Management Of Placenter Praevia

Management of Placenta Praevia By Dr Dambo

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INTRODUCTION HISTORY TAKING PHYSICAL EXAMINATION INVESTIGATIONS DIAGNOSIS TREATMENT COMPLICATIONS PROGNOSIS CONCLUSION

Introduction Maternal and fetal morbidity and mortality from placenta praevia are considerable and are associated with high demands on health resources. Consensus views as to how we should manage these cases, especially in the face of a rising incidence of placenta praevia and its complications are therefore considered important.

History • Vaginal bleeding – It 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 High presenting part.

Physical Examination • • • • • •

Pallor Hypotension Tachycardia Soft and nontender uterus Normal fetal heart tones (usually) Vaginal bleeding -Bright red -Spotting -Profuse –with clots – Blood loss usually not extensive to produce shock – Do not perform digital vaginal examination because it may provoke uncontrollable bleeding.

Investigations • • • •

FBC+differentials Rh compatibility if needed Fibrin split products (FSP) and fibrinogen levels Prothrombin time (PT)/activated partial thromboplastin time (aPTT) • Type and hold for at least 4 units • Apt test to determine fetal origin of blood (as in the case of vasa previa) • Lecithin/sphingomyelin (L/S) ratio for fetal maturity, if needed

Investigations contd • Transabdominal ultrasonography – A simple, precise, and safe method to visualize the placenta, this ultrasonography has an accuracy of 9398%. – False-positive results can occur secondary to focal uterine contractions or bladder distention. • Transvaginal ultrasonography – Recent studies have shown that the transvaginal method is safer and more accurate than the transabdominal method. Transvaginal ultrasound is also considered more accurate than transabdominal ultrasound. 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.

Investigations contd • Magnetic Resonance Imaging (MRI) -It is a very accurate method of diagnosing PP -It is available only in few centres -It is an expensive investigation • Soft tissue placentography, compression radiography, isotopic placentography, arterial placentography,

DIAGNOSIS • Transvaginal ultrasonography • 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.

Treatment • It depends on the gestational age • The extent of haemorrhage • Type of placenta praevia

Treatment contd • Expectant management -The aim is to allow the pregnancy to continue to a point at which the baby is unlikely to encounter major complications of immaturity after delivery. • This policy was introduce by Macafee in 1945 at Royal Maternity Hospital Belfast it involves:1, From the time of diagnosis, the woman was advised to remain in hospital.

2,Blood was to be constantly available for immediate transfusion. 3,Facilities were to be available for immediate caesarean section. 4,Anaemia was to be identified and corrected, if necessary by repeated blood transfusion, because of the likelyhood of further haemorrhage This policy was introduce to reduce the perinatal mortality associated with PP Normal Saline IVF

• With current anxieties about the risk of viral infections after blood transfusion, autologous blood donation can be considered. • It is likely to be of limited value in women with PP • Because bleeding occurs mainly as a result of placental detachment from lengthening lower uterine segement and dilating cervix, cervical cerclage has been advocated. Not backed up by sufficient evidence

• Also the use of tocolytic drugs to prevent premature labour may be indicated to prolong pregnancy at least up to 36weeks. • Although it is controversial. Due to the side effects of tocolytic drugs. • While on admission patient should be closely monitored. • Despite repeated blood transfusions and patient is deteriorating, pregnancy is terminated. • If GA if between 28-34wks corticosteriods is given to promote fetal lung maturity. This is given 24hours before termination.

ACTIVE MANAGEMENT Vaginal delivery -Reserve for patients with minor degree PP -Arm -oxytocin drip. Caesarean section -choice for major degree PP -resuscitation before surgery. -It can end up in caesarean hysterectomy -At least 2 units of blood crossmatched.

Complications Maternal -haemorrhage -shock -placenter accreta -death Fetal -prematurity -IUGR -Congenital anomalies -Fetal anemia and Rh isoimmunization • -fetal death

Prognosis With the abandonment of double set up, the use of caesarean section, use of banked blood and expertly administered anesthesia, the overall maternal and perinatal mortality and morbidity has fallen. Although premature labour, placenter seperation cord accidents an uncontrollable haemorrhage cannot be avoided.

Conclussion • Placenta previa is a disease that occur with increasing frequency in current obstetric practice. Ultrasonography has greatly improved the ability to diagnose this condition antenatally. Improvements in antibiotic therapy, neonatal intensive care, and blood component therapy have decreased the previously high maternal and fetal morbidity and mortality rates. However, this disease will pose a risk to the mother and fetus. Counseling and preparation for the problems that may ensue will greatly benefit the patient and the obstetrician.