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MRCOG PART 2 SBAs and EMQs

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Essay 336 - Placenta previa

Posted by Zarin G.
Zarin
A healthy 37 year old woman with 3 previous caesarean sections attends the antenatal clinic at 20 weeks gestation. Ultrasound scan shows an anterior placenta covering the internal os and extending onto the posterior uterine wall.

(a) Discuss the risks associated with these findings [5 marks].
Risks of major placenta previa as in this case are of antenatal torrential vaginal bleeding leading to maternal and fetal morbidity and mortality. The placenta is anterior:this can lead to intra-operative major haemorrhage due to the overlying uterine incision and of fetal morbidity/mortality if the fetus is not delivered quickly after incising the placenta. Associations are made with placenta accreta and possible bladder infiltration with an anterior placenta. A fetal malposition or unstable lie is probable in placenta previa. Risks associated with the patient\'s age are of gestational diabetes mellitus and pre-eclampsia. Risks of 3 previous c/sections include techinical difficulty in performing c/section due to adhesions and of possible uterine rupture.

(b) Discuss your subsequent antenatal care including planning for delivery [15 marks].
Counselling the patient as to the diagnosis and risks involved is key. She must be aware to attend as an emergency if vaginal bleeding is experienced, not to have sexual intercourse, to keep her notes with her at all times and that delivery by c/section is needed. A written information leaflet could be given.
A further obstetric uss is warranted at 32/40 to determine whether growth of the lower uterine segment has caused the placenta to move away from the internal os. This is unlikely given the dimensions. A colour doppler uss will determine whether accreta/percreta is present and the extent of invasion.
An elective c/section at 39/40 by an experienced team including a consultant obstetrician, with recourse to a urologist if needed, in an appropriate area eg, main theatres with interventional radiology should be performed. The neonatal team should be present at delivery. This may be more appropriate in a tertiary hospital, depending on resources at the index hospital. Bilateral uterine arteries may be occluded prior to uterine incision to reduce blood loss. Antenatal haemoglobin should be monitored and iron supplementation administered if needed. Prior to c/section, 4units of blood should be cross matched and available.
Consent for c/section should include the risks of hysterectomy, keeping the placenta in situ if accreta is suspected and of possible subsequent methotrexate administration. Discussion about effective long term contracepton should be documented and if the patient agrees to tubal sterilsation at the time of delivery, consent should be obtained on a separate form.
The patient\'s consultant obstetrian should be aware of the case. A low threshold should exist for administration of antenatal steroids after viability due to the high liklihood of preterm emergency delivery, possibly due to vaginal bleeding.
Posted by GULSHAN R.
(a)This patient with 3 previous caesarian section now present at 2o weeks pregnancy with ultrasound finding of placenta covering os make her a high risk pregnancy.But there is also a small chance of migration of placenta in upper segment lateron.There are a lot of risk associated with this finding.The placenta is anterior & covering the os so the placenta implanted over the previous scar,there is a chance of placenta accreta.Haemorragic complication is very common in placenta previa.It may occur in antepartum and postpartum.If antepartum haemorrage occur it endanger both maternal and fetal life.There is chance of fetal distress,IUGR,premturity and congenital malformation.Chance of malpresentation is very common & its related complication.Maternal complications include complications during caesarian section-chance of bleeding,difficult operation-difficult entry,adhesions,controll of bleeding.When there is morbidly adherent placenta -severe haemorrage,difficulty in removing placenta,uterine artery embolization even hysterectomy may be required.Postpartum haemorrage and sepsis higher.Recurrence is also higher if ligation or hysterectomy not done.

