Presentation on theme: "Associate Professor Iolanda Elena Blidaru Md, PhD."— Presentation transcript:
1 Associate Professor Iolanda Elena Blidaru Md, PhD. PLACENTA PRAEVIAAssociate ProfessorIolanda Elena BlidaruMd, PhD.
2 PLACENTA PRAEVIA Definition Placenta praevia = placental insertion over or very near the internal os of the cervix (in the lower uterine segment including the zone of effacement and dilatation).obstacle in front of the presenting partthe most frequent cause of third trimester bleeding
8 PLACENTA PRAEVIAThis classification is made on the basis of findings at the initial examination and may change in labor or as pregnancy advances.
9 PLACENTA PRAEVIA Incidence 0.5% -1% of all births US of early pregnancies - a large number of low-lying pregnancies subsequently aborted."placental migration" (US evaluation) → as pregnancy advances, the lower uterine segment lengthens and the placenta is drawn upward with the enlarging uterus.
11 PLACENTA PRAEVIA Etiology inflammatory or atrophic changes of the endometrium (endometritis, hypoplasia, submucous myomas, trauma) → defective decidual vascularizationtwin pregnancy, with large placental bedincreased surface of the placenta implanted in the lower uterine segment (tissues → unappropriate for nidation)
12 PLACENTA PRAEVIA Pathogenesis painless bleeding → maternal blood + fetal blood (a little part).Mechanisms:separation of the placenta from its implantation siteformation of the lower uterine segmenteffacement and dilatation of the cervix in laborrupture of the venous lake in the decidua basalis
13 Associated conditions PLACENTA PRAEVIAAssociated conditionsplacenta accreta → abnormally firm adherence to the uterine wallplacenta increta → placental villi invade the myometriumplacenta percreta → placental villi penetrate through the myometrium
14 PLACENTA PRAEVIA Clinical findings painless bleeding (maternal origin) slight or profuse hemorrhagethe blood is bright redpostpartal excessive hemorrhage →abnormal adherence,excessively large area of attachement,the poorly contracted lower uterine segment,lacerations in the cervix and lower segment.
15 PLACENTA PRAEVIA Diagnosis abdominal examination: abnormal fetal presentation (transverse lie, breech presentation), the presenting part is high above the inlet and deviated anteriorly or laterallyFHR - normalIf cervical os dilated → cautious inspectiondigital examination is never permitted unless at term pregnancy, in an operating room with all the preparations for immediate cesarean section; the examination can cause life-threatening hemorrhage.
16 PLACENTA PRAEVIA Diagnosis Sonography transabdominal US (96% accuracy) transvaginal UStransperineal US
17 Differential diagnosis PLACENTA PRAEVIADifferential diagnosisCervical bleeding → benign / malignant lesionsEndouterine bleeding:premature separation of the normally implanted placenta,rupture of umbilical cord vessels,premature labor.
18 Practically all women do need cesarean section. PLACENTA PRAEVIADELIVERY MODEPractically all women do need cesarean section.
19 CONDUCT AT THE DELIVERY PLACENTA PRAEVIACONDUCT AT THE DELIVERYSeveral clinical situations:1. The patient is in labor → cesarean section2. The fetus is mature and the bleeding does not stop → cesarean section3. The fetus is preterm and there is no indication for delivery → observe4. The bleeding is so severe, despite the fetus immaturity → cesarean section5. Total placenta praevia with dead fetus → cesarean section (the bleeding cannot be controlled).
20 CONDUCT AT THE DELIVERY PLACENTA PRAEVIACONDUCT AT THE DELIVERYIf placenta praevia + accreta, other methods of hemostasis:oversewing the implantation sitebilateral uterine / inernal iliac artery ligationpacking the lower uterine segment with gauzetotal abdominal hysterectomy.
21 CONDUCT AT THE DELIVERY PLACENTA PRAEVIACONDUCT AT THE DELIVERYVaginal delivery may be possible in:a multipara with a soft, effaced and partially dilated cervix + a minor degree of anterior placenta praevia + ruptured membranesif the fetus is dead, the cervix is soft and effaced, only an edge of placenta can be felt and bleeding is minimalbefore the 28th week, when the baby has little chance of surviving