APH: PLACENTA PREVIA

PRESENTER- DR.SHIVANGI & DR.ANSHUL

MODERATOR- DR.KAVITA AGGARWAL
ANTEPARTUM HEMORRHAGE
 It is defined as bleeding from or into the genital tract from
24 weeks till birth of the baby.

 Causes:
1. Placenta Previa – 31%
2. Abruptio placentae – 22%
3. Unclassified – 47%
PLACENTA PREVIA

 Placenta previa describes a placenta

that is implanted somewhere in the
LUS, either over or very near the
internal cervical os.

 As per recent workshop of AIUM, for

pregnancies greater than 16 weeks of
gestation, the placenta should be
reported as low lying when the placental
edge is less than 20mm from the internal
os or placenta previa if completely
covering the os.
INCIDENCE

 Incidence average 0.3% or 1 case per 300 to 400 deliveries.

Williams 25th edition

RISK FACTORS

DEMOGRAPHIC FACTORS CLINICAL FACTORS

 Maternal age.  Cesarean delivery

 Multiparity  ART
 Cigarette smoking  Multifetal gestation.
 Uterine leiomyomas.  Maternal serum alpha
fetoprotein
CLINICAL FEATURES

SYMPTOMS SIGNS

 Painless bleeding  Tachycardia

 Recurrent Bleeding  Hypotension
 Shock
CLASSIFICATION:
 OLD CLASSIFICATION
i) Grade I or minor placenta previa
ii) Grade II or marginal placenta previa
iii) Grade III or partial previa
iv) Grade IV or complete previa

 Grades I and II -minor placenta previa

 Grades III and IV - major placenta previa.

NEW CLASSIFICATION:
 National Institutes of Health (NIH) recommends following
classification-
i) Placenta Previa: the internal os is covered partially or
completely by placenta.
ii) Low Lying Placenta: implantation in the lower uterine
segment is such that the placental edge does not cover the internal
os but lies within a 2cm wide perimeter around the os.
PLACENTAL MIGRATION
 It is the apparent movement of placenta away from the internal
os.
 Occurs due to differential growth of upper and lower uterine
segments as pregnancy progresses.
 With greater upper uterine blood flow, placental growth occurs
more towards the fundus known as – trophotropism.
 Factors affecting placental migration:
- previous caesarean delivery
- placenta previa
Case 1:
• Patient X w/o Y, 30yrs of age, G3P2L2 32 weeks of
pregnancy presented to GRR at 3am on 4/12/20 with chief
complaints of bleeding per vaginum.
- single episode.
- mild, with soakage of 1 pad and no H/O passage
of clots.
- bright red in color.
• Was not associated with pain in abdomen or leaking per
vaginum.
• Fetal movement- adequate.
• No h/o any trauma, fall, intercourse, heavy weight lifting.
• No h/o similar episodes in past.
• No h/o headache, blurring of vision, edema of legs
• Obstetric History: married for 5yrs, non-consanguineous
marriage.
P1- 4yrs back/ Term Cesarean i.v.o NPOL/ No H/O any post
op complication.
P2- 2yrs back/ Term cesarean i.v.o Prev LSCS/ No H/O any
post op complication
G3- Present Pregnancy.

• Menstrual History:
LMP- 22/4/20
EDD- 29/1/21, cycles were regular, normal flow.

• 1st and 2nd trimester uneventful

• No significant past history or family history.
• No h/o any bleeding or clotting disorders.
• Personal history: education : 10th passed
- homemaker by profession
- normal bowel and bladder habits.
- no h/o any addiction/smoking/drug abuse
• EXAMINATION: GPE
- conscious, well oriented to time place and person
- sitting comfortably.
- general condition stable.
- afebrile to touch.
- BP 130/80 mmHg in sitting position in right brachial artery, PR
90/min in radial artery; regular in rate, rhythm, character, normovolumic,
no radio-radial or radiofemoral delay.
- RR-18/min thoracoabdominal.
- No pallor, Icterus, pedal edema
• Systemic Examination:
CVS/CNS/RESPI Examination: NAD
• Obstetric Examination:

1) Inspection:
- abdomen distended, all quadrants moving equally with
respiration.
- umbilicus flat and central.
- linea nigra and few striae gravidarum present.
- pfanneinsteil scar present. No sinus, fistula, dilated veins
present. No visible pulsations.
- all the hernial sites are free.
2) Palpation:
- local temperature normal.
- fundal height corresponds to 32 weeks.
- SFH 32cm, abdominal girth 34 inches.
- Fundal grip: smooth, hard, globular, ballotable mass s/o head
- Lateral grip: smooth curved part s/o back present on left side and irregular knob
like structure s/o limbs present on right side.
- Pelvic grip: braod, soft, irregular, non ballotable mass s/o breech
- uterus : relaxed, non-tense, non-tender.
- No scar tenderness. Uterine contour maintained.
- liquor appears to be normal clinically.
- No organomegaly.
3) Auscultation:
Fetal heart rate of 138bpm, regular auscultated on left side
near the umbilicus.

