placenta praevia and placenta accreta

CPC PresentationObstetrics and Gyneacology Department

24th June 2009

Supervisor:Dr Rahmah

Presenter: Shikin

Ng Bi YokeAng Xin XuanFoo Jen Chun

Syed Iqbal

History Puan X, 40 years old Gravida 6, para 5 2 previous delivery of emergency LSCS due to

poor progress and fetal distress

Chief compliant: - Sudden PAINLESS per vaginal bleeding at

32 weeks

Also presented with low lying placenta that was noted on 20th week of gestation

Older age group, Gravida 6th para 5 – (40 years old), mortality rate was increase in this age group

2 previous Caesarean section (emergency) – poor uterine contraction, scar formation that can lead to increase risk of adhesion

Q1. High Risk factors

low lying placenta noted with PAINLESS per vaginal bleeding – placenta previa which increase high chance of antepartum hemorrhage and complicate the delivery

4th and 5th pregnancy has emergency lower segment caesarean section which due to poor fetal progress and fetal distress – high chance of this complication re occur

Is the type of operation of choice

Transverse incision is made in the lower uterine segment

the uterus is opened in the lower segment and the baby’s head or breech as the case may be is delivered.

Q2. What is Lower segment Ceasearean Section

Slightly more complicated to perform, however repair of uterus is simple, the scar heals well and subsequent rupture is uncommon.

The LSCS is the procedure most commonly used today

General exam: not pale

Vital signs: normal

Abdominal exam: viable single fetus

Transverse lie

No contraction

Abdomen soft and non tender

Q. 3 What is the most likely diagnosis and give

reasons. (5 marks)

ANTEPARTUM HAEMORRHAGE SECONDARY TO PLACENTA PREVIA (PP)

Placenta situated wholly or partially within the lower segment of the uterus

Classification:◦ Type I: Low-lying placenta◦ Type II: Marginal placenta previa◦ Type III: Partial placenta previa◦ Type IV: Total placenta previa

PLACENTA PREVIA

Predisposing conditionMultiparityMaternal age >35 (2-3X higher risk if

over 35 years old) Increased surface area (multiple

pregnancy)Uterine scar SmokingPrevious dilatation and curettagePrevious placenta previa

Symptoms & signs

Painless per vaginal bleeding Abdomen is soft and non tender Fetal parts are easy felt Unstable lies High engaged presenting part

Massive antepartum haemorrhage Placenta accreta, increta and percreta Malpresentation Caesarean section Postpartum haemorrhage DIC Massive transfusion Infective hepatitis due to transfusion maternal death

Complications

REASONS1. Risk factors:

grandmultiparity (> 5 pregnancies) previous 2 caesarean sections

maternal age 40 years old

2. ‘low-lying’ placenta at 20 week of gestation(chance of migration is low because of uterine scar)3. Malpresentation of the fetus – transverse (complication of PP)

4. Abdomen: soft, non tender

DIFFERENTIAL DIAGNOSISAbruptio Placenta

Bleeding from genital tract due to premature separation of the normally sited placentaAssociated with pain, frequent uterine contraction; restlessness, pallor, cold and clammy extremities; tense and tender abdomen (woody hard); difficulty palpating fetal parts; PIH; DIVC

Vasa Previa An aberrrant feto placenta vessel running in the membraneRupture of vasa can occur in labour or with PPROM – vaginal bleedingFetal distress, acute fetal exsanguination and death

Circumvallate Placenta

Membrane appear to be attach internally to the placenta edgeAssociated with antepartum and postpartum haemorrhageDefinite diagnosis is made by placental examination post delivery

DIFFERENTIAL DIAGNOSISBleeding from the Succenturiate Lobe

The placenta is partly or completely divided into 2 or more lobesAssociated with antepartum and postpartum haemorrhageDefinite diagnosis is made by placental examination post delivery

Indeterminate Bleeding

Bleeding due to marginal separation of a normally sited placenta leading to a reduced functional reservedPainless per vaginal bleedingNo abruption or local lesionDiagnosis of exclusion

Local Genital Tract Lesions(cervical polyp, cervicitis, cervical carcinoma, vaginal trauma or vaginitis)

Can be detected by speculum examination and Pap smear

Q. 4 Name three (3) investigations that you

would order. (3 marks)

1. Ultrasound examinationTRANSVAGINAL ULTRASOUND (TVS) would be used instead of

transabdominal ultrasound. TVS is significantly more accurate, and its safety is well established.

