Placenta Previa

A 13 years experience at a tertiary care center in Western Saudi Arabia

Kristalenta Lamey S.Ked

Differential Diagnosis of Third Trimester
Bleeding

Placenta Previa Coagulation Disorder

Vaginal Lesion/Injury
Placental Abruption
Cervical Lesion/Injury
Uterine Rupture
Neoplasia
Vasa Previa
Bloody Show
Early labor
Hemorrhoids
Epidemiology of Third Trimester Bleeding
About 3.8 % of third trimester pregnancies
placenta previa - 22%; placental abruption - 31%
Serious problem in pregnancy associated with
maternal and fetal risks
Require urgent initial assessment and, occasionaly,
only partial diagnostic procedures

Oyelese Y, Smulian JC. Placenta Previa, Placenta Accreta, and Vasa Previa. Obstet Gynecol. 2006;107:927-941
Journal
A 13 years experience at a tertiary care center in Western Saudi Arabia
Objectives: To review cases of placenta previa in the last 13 years in a
tertiary teaching hospital to identify risk factors for maternal morbidity.
Methods: A retrospective analysis of all cases of placenta previa managed
at King Abdulaziz University Hospital (KAUH), Jeddah, Kingdom of Saudi
Arabia from January 2001 to December 2013.
Result : 11,412 (20.3%) delivered by cesarean section (C/S). The charts of
230 cases diagnosed with placenta previa was reviewed, and different
variables were collected and analyzed. Diagnoses were achieved in 94% of
them using ultrasound. The prevalence rate of placenta previa was 4.1 per
1000 births. Cesarean section was carried out as an emergency procedure
in 130 (56.5%) women and as elective in 100 (43.5%) women. Of them, 26
patients were admitted to the intensive care unit (ICU) (11.3%), all of which
received blood transfusion >6 units and 22 patients had a hysterectomy for
uncontrollable bleeding.
Journal
Conclusion: Placenta previa is one of the leading causes of maternal morbidity
and mortality. Every hospital must have a protocol, or algorithm for the
management of placenta previa. Risk factors for maternal morbidity included
complete previa, history of previous C/S, emergency C/S at a gestational age of
<36 weeks, and estimated blood loss >2000 ml.

From the Department of Obstetrics & Gynecology (Abduljabbar), Medical College,

King Abdulaziz University and the Department of Obstetrics & Gynecology
(Bahkali, Al-Basri, Shoudary, Dause, Mira, Khojah), King Abdulaziz University
Hospital, Jeddah, Kingdom of Saudi Arabia.
Received 30th August 2016. Accepted 27th April 2016.
Address correspondence and reprint request to: Dr. Hassan S. Abduljabbar,
Department of Obstetrics & Gynecology, Medical College, King Abdulaziz University,
Jeddah, Kingdom of Saudi Arabia. E-mail: profaj17@yahoo.com
Journal
Placenta Previa defined as a condition that occurs in pregnancy when
the placenta abnormally implanted in the lower uterine segment,
Partially or totally covering the internal cervical os.1 Complete
placenta previa is when it covers the internal os, partial is when the
placenta partially covers the os, and marginal is when the placenta
approaches the border of the os.
Placenta Previa
Defined as the abnormal implantation of the placenta
in the lower uterine segment
Placenta Previa
Bleeding results from small disruptions in
the placental attachment during normal
development and thinning of the lower
uterine segment
The degree of placenta previa cannot alone
predict the clinical course accurately, nor
can it serve as the sole guide for
management decisions
As a consequence the importance of
presented classifications has diminished
Placenta previa - Epidemiology
4 percent of ultrasound studies performed at 20 to 24 weeks

0,4% at term

The diagnosis of placenta previa is common before the third trimester, but
up to 95% resolve before delivery
Placenta Previa - Risk Factors

Previous CS Smoking
Previous uterine Multiple gestation
instrumentation Prior placenta previa
Multiparity Uterine fibroids
Advanced maternal age
Placenta Previa - Risk Factors

Risk of recurrent placenta previa is 4% to 8%

Risk of placenta previa increases with the number of prior cesarean
sections, rising to 10% with four or more
For woman older than 40 years risk is 2%
Placenta Previa - Clinical presentation
Episode of bleeding has a peak incidence at about the 34th week of
pregnancy
One-third of cases become symptomatic before the 30th week and
one-third after the 36th week
Approximately 10% of cases, bleeding begins only with the onset of
labor
Placenta Previa - Diagnosis
Transabdominal sonography

Transvaginal sonography

Magnetic resonance imaging

Warshak, Carri R. MD; Eskander, Ramez MD; Hull, Andrew D. MD; Scioscia, Angela L. MD; Mattrey, Robert F. MD; Benirschke, Kurt MD;
Resnik, Robert MD
Placenta Previa - Morbidity and Mortality

Placenta Previa is rarely a cause of life-threatening maternal hemorrhage unless

instrumentation or digital exam is performed

The most common morbidity with this problem is the necessity for operative
delivery and the risks associated with surgical intervention

Perinatal morbidity and mortality are primarily related to the complications of

prematurity, because the hemorrhage is maternal.
Placenta Previa - Morbidity and Mortality

Reduction in both maternal and perinatal mortality rates over the

past 40 years
Expectant management approach and the liberal use of cesarean
section rather than vaginal delivery
Maternal mortality rate has fallen from between 25% and 30% to less
than 1%.
Total perinatal mortality rate has fallen from between 60% and 70%
to under 10%
Placenta Previa - Morbidity and Mortality

Goal is to obtain the maximum fetal maturation possible while

minimizing the risk to both the fetus and the mother

In a significant proportion of cases delivery may be safely delayed to a

more advanced stage of maturity
Placenta Previa - Management
It is reasonable to hospitalize women in the situation of acute
bleeding episode or uterine contractions
Women who present with bleeding in the second half of pregnancy
should have a sonographic examination for placental location prior to
any attempt to perform a digital examination
Placenta Previa - Management

Blood count and type and screen

At least 4 units of compatible packed red blood cells and coagulation
factors at short notice
Rh immune globulin to Rh-negative women
Placenta Previa - Management
Steroids should be administered in women between 24 and 34 weeks
of gestation
Before 32 weeks of gestation, with no maternal or fetal compromise
blood transfusions should be considered
Tocolysis ?
Placenta Previa - Management
When the patient has had no further bleeding for 48 hours, she may
be considered for discharge
Women who are stable and asymptomatic, and who are reliable and
have quick access to hospital, may be considered for outpatient
management
Placenta Previa - Delivery
Cesarean delivery at 36-37 weeks of gestation - documentation of
fetal lung maturity by amniocentesis
Placental edge is 2 cm or more from the internal os at term - good
chances to deliver vaginally
Regional anesthesia - less blood loss and requirements for blood
transfusion
THANKS