Obstetrical Hemorrhage: PPH Hale T., O & G Resident,

Mekelle University, College of Health Sciences, Dep't of OB-GYN

May 26, 2016

• Contents– Discussion on

• Placenta Previa • Placenta Accrete Syndrome • Placenta Accrete Syndrome

– Comments and Recommendations

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Introduction

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• Any degree of bleeding in a pregnant mother is pathologic; excluding – Implantation bleeding – Bloody show – Bloody show – Bleeding in the third stage of labor

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• Placenta Previa – Placenta goes before the fetus into the birth

canal – Implantation of a placenta in the lower uterine – Implantation of a placenta in the lower uterine

segment (adjucent or over the internal Os)

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• New classification of placental implantation – Normally implanted– Placenta previa – Placenta previa – Low lying placenta

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• Degrees of Placenta Previa

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Ultrasound in Obstetrics & Gynecology_ A Practical Approach - Clip 10.6.mp4

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• GA greater than 16 weeks– Placenta > 2 cms away from Os - Normal– Placenta < 2 cms but not covering - PP

• Follow up U/S at 32 weeks – Placental edge > 2 cms – Placental edge > 2 cms

» Do color dopler U/S at 32 weeks to rule out vasa previa

– Still less than 2 cms » Follow up U/S at 36 weeks

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Placenta Previa

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Ultrasound in Obstetrics & Gynecology_ A Practical Approach - Clip 13.1.mp4

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• Placental Migration – Apparent movement of the placenta away

from the internal os• Imprecision of two-dimensional sonography• Imprecision of two-dimensional sonography• Differential growth of the lower and upper

uterine segments– A low-lying placenta is less likely to “migrate”

within a uterus with a prior cesarean hysterotomy scar

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• Also – Lengthening of the lower uterine segment – Progressive unidirectional growth of

trophoblastic tissue toward the fundustrophoblastic tissue toward the fundus– Placental atrophy

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• Predictors of hemorrhage in PP– Placentas that cover the os– Placentas near the Os have a greater risk of

bleeding if the placental edge is thick (>1 cm)bleeding if the placental edge is thick (>1 cm)– Identification of an echo-free space in the

placental edge covering the internal os– Cervical length ≤3 cm

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• Admission – After 28 weeks – Before 28 weeks

• If there is bleeding or contraction • If there is bleeding or contraction

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• Classification – Placenta Previa

• Internal os is covered partially or completely by placenta

– Low lying placenta • Placental edge does not reach the internal

os and remains outside a 2-cm wide perimeter around the os

– Somewhat but not always related is vasa previa, in which fetal vessels course through membranes and present at the cervical os

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• Incidence– 0.3% or– 1 per 300-400 deliveries

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• Risk Factors 1. Maternal age

• Age above 35 years 2. Multiparity

• Para 5 and above (80% of cases of PP are multipara)

3. Prior Cesarean deliveries / Myomectomy / Hysterectomy / Prior curretage Hysterectomy / Prior curretage • 8 fold if they had more than 4 CD

4. Cigarrete Smoking • Compensatory placental hypertrophy • Decidual vasculopathy

5. Elevated Prenatal Screening MSAFP Level• increased risk for previa and a host of other

abnormalitiesHale T., M.D., Resident Physician 27

• Also...– Multifetal gestation – Infertility treatment – Uterine instrumentation – Uterine instrumentation – Abortion – Male fetus – Nonwhite race– Previous placenta previa

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• Pathogenesis – Suboptimal endometrium in the upper

endometrial cavity • Droping down theory • Droping down theory

– Large placenta – Defective decidualization – Persistence of chorionic activity

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• Pathophysiology – Changes in the cervix and lower uterine

segment apply shearing forces to the inelastic placental attachment site, inelastic placental attachment site, resulting in partial detachment

• Lower uterine segment - Soft and friable – Vaginal examination or – Coitus

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• Clinical Feature – Asymptomatic – Vaginal bleeding

• Painless• Painless• Without warning

– Sentinel bleed• Ceases and recurs

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• Sequele – Severe bleeding – Preterm birth – Cesarean delivery – Cesarean delivery