It is used to: To determine the site of the placenta In PP, to determine the type of previa and anterior or posterior

previa To access fetal growth and amniotic fluid volume

With the help of COLOUR FLOW DOPPLER ULTRASOUND, other problems like vasa previa and placenta accreta can be diagnosed

it should be performed in women with PP who are at increased risk of placenta accreta. Where this is not possible locally, such women should be managed as if they have placenta accreta until proven otherwise.

2. Cardiotocography (CTG) To rule out fetal distress Usually normal in placenta previa, abnormal

in abruptio placenta

3. Full blood count To look for anemia due to antepartum

haemorrhage

Ultrasound examination confirmed the diagnosis of anterior placenta previa with the lower edge covering the internal os. She experienced no further bleeding and was observed in the antenatal ward.

Def.: Placenta implantation with abnormally firm adherence to the uterine wall

◦ Placenta accreta placental villi attached to the myometrium

◦ Placenta increta placental villi invading the myometrium

◦ Placenta percreta placental villi penetrating through the myometrium

Placenta Accreta/Increta/Percreta

“Women with a placenta previa and a prior CS are at high risk for

placenta accreta. “ Oppenheimer O et al. Clinical Practice Guideline: Diagnosis and Management of Placenta Previa. Society of

Obstetricians and Gynaecologists, 2007.

“The risk of placenta accreta in the presence of placenta previa increases dramatically with the number of previous CS, with a 25% risk for one prior CS, and more than 40% for two prior CS.”

Clark SL, Koonings PP, Phelan JP. Placenta praevia / accreta and prior caesarean section. Obstet Gynecol 1985;66:89–92.

Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107:1226–32.

“Women with placenta praevia are at increased risk of having a morbidly adherent placenta if they have an anterior placenta praevia and have previously been delivered by caesarean section.”

Miller DA, Chollet JA,Goodwin TM.Clinical risk factors for placenta praevia–placenta accreta. Am J Obstet Gynecol 1997;177:210–14.

Gielchinsky Y, Rojansky N, Fasouliotis SJ, Ezra Y. Placenta accreta: summary of 10 years: a survey of 310 cases. Placenta 2002;23:210–14.

Risk Factor of Placenta Accreta/Increta/Percreta

“Placenta accreta is a significant

condition with high potential for hysterectomy, and a maternal death rate reported at 7%”

O’Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol 1996;75:1632–8.

How would you manage her now? (10m)

Q5

Admission to the ward till delivery

Close observation for any further bleeding

The availability of at least 2 units of grouped and cross-matched blood at all times for the patient

The liberal use of Caesarean section for delivery of the fetus as soon as fetal maturity is achieved.

McCafee Regime

“Women with major placenta praevia

who have previously bled should be admitted and managed as inpatients from 32 weeks of gestation.”

Peterson-Brown S et al. Greentop Guidelines: Placenta previa and placenta accreta: Diagnosis and management. Royal College of Obstetricians and Gynaecologists, 2005

ADMISSION

Love C D et al. Major placenta praevia should not preclude out-patient management. Eur J Obstet Gynecol Reprod Biol. 2004 Nov 10;117(1):24-9.

Rosen D M,Peek M J. Do women with placenta praevia without antepartum haemorrhage require hospitalization? Aust N Z J Obstet Gynaecol. 1994 May;34(2):130-4.

Wing D A et al. Management of the symptomatic placenta previa: a randomized, controlled trial of inpatient versus outpatient expectant management. Am J Obstet Gynecol 1996 Oct;175(4 Pt 1):806-11.

“Prolonged inpatient care can be

associated with an increased risk of thromboembolism.”


“Outpatient management of placenta previa may be appropriate for stable women with home support, close proximity to hospital, and readily available transportation and telephone communication.”

Oppenheimer O et al. Clinical Practice Guideline: Diagnosis and Management of Placenta Previa. Society of Obstetricians and Gynaecologists of Canada, 2007.

“Women managed at home should be encouraged to ensure that they have safety precautions in place, including having someone available to help them should the need arise and, particularly, having ready access to the hospital. It should be made clear to any woman being managed at home that she should attend hospital immediately if she experiences any bleeding, any contractions or any pain (including vague suprapubic period-like aches).”


Vital signs Pad chart Speculum examination Basic investigations Optimize haemoglobin level

Close Observation for Further Bleeding

“Clinicians should offer antenatal corticosteroid treatment to women at risk of preterm delivery because antenatal corticosteroids are associated with a significant reduction in rates of RDS, neonatal death and intraventricular haemorrhage.”

