Placenta previa

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Placenta previa

• Teng Yincheng M.D.,
  Ph.D., Professor
• 
  Department Of Obstetrics
  Gynecology
• 
  Renji Hospital Affiliated to SJTU
  School of Medicine
• 
  

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The placenta provides the fetus with oxygen and
nutrients and takes away waste such as carbon
dioxide via the umbilical cord.
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• Definition    Placenta previa is a condition that
  may occur during pregnancy when the placenta
  implants in the lower part of the uterus and
  obstructs the cervical opening to the vagina
  (birth canal).
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Incidence

• The incidence of placenta previa is approximately
  1 out of 200 births.
• increases with each pregnancy, and it is
  estimated that the incidence in women who have
  had 6 or more previous deliveries may be as high
  as 1 in 20 births.
• doubled in multiple pregnancy (such as twins and
  triplets).

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Etiology

• Endometrium factors
• a scarred endometrium (lining of the uterus)
• Curretage for several times
• an abnormal uterus
• Placental factors
• Large
• abnormal formation of the placenta.
• Development retardation of fertilized egg

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• Risk factors include multiparity (previous
  deliveries), multiple pregnancy, previous
  myomectomy (removal of uterine fibroids through
  an incision in the uterus), and a previous
  C-section (if the scar is low and close to the
  vaginal cervix region).

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classification

• Complete placenta previa
• Partial placenta previa
• Marginal placenta previa

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Clinical findings

• Symptoms   
• Spotting during the first and second trimesters
• Sudden, painless, and profuse vaginal bleeding in
  pregnancy during the third trimester (usually
  after 28 weeks)
• --Bleeding may not occur until after labor starts
  in some cases
• --Anemia,shock

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• Signs
• The uterus is usually soft and relaxed.
• The infant position is oblique ( // ) or
  transverse ( ) in about 15 of cases.
• Fetal distress is not usually present unless
  vaginal blood loss has been heavy enough to
  induce maternal shock, placenta abruptio, or a
  cord accident occurs.
• No digital examination!

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Accessory examinations

• Ultrasonography
• Accuracy 95
• 34th week
• Postpartum examination of placenta and membrane
• 7cm

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• Diagnosis
• Differential diagnosis

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Complications   

• Maternal complications
• major hemorrhage, shock, and death.
• Implanted placenta
• Anemia and infection
• Fetal complications
• Prematurity (infant is less than 36 weeks
  gestation) is responsible for about 60 of infant
  deaths secondary to placenta previa.
• Fetal blood loss or hemorrhage may occur because
  of the placenta tearing away from the uterine
  wall during labor. It may also occur with entry
  into the uterus during a C-section delivery.
  Maternal complications

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Treatment

• The course of treatment depends on the amount of
  abnormal uterine bleeding, whether the fetus is
  developed enough to survive outside the uterus,
  the amount of placenta over the cervix, the
  position of the fetus, the parity (number of
  previous births) for the mother, and the presence
  or absence of labor.

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• Early in pregnancy, transfusions may be given to
  replace maternal blood loss. Medications may be
  given to prevent premature labor, prolonging
  pregnancy to at least 36 weeks. Beyond 36 weeks,
  the benefits of additional infant maturity have
  to be weighed against the potential for major
  hemorrhage.

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• Cesarean section is the method for delivery. It
  has proven to be the most important factor in
  reducing maternal and infant death rates.

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Expectations (prognosis)

• The maternal prognosis (probable outcome) is
  excellent when managed appropriately. This is
  done by hospitalizing those at risk who are
  exhibiting signs and symptoms, and by performing
  C-section delivery.

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ABRUPTIO PLACENTAE
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Definition

• Abruptio Placentae( placental abruption)
• premature separation of the normally implanted
  placenta from the uterine wall.
• Incidence0.512.33 200300/1000
• 1 150/1000

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Etiology

• Mechanism hemorrhage into the decidua basalis,
  leading to premature placental separation and
  further bleeding.
• Associated factors
• Maternal hypertension
• Sudden decompression of the uterus
• Maternal cocaine use
• trauma

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Classification

• Concealed separation no vaginal bleeding
• Apparent separation vaginal bleeding will be
• Mixed separation vaginal bleeding will be
  apparent

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Diagnosis

• Classic clinical presentation
• vaginal bleeding
• Tender uterus
• Uterine contractions
• Fetal distress

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• Coagulation abnormalities
• Hypofibrinogenemia
• Increaseing levels of fibrin degradation products
• decreasing platelet count
• Increasing prothrombin time and partial
  thromboplastin time
• Decreasing other serum clotting factors

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• Ultrasonography
• relatively large retroplacental clots may be
  detected
• Placental examination
• The extent of placental abruption of the
  maternal surface of the placenta on which a clot
  is detect at the time of delivery.

