grouping, typing and if possible, cross-
matching should be performed
MANAGEM
Oxygen SOS
ENT AT THE
PRIMARY The woman should be transferred along with a
hospital staff member to the nearest functional higher
HEALTH centre (informed beforehand)
CENTRE In case a woman diagnosed with placenta previa
delivers in the PHC, the delivery is conducted with two
IV lines and active management of third stage of
labour should be performed

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 Maternal mortality is usually due to massive
obstetric hemorrhage, especially if there is
MATERNAL AND associated adherent placenta.
FETAL Preterm delivery is a major cause of
MORTALITY
perinatal death, even though expectant
management of placenta previa is practiced.

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