“ Every effort should be made to initiate antenatal corticosteroid therapy in women between 24 and 34 weeks of gestation with any of the following:

● threatened preterm labour ● antepartum haemorrhage ● preterm rupture of membranes ● any condition requiring elective preterm delivery.”

“Betamethasone is the steroid of choice to enhance lung maturation. Recommended therapy involves two doses of betamethasone 12 mg, given intramuscularly 24 hours apart.”

Penney G C et al. Greentop Guidelines: Antenatall Corticosteroids To Prevent Respiratory Distress Syndrome. Royal College of Obstetricians and Gynaecologists, 2004

Antenatal Corticosteroid

The availability of at least 2 units of grouped and cross-matched blood at all times for the patient

“The amount of blood loss in the 22 cases of placenta

accreta ranged from 590 to 10500 ml.” Kato R et al. Anesthetic management for cases of placenta accreta presented

for cesarean section: a 7-year single-center experience. Masui 2008: 57(11):1421-6.

“Mean estimated blood loss: 3000 to 5000 ml” Catanzarite et al.: Contemporary Obstetrics and Gynaecology, 1996.

Blood

What is your plan for her delivery? (2m)

Q6

Indication - Major placenta previa - 2 previous scars

Timing: Term

Other issues - transverse lie - anterior placenta previa Kronig or De Lee - placenta accreta/increta/percreta

http://emedicine.medscape.com/article/263424-overview . Cited: 19th July 2009

Lower Segment Caesarean Section

http://emedicine.medscape.com/article/263424-overview

“When prolonged surgery is anticipated in women with prenatally diagnosed placenta accreta, general anaesthesia may be preferable, and regional analgesia could be converted to general anaesthesia if undiagnosed accreta is encountered.”

Parekh N, Husaini SW, Russel IF. Caesarean section for placenta praevia: a retrospective study of anaesthetic management. Br J Anaesth 2000;84:725–30.

Kato R et al. Anesthetic management for cases of placenta accreta presented for cesarean section: a 7-year single-center experience. Masui

2008: 57(11):1421-6.

ANAESTHESIA

“There is no evidence from this review to show that RA is superior to GA in terms of major maternal or neonatal outcomes.”

Afolabi BB, Lesi AFE, Merah NA. Regional versus general anaesthesia for caesarean section. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004350. DOI: 10.1002/14651858.CD004350.pub2

Q7.What are the complications that you will anticipate during delivery?

(3 marks)

Compared with a vaginal delivery, maternal mortality and especially morbidity is increased with cesarean delivery to approximately twice the rate after a vaginal delivery. The overall maternal mortality rate is 6-22 deaths per 100,000 live births, with approximately one third to one half of maternal deaths after cesarean delivery being directly attributable to the operative procedure itself.

1) Hemorrhagea) Post partum hemorrhage●placenta attaches to the lower part of uterus●does not contract effectively●placental surface will continue to bleed

b) Uterine lacerations●especially of the lower uterine segment, are more common with a transverse uterine incision. These lacerations can extend laterally or inferiorly.

2) Placenta accreta● Abnormal adherent of placenta● Placenta accreta -placenta is invading the decidua basalis of myometrium

-common in anterior placenta previa with previous C-sec

-difficulty in delivering and separation of placenta

-cause severe bleeding -emergency hysterectomy is life

saving

3) Injury to bladder and ureter

- adhesion of pelvic organs due to previous ceaserian section will cause pelvic anatomy distortion. This will predispose to bladder and ureter injury during delivery.-The bladder most commonly is injured when entering the peritoneal cavity or when separating the bladder from the lower uterine segment-Injury to the ureter occurs in up to 0.1% of all cesarean deliveries and up to 0.5% of cesarean hysterectomies. It is most likely to occur when repairing extensive lacerations of the uterus.

4) Anaesthetic complications

- in emergency ceaserian section, aspiration or Meldelson's syndrome will happen if the patient is not well prepared or fasted

(kulen,3rd edition)

Q8

How would you counsel the patient?