4) Local examination: external genitalia appears normal, no

active bleeding present but genitals stained with blood.

5) Per vaginum examination: contra indicated in case of APH

unless placenta previa is ruled out.
DIAGNOSIS:

A 30yr old, G3P2L2 at 32 weeks gestation with

single live intrauterine fetus in breech presentation
with previous 2 LSCS with APH with placenta
previa with placenta accreta
INVESTIGATIONS

1. Complete hemogram.
2. Blood grouping.
3. Bleeding time, Clotting time.
4. Coagulation profile.
5. LFT/KFT/SE
 DIAGNOSIS

Double Set Up Examination

• done only when sonography is not readily available

• A gentle per speculum examination is done to exclude local causes of bleeding
in cervix and vagina.
• Vaginal examination is carefully done, first through the fornices and if no
bogginess is felt, then finger is introduced through the os to feel for placenta.
• It should not be performed unless delivery is planned. A cervical digital
examination is done with the woman in an operating room and with
preparations for immediate cesarean delivery. Even the gentlest examination
can cause torrential hemorrhage.
Transabdominal Scan (TAS)
• If the placenta clearly overlies the cervix or if it lies away from the lower
uterine segment, the examination has excellent sensitivity and negative-
predictive value.

• Also, a full bladder may artificially elongate the cervix and compress the
lower uterine segment to give the impression that the placenta overlies the
cervix.

Translabial/Transperineal Scan
• is an alternative technique that provides excellent images of cervix and
placenta. The use of three dimensional ultrasound may also prove
accuracy
Transvaginal scan (TVS)
• most accurate method of assessment.
• superior to transabdominal and transperineal approaches.
• It is safe, even when there is bleeding.
• TVS is recommended at 36 weeks of gestation in cases with persistent low lying or
placenta previa at 32 weeks of gestation and are asymptomatic, to confirm about mode
of delivery.
• It is also recommended for cervical length measurement, which may facilitate
management decisions in asymptomatic patients.
• A short cervical length on TVS
(less than 25mm) before 34 weeks
gestation, increases risk for preterm
emergency delivery and massive
hemorrhage at cesarean section
MR Imaging
• Using MR imaging, several investigators have reported excellent results
in visualizing placental abnormalities. MR imaging has proved useful for
evaluation of morbidly adherent placenta.

Maternal serum alpha fetoprotein levels (MSAFP)

• > 2.0 multiple of medians(MoM) at 16 weeks gestation shows greater risk
for previa and late pregnancy bleeding and pre-term birth.
PREDICTORS OF BLEEDING IN PLACENTA PREVIA:

i. Placenta covering os.

ii. Placental edge within 1 cm of internal os
iii. Echo free space in placental edge.
iv. Cervical length before 34 weeks < 3 cms – risk of preterm
emergency delivery and massive hemorrhage.
 MANAGEMENT

Depends on-
 based on their individual clinical circumstances.
 fetal age and maturity,
 If patient is in labor, and
 bleeding severity.
 Morbidly adhered placenta
 MANAGEMENT
ALL APH PATIENTS ARE TO BE ADMITTED
 General and abdominal examination
 Clinical assessment of blood loss
 Hb%, hematocrit, ABO and Rh grouping
 Resuscitation, if necessary ( i.v infusion,
transfusion using wide bore cannula
 Localisation of placenta on USG

Expectant Active Interference

management  Bleeding profusely
 No active bleeding
 Pregnancy less than 36  Pregnancy more than
weeks 37 weeks
 Pt hemodynamically  Patient in labor
 FHS – absent
stable
 CTG - reactive  Gross fetal
36weeks malformations
 Steroid therapy: if < 34
wks

Ultrasonographic
evidence
 ULTRASONOGRAPHIC
EVIDENCE

PLACENTA PREVIA LOW LYING PLACENTA

CESAREAN
DELIVERY
 Role of antenatal Corticosteroid Therapy

 A single course of antenatal corticosteroid therapy is

recommended between 34 to 35+6 weeks of gestation for
pregnant women with a low lying placenta or placenta previa.

