Obstetric Hemorrhage- PPH

Obstetrical Hemorrhage: PPH Hale T., O & G Resident,

Mekelle University, College of Health Sciences, Dep't of OB-GYN

May 26, 2016

• Contents– Discussion on

• Placenta Previa • Placenta Accrete Syndrome • Placenta Accrete Syndrome

– Comments and Recommendations

Hale T., M.D., Resident Physician 2

Introduction


• Any degree of bleeding in a pregnant mother is pathologic; excluding – Implantation bleeding – Bloody show – Bloody show – Bleeding in the third stage of labor



• Placenta Previa – Placenta goes before the fetus into the birth

canal – Implantation of a placenta in the lower uterine – Implantation of a placenta in the lower uterine

segment (adjucent or over the internal Os)


• New classification of placental implantation – Normally implanted– Placenta previa – Placenta previa – Low lying placenta


• Degrees of Placenta Previa


Ultrasound in Obstetrics & Gynecology_ A Practical Approach - Clip 10.6.mp4





• GA greater than 16 weeks– Placenta > 2 cms away from Os - Normal– Placenta < 2 cms but not covering - PP

• Follow up U/S at 32 weeks – Placental edge > 2 cms – Placental edge > 2 cms

» Do color dopler U/S at 32 weeks to rule out vasa previa

– Still less than 2 cms » Follow up U/S at 36 weeks


Placenta Previa







• Placental Migration – Apparent movement of the placenta away

from the internal os• Imprecision of two-dimensional sonography• Imprecision of two-dimensional sonography• Differential growth of the lower and upper

uterine segments– A low-lying placenta is less likely to “migrate”

within a uterus with a prior cesarean hysterotomy scar


• Also – Lengthening of the lower uterine segment – Progressive unidirectional growth of

trophoblastic tissue toward the fundustrophoblastic tissue toward the fundus– Placental atrophy




• Predictors of hemorrhage in PP– Placentas that cover the os– Placentas near the Os have a greater risk of

bleeding if the placental edge is thick (>1 cm)bleeding if the placental edge is thick (>1 cm)– Identification of an echo-free space in the

placental edge covering the internal os– Cervical length ≤3 cm


• Admission – After 28 weeks – Before 28 weeks

• If there is bleeding or contraction • If there is bleeding or contraction


• Classification – Placenta Previa

• Internal os is covered partially or completely by placenta

– Low lying placenta • Placental edge does not reach the internal

os and remains outside a 2-cm wide perimeter around the os

– Somewhat but not always related is vasa previa, in which fetal vessels course through membranes and present at the cervical os


• Incidence– 0.3% or– 1 per 300-400 deliveries


• Risk Factors 1. Maternal age

• Age above 35 years 2. Multiparity

• Para 5 and above (80% of cases of PP are multipara)

3. Prior Cesarean deliveries / Myomectomy / Hysterectomy / Prior curretage Hysterectomy / Prior curretage • 8 fold if they had more than 4 CD

4. Cigarrete Smoking • Compensatory placental hypertrophy • Decidual vasculopathy

5. Elevated Prenatal Screening MSAFP Level• increased risk for previa and a host of other

abnormalitiesHale T., M.D., Resident Physician 27

• Also...– Multifetal gestation – Infertility treatment – Uterine instrumentation – Uterine instrumentation – Abortion – Male fetus – Nonwhite race– Previous placenta previa


• Pathogenesis – Suboptimal endometrium in the upper

endometrial cavity • Droping down theory • Droping down theory

– Large placenta – Defective decidualization – Persistence of chorionic activity


• Pathophysiology – Changes in the cervix and lower uterine

segment apply shearing forces to the inelastic placental attachment site, inelastic placental attachment site, resulting in partial detachment

• Lower uterine segment - Soft and friable – Vaginal examination or – Coitus


• Clinical Feature – Asymptomatic – Vaginal bleeding

• Painless• Painless• Without warning

– Sentinel bleed• Ceases and recurs


• Sequele – Severe bleeding – Preterm birth – Cesarean delivery – Cesarean delivery


