Supervisor: Dr Rahmah Presenter: Shikin Ng Bi Yoke Ang Xin Xuan Foo Jen Chun Syed Iqbal

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

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 babys head or breech as the case may be is delivered.

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

signs: normal

Vital Abdominal

exam: viable single fetus

Transverse No

lie

contraction

Abdomen

soft and non tender

What is the most likely diagnosis and give reasons. (5 marks)

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

 Multiparity Maternal age

>35 (2-3X higher risk if over 35 years old) Increased surface area (multiple pregnancy) Uterine scar Smoking Previous dilatation and curettage Previous placenta previa

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

1. 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

Abruptio Placenta

Bleeding from genital tract due to premature separation of the normally sited placenta Associated with pain, frequent uterine contraction; restlessness, pallor, cold and clammy extremities; tense and tender abdomen (woody hard); difficulty palpating fetal parts; PIH; DIVC An aberrrant feto placenta vessel running in the membrane Rupture of vasa can occur in labour or with PPROM vaginal bleeding Fetal distress, acute fetal exsanguination and death

Vasa Previa

Circumvallate Placenta

Membrane appear to be attach internally to the placenta edge Associated with antepartum and postpartum haemorrhage Definite diagnosis is made by placental examination post delivery

Bleeding from Succenturiate Lobe

the The placenta is partly or completely divided into 2 or more lobes Associated with antepartum and postpartum haemorrhage Definite diagnosis is made by placental examination post delivery Bleeding due to marginal separation of a normally sited placenta leading to a reduced functional reserved Painless per vaginal bleeding No abruption or local lesion Diagnosis of exclusion

Indeterminate Bleeding

Local Genital Tract Can be detected by speculum examination Lesions and Pap smear (cervical polyp, cervicitis, cervical carcinoma, vaginal trauma or vaginitis)

Name three (3) investigations that you would order. (3 marks)

TRANSVAGINAL 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.

To rule out fetal distress Usually normal in placenta previa, abnormal in abruptio placenta

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.

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.

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

Risk Factor of 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;66:8992. 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;107:122632.

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.
Obstet Gynecol 1997;177:21014.
Miller DA, Chollet JA,Goodwin TM.Clinical risk factors for placenta praeviaplacenta accreta. Am J Gielchinsky Y, Rojansky N, Fasouliotis SJ, Ezra Y. Placenta accreta: summary of 10 years: a survey of 310 cases. Placenta 2002;23:21014.

Placenta accreta is a significant condition with high potential for hysterectomy, and a maternal death rate reported at 7%
OBrien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol 1996;75:16328.

How would you manage her now?

(10m)

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.

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

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.

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

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

Vital signs Pad chart Speculum examination Basic investigations Optimize haemoglobin level

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

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.

What is your plan for her delivery?

(2m)

Indication - Major placenta previa - 2 previous scars Timing: Term

Other issues - transverse lie - anterior placenta previa - placenta accreta/increta/percreta

Kronig or De Lee

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

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;84:72530.

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.

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

(3 marks)

(kulen,3rd edition)

(10 marks)

At 36 weeks-profuse bleeding Emergency Caesarean Section Healthy female baby with BW of 2.5kg Adherent placenta ,required further surgical intervention

Question 9

What 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

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

Accreta

Increta

Percreta

Increta (17%)

Accreta (75-78%)

Percreta (5%)

Partial

Difficult to deliver the placenta results in PPH

Total

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

Anterior PP in patient with previous CS (40% risk) Underdeveloped/absent of decidua basalis which permits villous invasion of the myometrium Female fetus

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

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

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

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 serosabladder interface

Doppler ultrasonography turbulent blood flow through the lacunae

Sensitivity of 82.4%

Specificity of 96.8%

Reference: Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta praevia accreta by transabdominal color Doppler ultrasound. Ultrasound Obstet Gynecol

2000;15:2835.

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

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

Obstetrician

Anesthesiologist
Hematologist and Blood bank Neonatology Radiologist Urologist

Conservative To preserve fertility (usually w/o haemorrhage)

1) Leaving the placenta in situ and give methotrexate

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

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

1. Catanzarite et al.: Contemporary OB/GYN 1996 2. 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

Intraoperatively, experienced torrential bleeding Blood transfusion and maximum inotropic supports

Hypotension

Irreversible cardiac arrest

Puan X Teacher 40

Post Partum Haemorrhage

Puan X Teacher 40

Post Partum Haemorrhage Placenta Accreta

Puan X Teacher 40

Post Partum Haemorrhage Placenta Accreta Placenta Previa 16 weeks

Puan X Teacher 40

Post Partum Haemorrhage Placenta Accreta Placenta Previa 2 Previous Scars 16 weeks

Grandmulltipara