Indonesian Journal of Obstetrics & Gynecology Science

Total Placenta Previa with Complication of Post Partum Haemorrhage

at 39 Weeks Gestation on Multiparous

Reski Wulandari Roni, Ferri Waluyo Wiwoho Pujojati

General Practitioner, Obstetrician Gynecologist
Rumkit Tk II Dr R Hardjanto Balikpapan Provinsi KALTIM
Korespondensi : Reski Wulandari Roni, Email : reskiwulandari20@gmail.com

Abstract
The main cause of maternal mortality is bleeding. Placenta previa is one of the most common
causes of bleeding in pregnant women. [4] In Indonesia, according to the 2012 Indonesian
Demographic and Health Survey (IDHS), the maternal mortality rate in Indonesia is still
high at 359 per 100,000 live births. Based on data from 2010-2013, the biggest cause of
death for mothers is bleeding.[4] The purpose of writing this case report to author and reader
can understand the complications of placenta previa, that is postpartum hemorrhage and
how to manage this case. We report a 31 year old woman, multiparous case with Complete
Placenta Previa and a two times history of caesarian section who experienced Postpartum
Haemorrhage and Hypovolemic Shock. The patient's condition improved in 3 days after
surgery and Intensive Care Unit (ICU) treatment.

Key Word : Total Placenta Previa, Post Partum Haemorrhage.

Plasenta Previa Totalis dengan Komplikasi Perdarahan Post Partum

Pada Multipara di Usia Kehamilan 39 Minggu

Abstrak
Penyebab angka kematian ibu (AKI) yang utama ialah perdarahan. Plasenta previa
merupakan salah satu penyebab perdarahan yang tersering terjadi pada ibu hamil. [4]Di
Indonesia, menurut Survei Demografi dan Kesehatan Indonesia (SDKI) tahun 2012, angka
kematian ibu di Indonesia masih tinggi sebesar 359 per 100.000 kelahiran hidup. Berdasarkan
data dari tahun 2010-2013 penyebab kematian terbesar kematian ibu ialah perdarahan. [4]
Tujuan dari penulisan laporan kasus ini adalah agar penulis dan pembaca mampu memahami
komplikasi dari plasenta previa yaitu perdarahan post partum dan bagaimana managemen
tatalaksana dari pada kasus tersebut. Kami melaporkan kasus multipara berusia 31 tahun
dengan Plasenta Previa Totalis dan Riwayat SC 2x yang mengalami Perdarahan Post Partum
dan Syok Hipovolemik. Kondisi pasien membaik 3 hari pasca operasi dan perawatan
Intensive Care Unit (ICU).

Kata Kunci : Plasenta Previa Totalis, Perdarahan Post Partum.

 Reski Wulandari Roni : Complete Placenta Previa at 39 Weeks Gestation on Multiparous
Introduction
Most of the placenta will make an
implantation in a good place in order to
provide adequate nutrition for the fetus,
that is in the uterine fundus. However, this
is not always happend, leading to various
placental implantation abnormalities.[5]
Placenta previa is a placenta that
located in the lower uterine segment in
such a way that it is adjacent to or partially
or completely covers the internal uterine
ostium.[3,16] The incidence of placenta
previa is 4-5 per 1000 pregnancies. [7] The
incidence is 2.8/1000 deliveries in
singleton pregnancies and 3.9/1000
deliveries in twin pregnancies. [6]
Placenta previa is one of a problem
in pregnancy. This causes painless vaginal
bleeding and some cause bleeding profuse
enough and can endanger the condition of
the mother and fetus that should require
immediate delivery, either elective or
emergency. [6]
The factors that influence the
occurrence of placenta previa are increased
maternal parity, increased maternal age,
multiple pregnancies, curatage, previous
cesarean section, the presence of scar on
the uterus and myomectomy or
endometritis, a history of placenta previa,
and smoking habits. [13,7]
Defects in the uterus for example
due to cesarean section, scrapings and
myomectomy had a significant effect to
the inflammatory process and the
incidence of endometrial atrophy resulting
in inadequate decidua vascularization,
causing placenta previa.[13]
The incidence of placenta previa in
the second pregnancy with vaginal
delivery during the first pregnancy was 4.4
in 1000 births, while by cesarean section
was 8.8 in 1000 births. Other data states
that mothers with a history of one cesarean
section have a 2.2 times greater risk of
experiencing placenta previa. The risk
increases with the increase in history of
cesarean section, that 4.1 times for 2
cesarean sections and 22.4 times for a
history of 3 cesarean sections. [1,4,6,7]
This case is about a 31 years old
woman with complete placenta previa at
her 39 weeks of gestation and had two
history of caesarian section get post
partum haemorrhage after the last
caesarean section with anaemia.
This case has received approval
from the patient and the hospital medical
committee.
Objective
To present a common case of plasenta
previa and to discuss about theory and
management of complication caused by
pacenta previa.
Case Illustration
A 31-years old woman,
multiparous at 39 weeks gestation was
complained of vaginal bleeding. Bleeding
occurred since 1 day before admission to
the hospital and the blood came out in the
form of brown spots without any other
complaints, without abdominal pain.
Previously, the patient had experienced the
same thing in the 7th month of pregnancy
but the bleeding was only a spotting.
From the physical examination
and ultrasound performed at the hospital, it
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 Reski Wulandari Roni : Complete Placenta Previa at 39 Weeks Gestation on Multiparous

is found that the placenta completely caesarean section . The patient is directed
covers the birth canal. The patient is also to hospitalization and surgery plans the
known to have a two times history of next day.

