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Antepartum Hemorrhage e.c. Placenta Previa (DDx (Vasa Previa, Cervical or…
Antepartum Hemorrhage e.c. Placenta Previa
Definition
An obstetric complication that classically presents as painless vaginal bleeding in the third trimester secondary to an abnormal placentation near or covering the internal cervical os.
Types of Placenta Previa
Complete
complete coverage of the cervical os by the placenta
Marginal
the leading edge of the placenta is less than 2 cm from the internal os, but not fully covering
Pathophysiology
Etiology
Advancing maternal age (>35 years old)
Infertility Treatment
Multiparity
Multiple Gestation
Short interpregnancy interval
Previous uterine surgery, uterine insult or injury
Previous cesarean delivery
Previous or recurrent abortions
Previous placenta previa
Nonwhite ethnicity
Low social economic status
Smoking
Cocaine use
Complications
Maternal
Hemorrhage, including rebleeding
Placenta accrete, increta, and percreta
Higher rates of blood transfusion
Placental abruption
Preterm delivery
Increased incidence of postpartum endometritis
Mortality rate
Fetal
Congenital Malformations
Fetal Intrauterine Growth Retardation (IUGR)
Fetal anemia and Rh isoimmunization
Abnormal fetal presentation
Low birth weight (<2500 gr)
Neonatal Respiratory Distress Syndrome
Jaundice
Admission to the Neonatal Intensive Care Unit (NICU)
Longer Hospital Stay
Increased risk for infant neurodevelopment delay and Sudden Infant Death Syndrome
Neonatal Mortality Rate increases
Clinical Presentations
History
Painless, bright red vaginal bleeding that often stops spontaneously and then recurs with labor
Vaginal bleeding is most likely to occur in the third trimester
Placenta previa often leads to preterm delivery
Physical Examination
Speculum examination
Profuse hemmorhage
Hypotension
Tachycardia
Soft and nontender uterus
Normal fetal heart tones (usually)
DDx
Vasa Previa
Cervical or Vaginal laceration
Vaginal sidewall laceration
Miscarriage (spontaneous abortion)
Infection
Vaginal Bleeding
Lower Genital Tract Lesions
Bloody show
Abruptio placenta
Cervicitis
Disseminated Intravascular Coagulation
Pregnancy, Delivery
Premature Rupture of Membranes
Preterm Labor
Uterine Rupture in Pregnancy
Vaginitis
Vulvovaginitis
Workup
Laboratory Studies
Rh compatibility test
Levels of fibrin split products
Prothrombin Time (PT)/Activated Partial Thromboplastin Time (APTT)
Blood type and cross
Complete Blood Cell Count
Amniocentesis and fetal maturity testing
Kleihauer-Betke test
Fetal-Maternal Transfusion
Ultrasonography
Transvaginal USG
Transabdominal USG
Transperineal / Translabial USG
MRI
Management
Hospitalization
Tocolytics
Considering mode of Delivery
Surgical Intervention
Controlling blood loss
B-Lynch or parallel vertical compression sutures
Uterine artery ligation (O' Leary Stitch)
Hypogastric artery ligation
Hysterectomy
Consultations
Medications
Tocolytics
Prevent preterm labor and contractions
Magnesium Sulfate
Corticosteroids
Dexamethasone acetate (Baycadron)
Betamethasone (Celestone)
Adrenergic Agonists
Sympathomimetic Vasopressor activity
Terbutaline (Brethine)