 It is also recommended prior to 34 weeks of gestation in

women at higher risk of preterm birth.
Role Of Tocolytics

 Tocolysis for women presenting with symptomatic placenta previa or

a low lying placenta may be considered for 48hrs to facilitate
administration of antenatal corticosteroids.

 But, if delivery is indicated based on maternal or fetal concerns,

tocolysis should not be used in an attempt to prolong gestation.
When to plan termination of pregnancy?

 Regardless of POG: If patient presents in shock with bleeding profusely after

arranging adequate blood products.

 36 weeks POG: For women presenting with uncomplicated placenta praevia,

delivery should be considered between 36 weeks of gestation as the risk of
major hemorrhage increases rapidly after 36 weeks of gestation.

(RCOG – 2018)
Pre-requisites for termination
 Basic investigations
 Consent
 Blood or blood products to be arranged

 Delivery should be arranged in a maternity unit with on-site blood

transfusion services and access to critical care.

 For elective caesarean section, a senior obstetrician and senior

anaesthetist should be present within the delivery or theatre suite
where the surgery is occurring.
 Anesthesia: Regional anaesthesia is considered safe and is associated with
lower risks of haemorrhage than general anaesthesia for caesarean delivery in
women with placenta praevia or a low-lying placenta.
 SURGICAL APPROACH

 Vertical laparotomy incision to provide rapid entry in cases with torrential bleeding or
operating space if hysterectomy is required.

 If the placenta is transected during the uterine incision, immediately clamp the
umbilical cord after fetal delivery to avoid excessive fetal blood loss.

 Following placental removal, the placenta site may bleed uncontrollably due to poorly
contracted smooth muscle, which is characteristic of the lower uterine segment.

 If hemostasis at the placental implantation site cannot be obtained by adequate

uterotonic administration and pressure, it can be oversewn with 0-chromic sutures .
 If pharmacological measures fail to control haemorrhage, initiate intrauterine
tamponade and/ or surgical haemostatic techniques sooner rather than later. (Stepwise
devascularization).

 Early recourse to hysterectomy is recommended if conservative medical and surgical

interventions prove ineffective.

 Intraoperative interventional radiological techniques, including transarterial

embolization and temporary balloon occlusion of the internal iliac arteries.
MATERNAL AND FETAL MORBIDITY IN PP

MATERNAL:
i. Placenta Accreta
ii. Malpresentation: often associated fetal malpresentation (transverse
or breech presentation) requiring complex intraoperative
manoeuvres to deliver the baby.
iii. PPH
iv. Risks of multiple BT, Obs Hysterectomy, ICU admission.
v. Amniotic fluid embolism
FETAL:

i. Vasa previa and velamentous cord insertion.

ii. Preterm birth- 5 fold increased risk.
iii. PPROM
iv. Fetal growth restriction
v. Sudden IUD
vi. Fetal anemia
VASA PREVIA
 It occurs when the fetal vessels run through the free placental
membranes.

 Unprotected by placental tissue or Wharton`s jelly of the umbilical

cord, vasa previa is likely to rupture –
i) in active labor
ii) during amniotomy
iii) when located near or over cervix
iv) under the fetal presenting part

 It is uncommon, prevalence ranging between 1 in 1200 and 1 in 5000.

 Mortality rate- 60%

CLASSIFICATION:

Type 1 – when the vessel is connected to a velamentous umbilical

cord.
Type 2 – when it connects the placenta with a succenturiate or
accessory lobe.
DIAGNOSIS

1. During early labor by vaginal examination, detecting pulsating fetal vessels

inside the internal os.

2. Presence of dark red vaginal bleeding.

3. Acute fetal compromise after spontaneous or artificial rupture of placental

membranes.
MANAGEMENT

1. APT TEST – performed on vaginal blood if vasa previa is suspected

and the blood is suspected to be fetal in origin.
Method : Mix blood specimen with 3-5ml of tap water and
centrifuge. Supernatant must have pink color to proceed. To 5 parts of
supernatant, add 1 part of 0.25 N(1%) NaOH.
Interpretation : a pink color persisting over 2 minutes indicates fetal
hemoglobin.
Adult hemoglobin gives a pink color that becomes yellowish brown
in 2 minutes or less indicating denaturation of the adult hemoglobin.