Picture 1: Plasenta Covers the Whole Way of Birth

Lab results before surgery showed an After the sugery was completed,
insignificant rate of anemia with 9.9gr% the patient was transfer to the Intensive
of haemoglobin, erythrocytes 4.1 million, Care Unit (ICU) and the patient was
Leukocytes 8700 mm3, Thrombocytes closely observed. The patient furthermore
187,000/ uL, Ureum 9 mg / dl and showed improvement after the third day of
Creatinine 0.4 mg / dl. Furthermore, the stay in the ICU. The patient get well with
patient is planned for surgery the next day. stable hemodynamics and the haemoglobin
The baby was born healthy with an apgar back to normal at 11gr% after 4 bag
score 8 in the first minute and 9 in the fifth transfusin of blood.
minute, active motion, and weight 3200
grams. Discussion
The complications that caused by
Placenta previa is a condition when
low lying of placenta previa is post partum
the position of placenta in the lower
haemorrhage that occur during the surgery.
segment of uterus so that it closes of the
The estimated blood loss of the patien is
opening of the birth canal (ostium uteri
2500 cc then causes the patient's
internum). The incidence of placenta
haemoglobin become 1.8 g% and also
previa in the second pregnancy with
causes unstable hemodynamic. The
vaginal delivery during the first pregnancy
patient's blood pressure drops to 80/50
was 4.4 in 1000 births, while by cesarean
mmHg, and the patient's consciousness
section was 8.8 in 1000 births. [1,4,]
begins to decline. Furthermore,
Other data states that mothers with
hemodynamic improvement is carried out
a history of one cesarean section have a
in collaboration with Anesthesiologists, by
2.2 times greater risk of experiencing
installing 2 IV lines by inserting colloids
placenta previa. The risk increases with the
and crystalloids, as well as conducting
increase in history of cesarean section, that
intra-operative blood transfusions to
4.1 times for 2 cesarean sections and 22.4
overcome anemia that occurs in patients.

