Placenta Previa (Unavoidable Hemorrhage)

Placenta previa is the medical term for the placenta that has partially or totally unplanted within the lower uterine region of the uterus. In the final stages of pregnancy, the lower uterine segments expand, which prevents the placenta from stretching and causing it to become detached, which results in bleeding.

“Placenta Previa is implantation of the placenta at or near the cervix”. – According to IMPAC.

Incidence

• Placenta previa affects between 0.5 and 1% of pregnancies.
• It is observed in multiparous women in 80% of instances.
• Early in pregnancy, it is more prevalent.
• Placenta previa is responsible for about one-third of occurrences of antepartum hemorrhage.
• Nullipara -1/1000 -1/15,000 pregnancy

Etiology and Risk Factor

• The precise reason is idiopathic.
• Massive multiparty
• Large placental surface area in many pregnancies
• Prior to LSCS, there was a placenta previa.
• Past uterine operations
• Smoking
• Assisted reproduction
• Maternal age has increased (>35 years)
• Pregnancy terminations in the past
• beforehand curettage
• Fetal malpresentation: These are frequently a result of placenta previa rather than its primary cause.
• Both low placenta implantations and abnormal presentation may be predisposed by uterine anomalies.

Classification

Depending on how far a placenta extends to the lower segment, there are four different forms of placenta previa.

• The degree I or Lateral Placental Previa:Only the lower edge of the placenta extends up to internal OS, not the top section of the lower uterine segment. The least likelihood of anti-partum hemorrhage exists in these people. Normal blood loss is minimal, and the mother and fetus both remain healthy.
• Degree II or Marginal Placenta Previa: In this instance, the placenta's lower edge touches the internal OS margin but does not completely cover it. There are two different kinds of this, depending on the placenta's openness. As follows:
  • Type II A –Anterior
  • Type II B-Posterior
    The placenta previa of the posterior form is sometimes referred to as being harmful since it is prone to become crushed between the fetal head and the sacral promontory, interrupting the fetal blood supply and resulting in fetal discomfort.
• Degree III or Incomplete Central Placenta Praevia: When the placenta is closed or only partially dilated, it covers the internal OS; however, when it is fully dilated, it does not.
• Degree IV or Complete Central Placenta Previa: This is the most dangerous type of placenta, completely covering the internal organs whenever the cervix is open or partially dilated. A very high risk of severe bleeding exists, making vaginal delivery inappropriate.

Clinical Features

Symptom:

• Vaginal bleeding is the only symptom of placenta previa. Usually mild and spontaneous at first, bleeding might become more severe within hours. There is recurrent third trimester bleeding that has a quick onset, is painless, and appears causeless. These hemorrhage may be severe and result in maternal and fetal demise.
• One-third of patients had a history of mild warning hemorrhages.

Signs:

• Generally speaking, the condition includes pallor and anemia depending on how much blood is lost. A patient may occasionally be in shock as a result of server hemorrhage.
• The uterus' size corresponds to the length of the gestation.
• raised the foundational height
• No discomfort or sensitivity
• Without any specific sore spots, the uterus has a relaxed, elastic feel.
• malpresentation, such as a breech, a transverse lie, or an unstable lie, continuing.
• In the cephalic presentation, the head is floating.
• Unless there is a large placental separation, the FHS is often normal.
• Vulval examination To rule out the volume and color of blood loss, observation should be the only course of action. Blood is typically a bright red color. Examination of the vagina is not advised.

Confirming the diagnosis:

• History study
• inspection of the body
• The placenta can be located via ultrasound imaging. Plan delivery if placenta previa is confirmed and the fetus is developed.
• If the pregnancy is at least 37 weeks along and an ultrasound is unavailable or the report is questionable, check the woman and get her ready for a vaginal or caesarean delivery as follows:
  • Have active I/V lines and cross-matched blood on hand.
  • With the surgical team present, examine the women in the operating room.
  • Examining the cervix with a high-level, disinfected vaginal speculum.
  • Plan delivery if placenta tissue is visible and the cervix is only slightly dilated.
  • Palpate the vaginal fornices with caution if the cervix is not dilated.
  • Plan delivery if a spongy tissue is felt, which confirms placenta previa.
  • When a strong fetal heartbeat is detected (major placenta previa is ruled out), induce delivery.
• Conduct a cautious digital examination if the diagnosis of placenta previa is still in question.
• If any cervix soft tissue is felt (placenta previa is confirmed, plan delivery.)
• If fetal parts and membranes are detectable both centrally and peripherally Continue with the induction of labor.