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• Complication
• DIC
• Shock
• Amniotic fluid embolism
• Acute renal dysfunction

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Management

• Maintain hemodynamic stabilization ( Transfusion
  therapy)
• Crystalloid transfusion
• Whole blood therapy
• Component therapy
• Correct coagulation status

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• Delivery
• When the fetus is mature,vaginal delivery is
  preferable unless there is evidence of fetal
  distress or hemodynamic instability.
• When the fetus is not mature and placental
  abruption is limited,observation with close
  monitoring of both fetal and maternal status.

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Normal and Abnormal Puerperium
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Definition

• The time from the delivery of the placenta
  through the first few weeks after the delivery.
• 6 weeks in duration.
• By 6 weeks after delivery, most of the changes of
  pregnancy, labor, and delivery have resolved and
  the body has reverted to the nonpregnant state.

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• The relevant anatomy and physiology in the
  puerperium
• Reproductive organs
• Uterus
• 1000g ? 50-100g
• The endometrial lining rapidly regenerates (16
  days)
• The placental site undergoes a series of changes
  in the postpartum period

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• Cervix
• it never returns to the nulliparous state.
• the external os is closed to the extent that a
  finger could not be easily introduced.
• Vagina
• shrinks to a nonpregnant state
• resolution of the increased vascularity and edema
  occurs by 3 weeks
• the vaginal epithelium appears atrophic on smear.
  This is restored by weeks 6-10.

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• Perineum
• swelling and engorgement are completely gone
  within 1-2 weeks
• the muscle tone may or may not return to normal,
  depending on the extent of injury.
• Ovaries
• ovulate as early as 27 days after delivery (not
  breastfeed ) 12 weeks (most) 7-9 weeks (mean).
• the suppression of ovulation due to the elevation
  in prolactin

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• Breasts
• Lactation can occur by 16 weeks' gestation.
• Lactogenesis is initially triggered by the
  delivery of the placenta (E?P?and prolactin).
• the prolactin levels decrease and return to
  normal within 2-3 weeks (not breastfeeding)
• The colostrum??(the first 7 days)
• The milk continues to change throughout the
  period of breastfeeding to meet the changing
  demands of the baby.

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Manifestation

• Fever (24 hours)
• Pain (uterine contraction)
• Sweat
• Lochia ??
• a large amount of red blood initially flows from
  the uterus as the contraction phase rapidly
  occurs. (5 weeks)
• lochia rubra lochia serosa (brownish red, with a
  more watery consistency) lochia alba (yellow)

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Management

• 1. 2 hours after delivery
• Bleeding
• Uterine contraction
• HR and Bp and R and T
• 1 weeks after delivery
• Bleeding
• Emiction and defecate
• Lochia
• Episiotomy and Laceration
• Breast

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Puerperal Infection

• Puerperal Infection
• any bacterial infection of the genital tract
  after delivery. Incidence 6. The most important
  cause of maternal death.
• Puerperal Morbidity
• temperature 38.0? or highter, the temperature
  to occur on any 2 of the first 10days postpartum,
  exclusive of the first 24 hours, and to be taken
  by mouth by a standard technique at least four
  times daily.

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• Risk factors
• PROM
• Anemia
• Hemorrhage
• EP and CS
• Placenta retain

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• Common pathogens
• Aerobes
• Group A, B, and D streptococci??????
• Gram-negative bacteria Escherichia coli????,
  Klebsiella?????
• Staphylococcus aureus????

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• Anaerobes
• Petococcus species????
• Petostreptococcus species?????
• Bacteroides fragilis group?????
• Clostridium species??????
• Other
• Chlamydia trachomatis?????
• Mycoplasma species???

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• Manifestation
• Acute vulvitis vaginitis and cervicitis
• Uterine infection
• Adnexal infections
• Septic pelvic thrombophlebitis ??????
• ???

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• Diagnosis
• History
• Physical examination and PV
• Lab finding
• Differential diagnosis

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• Treatment
• Nutrition anemia prevention
• Antimicrobial treatment
• broad-spectrum, high dose, long time
• Drainage
• Treatment of thrombophlebitis

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Late Postpartum Hemorrhage

• Definition
• Uterine bleeding by 24 hours after delivery.
• Etiology
• Placenta or membrane or decidua retain
• Abnormal redintegration
• Infection
• Problems of incision
• tumor

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• Diagnosis
• Treatment
• 1.antibotics oxytocin PG ????? ???
• 2.uterine curettage
• 3.hysterectomy

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THANKS FOR YOUR ATTENTION
Teng Yincheng M.D., Ph.D., Professor Dep. of
Obstet. Gynecol. Renji Hospital Affiliated to
SJTU School of Medicine