• Other associated problems with PP– Preterm labor and rupture of the membranes– Malpresentation– Intrauterine growth restriction– Intrauterine growth restriction– Vasa previa and velamentous umbilical cord– Congenital anomalies – Amniotic fluid embolism


• Coagulation Defects– Placenta previa rarely complicated by

coagulopathy • Placental thromboplastin readily escape through • Placental thromboplastin readily escape through

the cervical canal • Paucity of large myometrial veins


• Diagnosis – Historical presentation – Double set-up technique

• Almost obsolete – Sonographic placental localization

• 96% accuracy, • 96% accuracy, • 100% negative predictive value

– Transabdominal – Transperineal – Transvaginal

– MRI• For evaluation of placenta accreta


Management



• Expectant management– Candidates? – When should termination be effected?– Home or Hospital? – Home or Hospital?


Placenta Accrete Syndrome• Abnormally implanted placenta

– Placenta Accrete Syndromes• Placenta accreta, increta, percreta

– Abnormally firm placental attachment – Abnormally firm placental attachment – Poorly developed decidua that lines the lower uterine

segment – Previa overlying a prior cesarean incision conveys a

particularly high risk for accreta carries a major risk of placental accrete Syndrome


• Abnormality of placental implantation– Anchoring placental villi normally attaches to

the decidua • Accreta• Accreta

– Anchoring placental villi attach to myometrium• Increta

– Anchoring placental villi penetrate into the myometrium• Percreta

– Anchoring placental villi penetrate through the myometrium to the uterine serosa or adjacent organs



• Incidence – Increasing at an alarming rate – Accreta > Increta > Percreta


• Pathogenesis – Defective decidualization – Excessive extravillous trophoblastic invasion– Defective maternal vascular remodeling in the – Defective maternal vascular remodeling in the

area of a hysterotomy scar– Partial or complete dehiscence of a uterine

scar


• Risk Factors – Placenta previa – Placenta previa after previous CD scar– Adavanced maternal age– Multiparity – Endometrial ablation – Endometrial ablation – Prior endometrial irradiation – Leiomyomas – Uterine anomalies – Smoking





Risk of Placenta Accreta Syndrome - In the absence of PP


• Clinical Presentation – Life threatening torential bleeding during an

attempt to separate the placenta manually – No plane of separation – No plane of separation – 2/3 of peripartum hysterectomies


• Sequeae– Unplanned surgeries / Hysterectomies – Death– ARDS– ARDS– DIC– PPH – Preterm birth – SGA infants


• Ultrasound Predictors of PPH in a patient with APH (Placenta Previa)– If there is placenta accreta syndrome – Thickness of the lower edge > 1 cms – Thickness of the lower edge > 1 cms – If placenta covers the internal Os


• Imaging – Sonography

• Conventional • 3-D Ultrasound • 3-D Ultrasound • Color dopler

– MRI


Ultrasound Diagnostic Findings in Placenta Accreta



A. Normal Placenta B. Placenta Accreta







• MRI Diagnositc Features of Placenta Accreta – Uterine bulging – Heterogenous signal intensity – Heterogenous signal intensity – Dark intraplacental bands – Abnormal placental vascularity – Focal interruptions in the myometrial wall – Tenting of the bladder – Invasion of nearby organs




• Lab– Elevated maternal serum AFP – Hematuria – Histology – Histology


• Management– Team work – Always CD– Hysterectomy Vs Conservative – Hysterectomy Vs Conservative – Leaving the placenta for natural resoprtion– Use of systemic methotrexate


Recommendations • In this patient

– Placental Accreta Syndrome should be rulled in or out with dopler study

– Infraumblical midline abdominal incision – Infraumblical midline abdominal incision should be planned

– Mother should be counseled on histeroctomy and OR materials should be prepared for hysterctomy

– The most senior person in the labor ward should be involved in the OT Hale T., M.D., Resident Physician 65

REFERENCES


REFERENCES


REFERENCES


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Obstetric Hemorrhage- PPH