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 Reski Wulandari Roni : Complete Placenta Previa at 39 Weeks Gestation on Multiparous
times for a history of 3 cesarean sections.
[1,4,6,7]
Women over 30 years of age tend to
get placenta previa. [11]
Early in pregnancy, the placenta
begins to form, a round, flat organ that is
responsible for providing oxygen and
nutrients for the baby's growth and
removing waste products from the baby's
blood. The placenta is attached to the
uterine wall and to the baby's umbilical
cord which forms an important connection
between mother and baby. [16,18]
There are 4 classification of
placenta previa : [3]
a. Partial Placenta Previa which is
when the placenta covers a half of
internal uterine ostium.
b. Marginal Placenta Previa which is
when the placenta covers lower
edge of internal ostium internum.
c. Low-lying Placenta Previa which is
when the placenta covers
approximately 2 cm of internal
uterine ostium.
Table 1: History of labor by caesarean section increases the incidence of placenta previa
in subsequent pregnancies [7,11]
Type of Previa Previous Caesarean
Delivery
Complete No.
Complete Yes
Partial No.
Partial Yes
Overall
Diagnosis enforced by the presence
of clinical symptoms and several
examinations, including:[1,3,4,7,9]
1. History Taking / Anamnesis
The first symptom that brings the
patient to the doctor or hospital is bleeding
d. Complete/ Total Placenta Previa
which is when hat placenta covers
entire of internal uterine ostium.
The etiology of placenta previa is
not known with certainty, but several risk
factors have been established as conditions
that are associated with the occurrence of
placenta previa. These risk factors include
old age pregnancy, multiparity, multiple
pregnancy, smoking during pregnancy,
male fetus, history of pregnancy abortion,
history of uterine surgery, history of
placenta previa in previous pregnancies
and IVF.[17, 19]
The pathogenesis of placenta previa is
unclear. Reduced vascularization or
atrophic changes in the decidua due to past
labor may not always lead to placenta
previa, because it is not clear that placenta
previa is present in the majority of patients
with high parity. Bleeding without reason
and without pain is the main and first
symptom of placenta previa. [1,10,13]
15 to 19 24 to 27 32 to 35
weeks weeks weeks
20 56 90
41 84 89
6 12 39
7 40 63
12 49 73
after 28 weeks of pregnancy or in late
pregnancy (third trimester), the peak
incidence is at 34 weeks of gestation. The
nature of the bleeding without a cause
(causeless), without pain (painless), and
recurrent.
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 Reski Wulandari Roni : Complete Placenta Previa at 39 Weeks Gestation on Multiparous
2. Physical Examination
A speculum examination may be
performed to assess the vagina and cervix.
Vaginal touchers should be avoided in all
women with antepartum haemorrhage until
it is diagnosed as non-placental previa
3. Additional Examination
Ultrasound Examination
a) Transvaginal ultrasound with an
accurate 100% identification of
placenta previa
b) Transabdominal ultrasound with
an accuracy of around 95%
MRI can be used to assist in the
identification of placenta accreta, increta,
and placenta perkreta.
The principal management of
placenta previa is must be carried out
immediately in all cases of antepartum
hemorrhage is to assess the condition of
the mother and fetus, perform appropriate
resuscitation if necessary, if there is fetal
distress and the baby is mature enough to
be born, it is necessary to consider
terminating the pregnancy and
administering anti-D immunoglobulin to
all mothers with negative rhesus.[9,10]
Management of mothers with
symptomatic placenta previa includes:
after being diagnosed, the mother is
advised to be hospitalized, blood
transfusions are available if needed
immediately, supporting facilities for
emergency cesarean section, delivery plans
at 38 weeks of pregnancy but if there are
indications before the time of delivery
determined, a cesarean section can be
performed at that time. [11,13]
The methode of delivery is
determined by the distance between the
placental edge and the internal uterine os
by transvaginal ultrasound examination at
35 weeks of gestation. If the distance is
>20 mm vaginal delivery is most likely
successful. If the distance between the
edge of the placenta and the internal
uterine ostium is 0-20 mm, a cesarean
section is likely to be performed, but
vaginal delivery can still be performed
depending on the clinical condition of the
patient. [18]
In placenta previa, bleeding may
continue after the placenta is delivered
from the implantation site because the
lower uterine segment cannot contract
properly. Bleeding can also occur from
cervical laseration, especially after manual
placentation due to placenta that is too
attached. [3]
Rosenberg et al stated that the
incidence of postpartum hemorrhage in
placenta previa was 1.4%, higher than not
placenta previa, which was 0.5%.
Hasegawa et al stated that postpartum
hemorrhage morbidity has a relative risk
of 1.86 for placenta previa.[5]
Post partum hemorrhage was defined
as the loss of 500 ml or more of blood
after vaginal delivery or 1000 ml or more
after cesarean section. Postpartum
hemorrhage can be caused by, first: uterine
atony. Uterine atony is the inability of the
uterus, especially the myometrium, to
contract after the placenta is delievered.
[12,13]
Post partum hemorrhage is
physiologically controlled by the
contraction of the myometrial fibers,
especially those around the blood vessels
that supply blood to the placental
attachment. Failure to contract and retract
the myometrial fibers can cause rapid and
severe bleeding and hypovolemic shock.
[10,14]
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 Reski Wulandari Roni : Complete Placenta Previa at 39 Weeks Gestation on Multiparous
Uterine atony is the most common
cause of post partum haemorrhage, up to
about 70% of cases. Atony can occur after
vaginal delivery, vaginal operative
delivery or abdominal delivery. Research
so far has shown that uterine atony is
higher in abdominal labor than in vaginal
delivery.[14]
Second: birth canal laceration.
Laseration of the birth canal are usually
the result of an episiotomy, spontaneous
laseration of the perineum, forceps trauma
or vacuum extraction, or due to the
extraction version.[12,13]
Third: placental retention. Placental
retention is the placenta that has not been
born until or beyond 30 minutes after the
baby is born. This is because the placenta
has not yet separated from the uterine wall
or the placenta has separated but not yet
been born. Placental retention is the third
most common etiology of postpartum
hemorrhage (20% - 30% of cases).[12,13]
The management of a patient with post
partum haemorrhage has two main
components, resuscitation and
management of obstetric hemorrhage that
may be accompanied by hypovolemic
shock and identification and management
of the cause of the bleeding. The
successful management of postpartum
hemorrhage requires that both components
be managed simultaneously and
systematically .[15,16]
The use of uterotonics (oxytocin alone
as the first choice) plays a central role in
the management of postpartum
hemorrhage. Uterine massage is
recommended immediately after diagnosis
and resuscitation of isotonic crystalloid
fluids is also recommended. The use of
tranexamic acid is recommended in cases
of bleeding that is difficult to treat or
bleeding remains associated with trauma.
If there is persistent bleeding and the
source of the bleeding is known, uterine
artery embolization should be considered.
[15,16]
In pregnancies with placenta previa, it
should be noted that rebleeding is usually
more frequent. Blood transfusion should
be given immediately if there are
symptoms of hypovolemia shock due to
massive bleeding even though the clinical
appearance is good.[10] Bhatt et al found
64.7% of mothers with placenta previa
required blood transfusion.[1]
Conclusion
Post partum and antepartum
hemorrhage is the most frequent
occurrence and causes the death of the
mother the most. Early diagnosis is very
important in order to prevent excessive
bleeding during labor. Proper management
of placenta previa and postpartum
hemorrhage is a very important thing for
the safety of both mother and child.
Acknowledgements
The author would like to thank the mentor
dr. Ferri Waluyo Wiwoho Pujojati
Obstetrician Gynecologist for his direction
and guidance in this paper.
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