(b) Multidisciplinary team should be involve including-senior obstretitian,haematologist and neonatologist.
Counselling of the patient and her family about the risk of haemorrage,blood transfusion and major surgicalinterventions like hysterectomy and documented.
If the patient is symptomatic in-patient management should be done.
If the patient is asymptomatic out patient management can be done with proper explanation of the condition & adviced to attain hospital if any bleeding,contraction and abdominal pain.Otherwise admit the patient at 32-36 weeks & repeat scan and plan of delivery should be made.
At present proper examination and investigations should be done to optimise patients general condition and if no problem go through routine antenatal care.
Examine patient\'s general condition-pulse ,blood pressure, anaemia.P/A/E:fundal height appropriate for gestational age,presentation.
Blood should be sent for grouping & crossmatching and blood should be save.Haematologist involve in women with atypical antibodies.FBC to see Hb%.other routine investigations should be done as usual.Arrange an anomaly scan as chance of congenital malformation.Color doppler imaging can be done to see placenta accreta.If the patient is Rh -ve and there is bleeding any time anti-D prophylaxis should be given.
If hospital admission require asses for risk of VTE and need for thromboprophylaxis.
Monitor the baby by serial USG 28 weeks onward for growth,fetal kick count.
Plan for delivery :depend on clinical condition ,usg finding and gestational age.
Delivery should be in a tertiary hospital by consultant obstretrician in presence of neonatologist,adequate staff and availability of blood.Senior anaesthetist should also be inform.
Mode of delivery must be C/S as there is 3 previous C/S and placenta covering os.General anaesthesia should be considered although there is recent data about safety of regional anaesthesia.
Intravenous oxytocin should be continue to prevent haemorrage after delivery.if needed ergometrine and PGs can be used.Preparation should be take to manage PPH if occur.
Careful monitoring of the patient-vital signs,urine output,p/v/b.
Arrage follow up visit.Contraceptive advise for ligation as pregnancy increases her chance of mortality & morbidity.
Posted by Ir A.
A healthy 37 year old woman with 3 previous caesarean sections attends the antenatal clinic at 20 weeks gestation. Ultrasound scan shows an anterior placenta covering the internal os and extending onto the posterior uterine wall. (a) Discuss the risks associated with these findings [5 marks]. (b) Discuss your subsequent antenatal care including planning for delivery [15 marks].

a) Risks associated with the ultrasound findings of major placenta praevia include antepartum as well as postpartum haemorrhage. The haemorrhage can be torrential requiring transfusion of blood and blood products. There is a very high risk of placenta accreta in view of the previous 3 cesareans. She may require cesarean hysterectomy at the time of delivery. There is increased risk of dilutional intravascular coagulopathy (DIC) and venous thromboembolism (VTE) subsequent from massive blood loss. The patient may require premature delivery due to APH with the associated risk of prematurity and increased perinatal morbidity and mortality. There is increased risk of maternal mortality.