(10 marks)

1)If discharge -near the hospital -availability of transport -if further bleeding,come to hospital immediately -avoid sexual intercouse -diet : healthy diet rich in iron

2) Prolonged admission -Financial ( treatment and surgery bills) -Social ( job, other children) -Emotional ( worry, anxious)

3) Risk of blood transfusion

4) Risk of post partum hemorrhage

5) Risk of life saving hysterectomy if the surgeon anticipates placenta accreta during delivery

-affect need for further childbearing and sexual function

-obtain the consent for emergency hysterectomy

6) Counsel on family planning and offer tubal ligation or other contraceptive methods (40 y/o with 6 children)

At 36 weeks-profuse bleeding

Emergency Caesarean Section

Healthy female baby with BW of 2.5kg

Adherent placenta ,required further surgical intervention

Question 9What is the diagnosis and how would you manage this problem? (2m)

Morbid adherence of the placenta

1 in 2,500 pregnancies, increasing

~10% of cases of placenta previa

Placenta Accreta

Accreta

PercretaIncreta

Etiology: partial or total absence of the decidua basalis and imperfect development of the fibrinoid layer

Accreta (75-78%)

Increta (17%)

Percreta (5%)

• Difficult to deliver the placenta results in PPH

Partial

• Placenta separation does not occur normally and there is no distinct separation Total

Anterior PP in patient with previous CS (40% risk)

Underdeveloped/absent of decidua basalis which permits villous invasion of the myometrium

Female fetus

Risks factors

Reference: Royal College of O&G, Guideline No. 27, revised October 2005

Risk of developing placenta accreta in women with placenta previa

No previous C/S 1% - 5%

One previous C/S 30%

Two or more C/S 40% and higher

Risks factors

Maternal age ≥35 years Multiparity: gravida ≥6 Prior myomectomy Asherman's syndrome Submucous leiomyomata

Other Risks Factors

Reference: WHEC Practice Bulletin and Clinical Management Guidelines

Very rarely recognized before birth Very difficult to diagnose High index of suspicion in high risks patient

1) Ultrasound- Colour flow Doppler ultrasonography

- Power amplitude ultrasonic angiography

2) MRI

Diagnosis

Irregularly shaped placental lacunae (vascular spaces) within the placenta

Thinning of the myometrium overlying the placenta

Loss of the retroplacental "clear space“

Protrusion of the placenta into the bladder

Increased vascularity of the uterine serosa-bladder interface

Doppler ultrasonography turbulent blood flow through the lacunae

Ultrasonography

Sensitivity of 82.4%

Specificity of 96.8%

Reference: Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta praevia accreta bytransabdominal color Doppler ultrasound. Ultrasound Obstet Gynecol 2000;15:28–35.

sensitivities 33%-38% too poor to be useful clinically Need further experience and/or refinements

occur with MRI.

MRI

Reference: Royal College of O&G, Guideline No. 27, revised October 2005

Obstetrician Anesthesiologist Hematologist and Blood bank Neonatology Radiologist Urologist

Multidisciplinary approach

Conservative To preserve fertility (usually w/o

haemorrhage)

1) Leaving the placenta in situ and give methotrexate

Management

•Numerous hemorrhagic and infectious complications•Maternal mortality is much higher than cesarean hysterectomy

Reference: Robert Resnik, Contemporary OB/GYN 2001 11:122-129

Advantages: Lower estimated

blood loss, reduced blood transfusion

More clean operative field

Avoidance of hysterectomy

Complication (6% to 7%)1,2

Post-procedure fever

Pelvic infection

2) Prophylactic or therapeutic uterine artery embolisation, or internal iliac artery ligation

1. Vedantham: American J of Obs and Gyn 1997; 176(4): 938-948 2. Hansch : American J of Obs and Gyn 1999; 180(6): 1454-1460

Selective Arterial Embolization

About 66% to 85% of placenta accreta require cesarean hysterectomy1,2

Management

1. Catanzarite et al.: Contemporary OB/GYN 19962. Chattopadhyay: Eur J Obs Gyn Reprod Biol 1993; 52: 151-156

Surgical/ radical Mx In high risk patient, decision for

hysterectomy need to be done SOONER rather than LATER

Hysterectomy

Management

Intraoperatively, experienced torrential bleeding

Blood transfusion and maximum inotropic supports

Hypotension

Irreversible cardiac arrest

Post Partum Haemorrhage

Puan XTeacher 40


Placenta Accreta

Puan XTeacher 40


Placenta Accreta

Placenta Previa

Puan XTeacher 40

16 weeks


Placenta Accreta

Placenta Previa

2 Previous Scars

Grandmulltipara

Puan XTeacher 40

16 weeks

placenta praevia and placenta accreta

Documents