Placenta previa is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix.It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum haemorrhage (vaginal bleeding). It affects approximately 0.5% of all labours.
PHYSIOLOGY.
Placenta praevia is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection.In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a normal pregnancy the placenta does not overlie it, so there is no bleeding. If the placenta does overlie the lower segment, as is the case with placenta praevia, it may shear off and a small section may bleed.
RISK FACTORS.
The following have been identified as risk factors for placenta praevia:
-Previous placenta previa, caesarean delivery,or D&C e.g. used for incomplete or missed miscarriage, abortion, to treat or investigate heavy bleeding or other diagnostic purposes.
-Alcohol use during pregnancy.
-Women who have had previous pregnancies, especially a large number of closely spaced pregnancies, are at higher risk.
-Smoking during pregnancy; cocaine use during pregnancy.
-Women who are younger than 20 are at higher risk and women older than 30 are at increasing risk as they get older.
-Women with a large placentae from twins or erythroblastosis are at higher risk.
-Race is a controversial risk factor, with some studies finding that people from Asia and Africa are at higher risk and others finding no difference.
-Placenta previa is itself a risk factor of placenta accreta.
SYMPTOMS
The main symptom of placenta previa is sudden bleeding from the vagina. Some women have cramps, too. The bleeding often starts near the end of the second trimester or beginning of the third trimester.Bleeding may be severe. It may stop on its own but can start again days or weeks later.Labor sometimes starts within several days of heavy bleeding. Sometimes, bleeding may not occur until after labor starts.
DIAGNOSIS
Women with placenta previa often present with painless, bright red vaginal bleeding. This bleeding often starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation. Abdominal examination usually finds the uterus non-tender and relaxed. Leopold's Maneuvers may find the fetus in an oblique or breech position or lying transverse as a result of the abnormal position of the placenta. Praevia can be confirmed with an ultrasound. In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with an examination in the surgical theatre.
The proper timing of an examination in theatre is important. If the woman is not bleeding severely she can be managed non-operatively until the 36th week. By this time the baby's chance of survival is as good as at full term.
Placenta previa is classified according to the placement of the placenta:
Type I or low lying: The placenta encroaches the lower segment of the uterus but does not infringe on the cervical os.
Type II or marginal: The placenta touches, but does not cover, the top of the cervix.
Type III or partial: The placenta partially covers the top of the cervix
Type IV or complete: The placenta completely covers the top of the cervix
INTERVENTION.
An initial assessment to determine the status of the mother and fetus is required. Although mothers used to be treated in the hospital from the first bleeding episode until birth, it is now considered safe to treat placenta praevia on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the fetus are in distress. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary.
There is debate as to whether vaginal delivery or delivery by Caesarean section is the safest method. In cases of fetal distress a Caesarean section is indicated. Caesarian section is contraindicated in cases of disseminated intravascular coagulation.
Placenta praevia increases the risk of puerperal sepsis and postpartum haemorrhage because the lower segment to which the placenta was attached contracts less well post-delivery.
PROGNOSIS
The biggest risk is severe bleeding that can be life threatening to the mother and baby. If you have severe bleeding, you baby may need to be delivered early, before major organs, such as the lungs, have developed.