C) This patient should be followed up in a consultant led unit.
She should be informed about the diagnosis and the associated risks. Her antenatal records should be reviewed if available and information regarding any preoperative, intraoperative or postoperative complications should be sought. Blood should be tested for atypical antibodies and full blood count. Anaemia should be corrected with oral or parenteral iron as appropriate. She should be provided with written information. She should be instructed to report to the hospital immediately in case of abdominal pain or bleeding per vaginum. The 24 hour hospital helpline and emergency contact numbers should be provided to her. She should be asked about any objections to transfusion of blood products.
Fetal growth should be monitored by symphysiofundal height at each visit. She should have a repeat scan at 32 weeks for placental localization. If she has bleeding at any time earlier, the ultrasound should be done earlier. A colour flow doppler ultrasound will help in diagnosing placenta accreta. Transvaginal scan is more sensitive and deemed to be safe in placenta praevia.
She should be admitted to the hospital at 34 weeks. Blood should be taken for group and save every 7 days. Prolonged admission is associated with increased risk of VTE. She should be encouraged to ambulate and should be given thromboembolic deterrant (TED) stockings. If she declines admission, she should be advised to stay near the hospital and in the presence of a full time companion.
The plan of delivery should be discussed with her and documented in the notes. The risks of massive haemorrhage, blood transfusion and cesarean hysterectomy should be discussed and an informed consent should be taken. Cesarean should be planned at 38 weeks to minimize neonatal morbidity and paediatricians should be informed beforehand. She should be reviewed by the anaesthetist. The blood bank should be informed about the surgery beforehand.
In case placenta accreta is diagnosed, the use of upper segment uterine incision and posibility of leaving the placenta in situ should be discussed with her by the consultant obstetrician. If facilities are available, a consultation with interventional radiologist may be taken for preoperative femoral artery catheter placement and intraoperative uterine artery embolization after the delivery of the baby.
Posted by Chitra.s M.
A.There is increased likelihood of persistent major placenta previa and increased chances of placenta accreta.The maternal risks include increased maternal morbidity due to potentially massive antepartum,intra and postpartum haemorrhage and need for blood transfusion.There is an increased risk of intraoperative visceral damage(bowel,bladder) and hysterectomy.There is an increased risk of need for ICU care and maternal mortality.Fetal risks include higher chances of perinatal morbidity due to preterm delivery and increased likelihood of NICU/SCBU admission.
B.The woman is cared for in a consultant led unit with onsite blood bank and NICU facilities.The woman is explained about the diagnosis of the placenta covering the os .She is informed that USS is required in 3rd trimester for placental location .The woman is advised to attend hospital immediately in case of vaginal bleed or lower abdominal pain.Her views regarding blood transfusion are discussed and noted.Full blood count is done and anaemia ,if present, is corrected by oral iron.Screen for atypical antibodies should be done.The woman is given written information and emergency contact numbers.Any episodes of antepartum haemorrhage are dealt with admission for maternal and fetal monitoring and placental localisation.Corticosteroids are given for fetal lung maturity at<34 weeks gestation.AntiD is administered if the woman is Rh negative.Consultant based decision to deliver is taken in case of maternal/fetal compromise.If the woman is asymptomatic, transvaginal ultrasound scan is done at 32 weeks gestation for placental localisation.Admission is offered at 32-34 weeks gestation if major placenta previa is diagnosed.Additional imaging by power doppler or MRI is done for evidence of placenta accreta as it helps to plan further management.Admission is offered at 36 weeks for asymptomatic minor previa.If the woman refuses admission,outpatient care can be considered if the woman has a constant companion with her and has ready access to hospital in case of emergency.Unit protocols are followed.Multidisciplinary team review by consultant obstetrician,consultant anaesthetist and neonatologist is done by 32 weeks to plan delivery.The risks of massive haemorrhage, need for blood transfusion ,the possible need for hysterectomy in case of massive haemorrhage and/or placenta accreta is discussed.The woman\'s views on leaving the placenta in situ or proceeding to hysterectomy if accreta is confirmed intraoperatively,blood transfusion and any objections are discussed and documented.Use of intraoperative cell salvage and interventional radiology is discussed if available ,especially if the woman refuses donor blood transfusion.Delivery by planned ceserean section at 37 -38 weeks is made with a documented plan for management of haemorrhage,maternal/fetal compromise prior to this.Risk assessment for venousthromboembolism is done and TED stockings use considered.
Posted by S P.
A.The women should be explained of the ultrasound findinds gently and made aware of associated risks.Risk of severe antepartum haemorhage associated with both maternal and fetal morbidity and mortality . This might warrant preterm delivery .There increased risk of placenta acreta ,withan anterior placenta previa with h/o previous section.This increases the chances of post partum haemorrhage following delivery which will be ceasarean section[only safe option in veiw of history and clincal findings ].There may be a need of addtional procedures during surgery such as blood tranfusion .she might need ceasarean hysterectomy.There is an increased probability of congenital anomalioes associated with placenta previa, absolute risk being small.Possibility of IUGR.Also increased rate of still birth noted. The women should be reassured close follow up and prompt management will ensure safe pregnancy and delivery.
