Management of Type II Placenta Previa

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Management of Type II Placenta Previa
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• Dr. Geetha Balsarkar,
• Associate Professor and Unit incharge,
• Nowrosjee Wadia Maternity Hospital,
• Seth G.S. Medical college, Parel , Mumbai
• Joint Asst. Secretary to the Editor,
• Journal of Obstetrics and Gynecology of India,
• Secretary, AMWI, Mumbai branch

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Classification

• 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

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Diagnosis

• DO NOT DIAGNOSE via vaginal exam!
• (Exception-double setup)
• Ultrasound is the easiest, most reliable
• way to diagnose (95-98 accuracy)
• False positive- ultrasound with distended bladder
• Transvaginal or transperineal often superior to
  transabdominal methods

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Migration

• Clinically important bleeding is not likely
  before 24-26 weeks
  gestation
• The clinically important diagnosis of placenta
  previa is therefore a late second or early third
  trimester diagnosis
• Migration is a misnomer- the placental attachment
  does not change, the relative growth of the lower
  segment does

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Intervention

• 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.
  
• Bedrest probably indicated
• Antenatal testing probably indicated

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McCafee regime of expectant management
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Evaluation

• Evaluation for possibility of accreta needs to be
  considered
• Consideration for RHIG in rh negative patients
  with bleeding
• Episodic AFS testing with bleeding events
• Vigilance regarding fetal growth
• Follow up ultrasound if indicated

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Associated conditions

• Abnormal presentation (placenta raises presenting
  part)
• Oblique lie
• Transverse lie
• Placental abruption
• Placenta accreta (especially if prior ceserean
  section)
• Postpartum hemorrhage

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Think Accreta

• Previous cesarean scars
• Previous myomectomy scars
• Twins or multiple gestation
• Grand multipara

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Counseling

• Risk of severe life-threatening hemorrhage
• Risk of fetal death
• Risk of maternal death
• Blood transfusion may be necessary
• Hysterectomy may be needed to control bleeding

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Conservative measures

• If the bleeding is not life threatening or, if
  initially severe but begins to settle, then there
  is a place for conservative measures
• If the fetus is still preterm and the bleeding is
  under control, a policy of conservative
  management should be followed, at least until
  fetal maturity is achieved.

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Management Protocol

• Late pregnancy bleeding
• Ceserean delivery indications
• 37 weeks or
• Unstable Heavy bleed, hypotension, fetal
  distress

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Delivery

• Delivery should depend upon type of previa
• Complete previa c/section
• Low lying (probable attempted vaginaldelivery
• Marginal/partial (it depends!)
• Consider double setup for uncertain cases

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Delivery

• Immediate delivery of the fetus may be indicated
  if the fetus is mature
• 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 in a
  bleeding episode

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Vaginal delivery

• Tertiary center
• Blood crossmatched and ready
• Fetal monitoring
• Gentle PV examination ???? To assess progess of
  labour
• Everything ready for LSCS

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Thank you