2. TREATMENT: urgent cesarean section.

Placenta accreta
spectrum
 Etiopathogenesis
 The term morbidly adherent placenta used interchangeably with accreta
syndrome is characterised by abnormally implanted , invasive or adhered
placenta
 Abnormal placental adherence stems in from
I. partial or total absence of the Decius basalis
II. Imperfect development of nitabuch layer(zone of fibrinoid degeneration in
which trophoblast meet the basalis layer)
III. Microscopically,placental villi attach to smooth muscle fibre rather than to
decidedly cells and this decidual deficiency prevent normal separation of
placenta post delivery.
 Abnormal vascularisation
 Defect of trophoblastic function.
Most favoured hypothesis

 Defect of the endometrial myometrial interface leads to a

failure of normal decidualisation in the area of uterine
scar,which allows abnormally deep placental anchoring villi
and trophoblast infiltration
 ACOG 2018
Incidence and
classification
 Frequency of placenta accreta has increased over the years with
incidence being 1in 2500 births in 1980s to 1 per 272 births in
2016 owing to oncreasing trend in Caesarean section .
 Variants of placenta accreta are classified as per the depth of
trophoblastic growth.
 Placenta accreta – villi are attached to the myometrium.
 Placenta increta- villi invade the myometrium.
 Placenta percreta- villi penetrate through the myometrium to or
through the Serosa
 These three are encountered in a ratio of 80: 15:5

 Williams 25th edition and ACOG 2018.

 Risk factors

 Previous cesarean delivery- most common, incidence increases from 0.3% in women with one
previous Caesarean section to 6.74% for women with 5or more Caesarean section.
 Placenta Previa
 Placenta previa and previous Caesarean section
 Maternal age>35
 Prior uterinesurgeries
 Endometrial curettage
 Endometrial ablation
 Ashermann syndrome
 Previous history of placenta accreta(20%)
Biochemical markers

 MSAFP >2.5 mom has eight fold higher risk of accreta

 Maternal serum free beta hcg levels >2.5 mom has four fold higher
risk
 Elevated first trimester PAPP-A
 Myometrial fibres in the basal plate seen in antecedent pregnancies

 Williams 25th edition and FIGO consensus guidelines 2018.

  A symptomatic ,incidental finding
 Antenatal bleeding

Clinical  Profuse life threatening

haemorrhage at the time of
presentation attempted manual placental
separation
 Haematuria in case of bladder
invasion
USG
 Sonography is mostly used for antenatal diagnosis of accreta
 Rarely , cesarean scar pregnancy can be diagnosed in first trimester-gestational sac embedded in th
uterine window at the site of previous scar, gestational sac located in the lower uterine segment alo
with the presence of multiple irregular vascular spaces within the placental bed.
 Mostly diagnosed in second and third trimester
 Loss of normal hypoechoic retroplacental zone,
 Numerous vascular lacunae
 Placenta bulging into the bladder wall
 Myometrium below the placenta less than 1mm.
 Usg has sensitivity of 77%, specificity of 96%, ppv of 98%,sensitivity drops to 50% for posterior loat
located placenta
COLOR DOPPLER
 Colour Doppler along with usg can also be used for diagnosing accreta
 Hypervascularity seen in the placental bed
 Vessels bridging the placenta to the uterine margin sometimes beyond the serosa to the
bladder.
 Turbulent lacunae flow is the most common finding
 Although usg evaluation is important but absence of usg finding doesn’t rule out accreta
and clinical risk factors are equally important
 Hypervascularity seen between myometrium and posterior wall of bladder
 MRI
 MRI can provide information regarding posterior placenta previa and assess the depth of
invasion in suspected percreta like extension to bladder and parametrium.
 Features found on MRI include:-
o Dark intraplacental band on T2 weighted imaging
o Abnormal bulging of the placenta or uterus
o Abnormal or disorganised blood vessels
o Sensitivity is 94.4% and specificity is 84%
Maternal complications

 Primarily due to massive haemorrhage

 Leading cause of emergency hysterectomy
 Maternal morbidity 60%
 Maternal mortality 7%
 Perinatal complications mainly due to preterm births.
 Cystotomy(15.4%)
 Ureteral injuries(2.1%)
 Pulmonary embolism(2.1%)
 ICU (26.6%)
 Endometritis(3.5%)
Timing of delivery

 Timing of delivery should be planned at 35 weeks week for scheduled

cesarean delivery or hysterectomy without necessary amniocentesis
for fetal lung maturity.
 Waiting beyond 36 week is not recommended because one half of the
patient will require emergent delivery for hemorrhage.

