Placenta Previa

Assalamualaikum,

For my 2nd post, i would like to tell about my teaching with Dr Nirmala last week. she give task for us to prepare 2 gynae case. so, we have decided to find 1 case for each group. then, when the teaching session start, she ask every member in what case we prepared each. of coz, i get shocked! this is miscommunication.. fortunately, i had clerked 1 gynae case last week. but, she doesnt seem so interested. instead 1 of our member was chosen bcoz her case was placenta previa. so, the discussion begins...

i dont rmember the case scenario. i give a new example..

Madam Ma 23 yo Gravida 4 para 3+1 at 32 weeks POA with 1 previous LSCS admitted for expectant management of asymptomatic placenta previa type 2 posterior. (this is the skema of presentation of placenta previa)

LMP: 23/2/2011

EDD: 30/11/2011

Q: How placenta previa is classified?

A: Type 1 (5cm from internal os) - minor

Type 2 (reach the internal os but not cover it) -have post(major) and ant(minor)

Type 3 (cover internal os asymmetrically) - major

type 4 (cover internal os symmetrically) - major

Q: What type that patient not be admitted?

A: Type 1, Type 2 anterior

Q: Why only after 28 weeks we diagnosed as PP?

A: because below 28 weeks, the lower segment of uterus is growing anteriorly and superiorly moving the placenta together. this placenta attachment does not move. but the growing lower segment of uterus make it like 'moving'

Q: What complication can get by PP?

A: fetal malpresentation, abnormal lie, antepartum hemorrhage, retained placenta, IUGR?

Q: What is the risk factor for PP in this patient?

A: 1 previous scar

Q: What has been done in the ward?

A: 1. timing if delivery

2. giving steroid - 28 - 34 weeks

-preparation for unpredictable vaginal bleeding coz by shearing effect

- 10 % PP can complicated to abruptio

3. trace blood group and cross-matched

- prepare to tansfused blood

4. ultrasound scan - abnormal placenta implantation

- placent accreta - anchoring placental villi attach to the myometrium, rather than

being contained by decidual cells

- placenta increta - chorionic villi invade the myometrium

-placenta percreta- chorionic villi penetrate to or through the uterine serosa and may invade surrounding organs

Q: How do you diagnosed placenta accreta?

A: by doppler ultrasound (wether there is blood flow to bladder.)

Q: if in case there is no doppler, what can you use? How?

A: Ultrasound - can see 'placental lakes' with lose of hypoechoic shadow between the bladder and placenta bed

Q: Why PP can get IUGR?

A: she told us to find it but i still dont get the answer...

Q: What is the purpose of repeated FBC in this patient?

A: 28 -32 weeks because to rule out hemodilution

32 weeks and above - if vaginal bleeding

Q: Principle management of PP?

A: I would like to admit her for mccafee regime

Correction of anemia by blood transfusion and hematinics (based on severity)

If there is bleeding, put her on pad chart - see warning blood

Plan for delivery at 38 weeks ( LSCS by senior surgeon) - forceps

Complete dexamethasone

IV drip - 16 and 14 size

Outpatient if PP type minor

Monitor baby - US and CTG

Blood bank and neonatalogist to be ready

Q: if patient progress to PPH after delivery, how is it managed?

A: 1. Activate red alert

2. Resuscitation (ABC)

3. Catheterization

4. volume replacement (whole blood, crystalloid, tx DIVC)

5. improve uterine tone by simabed/syntometrine/oxytocin

5. find site of bleeding - iliac artery/uterine artery - ligation

6. if still failed, hysterectomy done

Q: if patient doesnt want to be admitted, is she allowed to go home?

A: Yes, if follow below conditions:

1. she has minor PP

2. her house is 15 minutes from hospital

3. she is educated aand know how to take care of herself

4. rest and no heavy work

5. avoid SI - can induce labour

6. Someone can bring her back if bleeding occur

7. know to comeback if got warning blood

The type of anaesthesia of this patient must GA because spinal can cause hypotension. in PP surgery, there will be lots of blood loss and patent can go further hypotensive. GA is easy to control the circulation in case the surgery went complicated.

can u interpret this U/S image?

C = full bladder

D = placenta

E = placental lakes