Management

Management at Home:

• The patient is placed on bed rest right away.
• Take her full medical history, gestational age, and due date into consideration.
• Keep the pads or clothing and keep an eye on the overall amount of blood lost, the color of the bleeding, and the consistency of the blood loss.
• Check the clothing for blood stains to determine how much blood has been lost.
• Quickly but gently examine your abdomen and auscultate your FHS.
• Never provide an enema or a PV exam.
• As soon as feasible, admit the patient to the hospital.

Management in Hospital:

• The patient was hospitalized and given resuscitation in case of shock. Blood, oxygen, and other I/V fluids are used to accomplish this.

Conservative Management:

The Johnson and Macfee protocol is a form of expectant care that entails careful non-interference and close observation. The following conditions must be met before receiving this course of treatment:

• Fewer than 37 weeks into a pregnancy.
• 600 ml was the initial amount of bleeding.
• Not in labor is the patient.
• The health of the mother and fetus is not at danger right away.
• For it to be considered successful, the duration should be greater than one week.

The management includes:

• The sanitary pad should be retained for examination in order to calculate blood loss and to measure hemoglobin in order to gauge the effectiveness of the treatment.
• Vital signs for FHS should be checked every 4-6 hours.
• Continue taking supplemental calcium, vitamin, and iron.
• To avoid straining at the stool, laxatives should be administered.
• Fully furnished beds with nightstand toilets.
• To increase adherence to bed rest, sedatives such as tab diazepam 5mg at bedtime may be prescribed.
• Blood loss needs to be categorized, cross-matched, and reserved for the patient's specific requirements.
• Blood or I/V fluid is used to treat the first blood loss.
• To evaluate the success of treatment, USG is preferred.
• After a few days, the patient might be allowed to take short walks, but she must stay in the hospital until she gives birth.

Up until the point of pregnancy, the course of treatment must be continued.

• It says labor will last 37 weeks.
• There is severe bleeding.
• If there is a maternal or fetal risk, the patient is promptly after delivery examined for decisive therapy.

Definitive Management:

Prompt delivery is part of the comprehensive management. This is taken into account when:

• The patient has now received a successful conservative therapy for 37 weeks.
• If the bleeding is really significant at either the beginning or the end.
• Patient is giving birth.
• Indications of fetal or maternal distress.
• Infant death inside the womb.

There are two ways of definitive management:

• Vaginal examination: It is done delicately while making all the necessary preparations for performing an emergency C/S.

• Caesarean section: The procedure used to treat placenta previa is the lower segment caesarean section. Severe bleeding, fetal distress, and associated complications are usually reasons to recommend a caesarean section in cases of placenta previa of a major degree.

  • If the baby is delivered via C/S and there is placental bleeding, inject 20 units of oxytocin at a rate of 60 drops per minute into 1 liter of I/V fluid (NS or R/L).
  • Manage bleeding in the postpartum period in accordance with PPH.

Complications

• Mother's shock
• Infant death inside the womb.
• Embolism of air.
• Extreme bleeding
• Malpresentation.
• Postpartum bleeding.
• Premature birth.
• Anomalies in the womb.

During Pregnancy:

• Anti partum hemorrhage with varying degree of shock
• Malpresentation
• Premature labor

During Labor:

• Early membrane rupturing
• Prolapsed cord
• Intrapartum bleeding
• A rise in the frequency of operational interferences
• Keep the placenta
• Sepsis rates are rising
• Subinvolution
• Embolism
• A little birth weight
• Asphyxia
• Infant hypoxia
• Birth trauma
• A congenital defect.

REFERENCE

BabyCenter. November 2016. https://www.babycenter.com/0_placenta-previa_830.bc

HealthLine. 2005. 2017 http://www.healthline.com/health/placenta-previa

Mayo Clinic. 1998. 09 May 2014 http://www.mayoclinic.org/diseases-conditions/placenta-previa/basics/definition/con-20032219

Medline Plus. 05 January 2017 https://medlineplus.gov/ency/article/000900.htm

Medscape. 1994. 2017 http://emedicine.medscape.com/article/262063-overview