 Delivery of patients with prenatally diagnosed PAS should be done in

a specialised center with multidisciplinary team, with NICU and ICU.
 Criteria for consideration of delivery in
accreta center of excellence
 Suspicion of placenta accreta on sonogram
 Placenta previa with abnormal ultrasound appearance
 Placenta previa with >3 prior cesarean deliveries
 History of classical cesarean delivery and anterior placentation
 History of endometrial ablation or pelvic irradiation
 Inability to adequately evaluate or exclude findings suspicious for
placenta accreta in women with risk factors for accreta
Suggested criteria for accreta center of
excellence

 Multi disciplinary team with experienced maternal fetal medicine

physician or obstetrician,imaging experts, interventional radiologist,
urologist, general surgeon, neonatologist,urologist
 ICU and neonatal ICU
 Blood services for massive blood transfusion ,cell salvage and
perfusionist.
Pre op preparation

 Build up Hb
 Proper consent
 Discussion of possible intervention
 Adequate blood arrangement
 Multi disciplinary team
Pre op prophylactic cathetrisation
 If accreta involves one or both ureter,cathetrisation may aid in dissection or identification or
may aid in injury.
 Balloon tipped intra arterial catheter to mitigate blood loss and thereby enhance surgical
visibility
 It can also be used to deliver emboli to bleeding arterial site.
 ACOG doesn’t recommend for intraarterial cathetrisation.
 Hysterectomy for suspected placenta
accreta
 Patient placed in lithotomy position and usually a vertical midline incision is given
 Cystoscopy with placement of retrograde ureteral stents can be considered
 After entry into the abdomen uterus should be visually inspected to confirm placental invasion into
adjacent organs.
 Usg can be done before surgery or intra op for placental localisation to assess the site of
hystrotomy incision.
 Classical or transverse fundal incision is made to avoid placenta.
 After fetal delivery extent of placental invasion is assessed without attempts at manual removal
of placenta. Attempt are associated with twice as much blood loss.
 Hysterotomy site is closed without disruption of placenta and placenta left in situ.
 Retropertoneal spaces are opened,Utero ovarian ligaments are divided and cardinal ligament is
dissected to the uterine arteries.
 Vesicouterine peritoneum is opened and the bladder is mobilised away from uterus.
 Uterine arteries are divided and vascular channels to the uterus secured.the uterus is placed on tractio
and dissection continued below placenta.if necessary, the fundus and placenta can be amputated to
facilitate visualisation. And completion of hysterectomy.
 Cervix and remainder of the lower uterine segment are removed,then vaginal cuff is closed.
 Topical hemostatic agents may be applied to the surgical bed as needed.
Delayed interval hysterectomy

 Placenta percreta
 To decrease blood loss
 To decrease tissue damage
 Conservative management
 Indications
 for women who desire future fertility
 For mainly placenta percreta when suspected morbidity is high
 In this case the placenta is left in situ , only feasible when there is no bleeding and placent
not disrupted.placental embolisation can be preferred for less bleeding and early resorptio
 Average time for placental resorption is 6month., complications include bleeding,
endomyometritis, sepsis and coagulopathy
 Follow up with serum beta hcg, usg and MRI.
 Patient may have recurrent placenta accreta in next pregnancy (22-29%)
 Role of methotrexate hasn’t been proven in conservative management
 One step procedure

 Enbloc resection of placenta with the uterine wall

 Uterine reconstruction
 Sometimes placenta can be removed hysteroscopically.
 Not suitable for patient with extensive lateral or cervical invasion
 Reasonable in patients with clearly delineated ,focal area of involvement
Triple p procedure

 Pre op placental localisation

 Pelvic devascularisation
 Placenta removal enbloc with myometrial excision and uterine repair
Interventional radiology

 Aim is mainly to reduce intra op haemorrhage

 Intra operative internal ilia artery or uterine artery embolisation
 Internal iliac artery, common iliac or abdominal aorta balloon
occlusion.
 Complications-thrombosis, ischemic injury to femoral nerve.
THANK YOU
INVESTIGATIONS
• All antenatal investigations were within normal limit
except USG at 20 weeks which revealed placenta
previa.
• All routine investigations were sent in emergency lab
and patient was sent for USG.
• CBC - 10.4/15.2/1.38 lakhs.
coag- 10.4/ 21.1/0.89
LFT- 1.0/0.2/ 33/ 23/ 161
KFT- 21/0.4
SE- 135/ 3.8
• USG: SLIUF, breech, FL=32 wks, liquor- adequate
placenta- anterior, completely covering
os(placenta previa) with multiple placental lakes with
turbulent flow, non visualisation of myometrium near
internal os. Retroplacental hypoechoic zone thinned out.