Placenta previa Teng Yincheng M.D., Ph.D., Professor Department Of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine The placenta provides the fetus with oxygen and nutrients and takes away waste such as carbon dioxide via the umbilical cord. 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).pregnancyvagina 28 , , Incidence The incidence of placenta previa is approximately 1 out of 200 births.incidence 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.pregnancy doubled in multiple pregnancy (such as twins and triplets). 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 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).C-sectioncervix classification Complete placenta previa Partial placenta previa Marginal placenta previa Clinical findings Symptoms Spotting during the first and second trimestersSpotting Sudden, painless, and profuse vaginal bleeding in pregnancy during the third trimester (usually after 28 weeks)vaginal bleeding in pregnancy --Bleeding may not occur until after labor starts in some cases --Anemia,shock 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.blood lossshockplacenta abruptio No digital examination Accessory examinations Ultrasonography: Accuracy 95% 34 th week Postpartum examination of placenta and membrane 7cm Diagnosis Differential diagnosis Complications Complications Maternal complications major hemorrhage, shock, and death.shock 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.Prematurity 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 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.abnormal uterine bleedingcervix 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.maternal blood loss Cesarean section is the method for delivery. It has proven to be the most important factor in reducing maternal and infant death rates.Cesarean section 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.C-section ABRUPTIO PLACENTAE Definition Abruptio Placentae( placental abruption): premature separation of the normally implanted placenta from the uterine wall. Incidence:0.51%~2.33% 200~300/1000 1% 150/1000 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 Classification Concealed separation: no vaginal bleeding Apparent separation :vaginal bleeding will be Mixed separation : vaginal bleeding will be apparent Diagnosis Classic clinical presentation : vaginal bleeding Tender uterus Uterine contractions Fetal distress Coagulation abnormalities Hypofibrinogenemia Increaseing levels of fibrin degradation products decreasing platelet count Increasing prothrombin time and partial thromboplastin time Decreasing other serum clotting factors 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. Complication DIC Shock Amniotic fluid embolism Acute renal dysfunction Management Maintain hemodynamic stabilization ( Transfusion therapy) Crystalloid transfusion Whole blood therapy Component therapy Correct coagulation status 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. Normal and Abnormal Puerperium 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. Definition The relevant anatomy and physiology in the puerperium 1.Reproductive organs 1)Uterus 1000g g The endometrial lining rapidly regenerates (16 days) The placental site undergoes a series of changes in the postpartum period 2)Cervix it never returns to the nulliparous state. the external os is closed to the extent that a finger could not be easily introduced. 3)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. 4)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. 5)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 6)Breasts Lactation can occur by 16 weeks' gestation. Lactogenesis is initially triggered by the delivery of the placenta (EPand 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. Manifestation 1.Fever (24 hours) 2.Pain (uterine contraction) 3.Sweat 4.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) Management 1. 2 hours after delivery Bleeding Uterine contraction HR and Bp and R and T 2.1 weeks after delivery Bleeding 3.Emiction and defecate 4.Lochia 5.Episiotomy and Laceration 6.Breast 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. Risk factors 1.PROM 2.Anemia 3.Hemorrhage 4.EP and CS 5.Placenta retain Common pathogens 1.Aerobes Group A, B, and D streptococci Gram-negative bacteria: Escherichia coli , Klebsiella Staphylococcus aureus 2.Anaerobes Petococcus species Petostreptococcus species Bacteroides fragilis group Clostridium species 3.Other Chlamydia trachomatis Mycoplasma species Manifestation Acute vulvitis vaginitis and cervicitis Uterine infection Adnexal infections Septic pelvic thrombophlebitis Diagnosis History Physical examination and PV Lab finding Differential diagnosis Treatment 1.Nutrition: anemia prevention 2.Antimicrobial treatment broad-spectrum, high dose, long time 3.Drainage 4.Treatment of thrombophlebitis 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 Diagnosis Treatment 1.antibotics oxytocin PG 2.uterine curettage 3.hysterectomy THANKS FOR YOUR ATTENTION Teng Yincheng M.D., Ph.D., Professor M.D., Ph.D., Professor Dep. of Obstet. & Gynecol. Renji Hospital Affiliated to SJTU School of Medicine