APH-PLACENTA PREVIA IN ENGLISH
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Ante partum hemorrhage (PLACENTA PREVIA)-
Antepartum hemorrhage- It is defined as bleeding from or into the
genital tract after the 24th week of pregnancy but before the birth of the
baby. (the first and second stage of labor are also included).
Causes- The causes of
antepartum hemorrhage fall into the following categories.
-Placental causes (Placenta Previa and abruptio placenta)
-Extra placental causes (cervico-vaginal leisons)
(In this class we will discuss about
placenta previa)
Placenta Previa-
When the placenta is implanted partially or completely over the lower
uterine segment (over and adjacent to the internal os) it is called placenta
previa.
CAUSES AND RISK FACTORS-
The high risk factors for
placenta previa are —
(a) Multiparity (b) Increased maternal age (> 35 years)
(c) History of previous cesarean section or any other scar in the uterus
(d) Placental size and abnormality
(e) Smoking — causes placental hypertrophy to compensate carbon monoxide
induced hypoxemia
(f) Prior curettage.
TYPES OF PLACENTA PREVIA-
There are four types of placenta previa depending upon the degree of
extension of placenta to the lower segment.-
Type—I (Low-lying): The major part of the placenta is attached
to the upper segment and only the lower margin encroaches onto the lower
segment but not up to the os.
Type—II (Marginal):
The placenta reaches the margin of the
internal os but does not cover it.
Type—III (Incomplete or partial central): The
placenta covers the internal os partially (covers the internal os when closed
but does not entirely do so when fully dilated).
Type—IV (Central or total):
The placenta completely covers the internal os
even after it is fully dilated.
CLINICAL MANIFESTATIONS-
The only symptom of placenta previa is vaginal bleeding. The classical
features of bleeding in placenta previa are sudden onset, painless,
apparently causeless and recurrent. In about 5% cases, it occurs for the
first time during labor, especially in primigravidae. In about one-third of
cases, there is a history of “vaginal bleeding” which is usually slight.
DIAGNOSTIC INVESTIGATIONS-
USG- Immediate re-localization of the placenta using ultrasonic scanning is
a definitive aid to diagnosis, and as well as confirming the existence of
placenta praevia it will establish its degree. Relying on an early pregnancy
scan at 20 weeks of pregnancy is not very useful when vaginal bleeding starts
in later pregnancy, as the placenta tends to migrate up the uterine wall as
uterus grows.
MANAGEMENT-
Ø Immediate
re-localization of the placenta using ultrasonic scanning is a definitive aid
to diagnosis, and as well as confirming the existence of placenta praevia it
will establish its degree. Relying on an early pregnancy scan at 20 weeks of
pregnancy is not very useful when vaginal bleeding starts in later pregnancy,
as the placenta tends to migrate up the uterine wall as uterus grows.
Ø if bleeding is
slight and the woman and fetus are well. The woman will be kept in hospital at
rest until bleeding has stopped.
Ø If there is no
further severe bleeding, vaginal birth is highly likely if the placental
location allows.
Ø Severe vaginal
bleeding will necessitate immediate birth of the baby by caesarean section
regardless of the location of the placenta
Ø Precautions
during vaginal delivery: (1)
All
possible steps should be taken to restore the blood volume. Arrangement of
blood transfusion should be made. (2) Oxytocin 10 IV/IM/methergine 0.2 mg
should be given intravenously with the delivery of the baby to prevent blood
loss in third stage. (3) Proper examination of the cervix should be done soon following
delivery to detect any evidences of tear. (4) Baby’s blood hemoglobin level is
to be checked and if necessary arrangements are to be made for blood
transfusion.
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