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• Other associated problems with PP– Preterm labor and rupture of the membranes– Malpresentation– Intrauterine growth restriction– Intrauterine growth restriction– Vasa previa and velamentous umbilical cord– Congenital anomalies – Amniotic fluid embolism

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• Coagulation Defects– Placenta previa rarely complicated by

coagulopathy • Placental thromboplastin readily escape through • Placental thromboplastin readily escape through

the cervical canal • Paucity of large myometrial veins

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• Diagnosis – Historical presentation – Double set-up technique

• Almost obsolete – Sonographic placental localization

• 96% accuracy, • 96% accuracy, • 100% negative predictive value

– Transabdominal – Transperineal – Transvaginal

– MRI• For evaluation of placenta accreta

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Management

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• Expectant management– Candidates? – When should termination be effected?– Home or Hospital? – Home or Hospital?

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Placenta Accrete Syndrome• Abnormally implanted placenta

– Placenta Accrete Syndromes• Placenta accreta, increta, percreta

– Abnormally firm placental attachment – Abnormally firm placental attachment – Poorly developed decidua that lines the lower uterine

segment – Previa overlying a prior cesarean incision conveys a

particularly high risk for accreta carries a major risk of placental accrete Syndrome

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• Abnormality of placental implantation– Anchoring placental villi normally attaches to

the decidua • Accreta• Accreta

– Anchoring placental villi attach to myometrium• Increta

– Anchoring placental villi penetrate into the myometrium• Percreta

– Anchoring placental villi penetrate through the myometrium to the uterine serosa or adjacent organs

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• Incidence – Increasing at an alarming rate – Accreta > Increta > Percreta

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• Pathogenesis – Defective decidualization – Excessive extravillous trophoblastic invasion– Defective maternal vascular remodeling in the – Defective maternal vascular remodeling in the

area of a hysterotomy scar– Partial or complete dehiscence of a uterine

scar

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• Risk Factors – Placenta previa – Placenta previa after previous CD scar– Adavanced maternal age– Multiparity – Endometrial ablation – Endometrial ablation – Prior endometrial irradiation – Leiomyomas – Uterine anomalies – Smoking

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Risk of Placenta Accreta Syndrome - In the absence of PP

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• Clinical Presentation – Life threatening torential bleeding during an

attempt to separate the placenta manually – No plane of separation – No plane of separation – 2/3 of peripartum hysterectomies

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• Sequeae– Unplanned surgeries / Hysterectomies – Death– ARDS– ARDS– DIC– PPH – Preterm birth – SGA infants

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• Ultrasound Predictors of PPH in a patient with APH (Placenta Previa)– If there is placenta accreta syndrome – Thickness of the lower edge > 1 cms – Thickness of the lower edge > 1 cms – If placenta covers the internal Os

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• Imaging – Sonography

• Conventional • 3-D Ultrasound • 3-D Ultrasound • Color dopler

– MRI

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Ultrasound Diagnostic Findings in Placenta Accreta

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A. Normal Placenta B. Placenta Accreta

Ultrasound in Obstetrics & Gynecology_ A Practical Approach - Clip 12.3.mp4

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• MRI Diagnositc Features of Placenta Accreta – Uterine bulging – Heterogenous signal intensity – Heterogenous signal intensity – Dark intraplacental bands – Abnormal placental vascularity – Focal interruptions in the myometrial wall – Tenting of the bladder – Invasion of nearby organs

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• Lab– Elevated maternal serum AFP – Hematuria – Histology – Histology

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• Management– Team work – Always CD– Hysterectomy Vs Conservative – Hysterectomy Vs Conservative – Leaving the placenta for natural resoprtion– Use of systemic methotrexate

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Recommendations • In this patient

– Placental Accreta Syndrome should be rulled in or out with dopler study

– Infraumblical midline abdominal incision – Infraumblical midline abdominal incision should be planned

– Mother should be counseled on histeroctomy and OR materials should be prepared for hysterctomy

– The most senior person in the labor ward should be involved in the OT Hale T., M.D., Resident Physician 65

REFERENCES

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REFERENCES

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REFERENCES

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Thank you for listening!

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