B.Being high risk pregnancy should be unde r consultant led tertiary set up.A detail anomaly scan should be arranged with 2 weeks . Antenal investigations would include fbc , blood group and save serum. follow up of Hb to prevent anaemia [futher compromise her state in event of bleed ] , use haematinics.Anti Dto be in event of bleed if Rh negative.Fetal growth monitoring with SFH and scans -every 4 weeks to rule out IUGR+/- doppler. TVs with doppler to R/o acreta [ can be done safely in previa ] MRI if aviable can also aid in its diagnosis .Low therehold of steroids for fetal lung maturity , as increased possibility of prematurity . Advised to avoid intercouse , attend hospital in case of bleeding or pain .At 32 weeks rpt scan to be dont to localise placenta , though with the findings of previos scan it will most probably be placenta previa major . In this case she should be adviced admission in the hospital due to increased chances of haemorrhage.Blood cross match to be done asper unit protocol ,replaced every 7 days.Encouraged to moblise ,Ted stockings, thomboprophylaxsis to avoid VTE.If shes wishes to be managed as outpatient contact details , direct acess to emergency sevices should be available along with 24 hour companion.Mode of delivery should be discusedd at 36 weeks , for eletive section at 38 weeks , .She should be informed of possibility of need of blood transfusion , cesaren hysterectomy , possibility of visceral injury.She should be given the opportunity to outline any procedures with should not be carried out without consent.All information to be documented .Written information given.PREanaethetic checkup to be done ,GA considered better due to possibility of further intervensions, womens wishes to be considered.The cesarean to be carried out by a consultant obstetecianwith expertise in obstetric hysterectomy . MDT approach consisting of paediatrician , haematologist{ need of blood and blood products] , radiologist,surgeon.Cross match at least 4 units blood . High uterine incision to avoid the placenta.Pre operative uterine catheterization, with embolectomy if needed. After delivery of baby give uterotonics as per unit protocol, run syntocinon infusion.Avoid peice removal of placenta if undelivered, it can be left in situ . Spontaneous expulsion occurs , accelerated with use of methotrexate.In event of PPh early restore to hysterectomy. Prophylactic antibiotics to be given . thomboprophylaxis to be continued provided bleedingis in control.
Posted by S P.
typing error -Embolisation if needed in event of PPH
Posted by Syamala H.
ansA:serious maternal risk associated with major degree of placenta previa life threatening hemorrhage which can be antepartum ,intrapartum or postpartum. need for massive blood transfusion and is associated complications like transmission of infection and immune reactions.possibility of morbidly adherent placenta (15% risk) which increases with increasing number of cesarean section. risk of hyterectomy during surgery (risk can be as high as 25/100 and if placenta morbidly adherent it is highly likely).also there is increased risk of bladder ureteric and bowel injury approx 6/100 due adhesion resulting from previous surgery.other risk include risk of hernia formation.also there is increased risk of VTEand risk of sepsis .patient may require ICU care and repeat surgery.future pregnancy risk are increased risk of repeat placenta previa or placenta accreta.risk of uterine rupture and stillbirth.
baby is at increased risk of perinatal morbidity and mortality from massive hemmorhage and prematurity.
ans b:
managment should be in consultant led unit with 24 hr facility for emergency admission,cesarean section,blood bank facility and facility ofadvanced neonatal resucsitation. patient should be explained that her placenta is covering her cervical os and is of major type. although under normal circumstaces 90% of low lying placeta migrate by end of second and early third trimester it is highly unlikely in her case owing to previous three surgey and major degree of previa as there is likelyhood of placenta being adherent to scar. she would require repeat TVS at 32 wks to reconfirm the diagnosis and plan managment of third trimester and delivery. doppler scan +/- MRI would be required to rule out morbidly adherent placenta. her antenatal recordsshould be reviewed to look for any operative complication in previous surgeries which can effect her pesent outcome. patient should have optimisation of hemoglobin level. she should be told to report immediatly in case of abdominal pain and bleeding.FBC group/Rh and antibodyscreen to be repeated at 28 wks to identify irregular antibodies.antenatal counselling regarding hemorrhage ,blood transfusion and major intervention like hysterectomy should be done and any objections noted.also in case of placenta accreta option of leaving placenta in situ and methotrxate and its post op complication like hemorrhage infectin and hysterctomy at later date should be discussed.patient requires in patient managment from 34 wks onward or earlier in case of any bleeding episode(selected patient who have not bled can be managed outpatient if in close proximity to hospital,having constant companian and transport available). blood should be available according to unit protocol and crossmatched every 7 days.steriods for lung maturation in any event of bleeding and TED stocking,mobilisation and maintanance of hydration to prevent VTE. if any associated high risk factor that mandates heparin,unfractionated heparin should be used as its action can be easily reversed. there is no role of cervical encircalage or tocolysis. delivery by elective lscs at 37-38 wks to be planned in consultation with anesthetist. blood bank to be notified for need of blood availibility. ICU bed availibility should be checked.. if facility available for cell salvage and intervention radiology proper consent to betaken and arrangement made. there is no role of autologus blood transfusion.surgery should ideally done by most experienced obstetrician or atleast supervised by him. senior anesthetist should be available in the suit.early recourse to medical and surgical means to achieve hemostasisis required.
Posted by L S.
LS:
(a) Discuss the risks associated with these findings [5 marks].
The ultrasound scan suggests a low lying placenta which will highly likely be a placenta praevia in the third trimester. Due to her previous caesarean sections, such a finding will put her at risk of a morbidly adherent placenta like placenta accreta. Both these conditions will put her at risk of antepartum and post partum hemorrhage which can be life threatening and will therefore be at risk of needing blood transfusion. The fetus with this condition is associated with a higher risk of congenital anomalies, intrauterine growth restriction, intrauterine death and malpositions.

(b) Discuss your subsequent antenatal care including planning for delivery [15 marks]
I will counsel her and inform the finding along with the risk and implications of such finding. Her rest of her antenatal care should be in a high risk pregnancy clinic under a senior obstetrician experienced in such condition. A detailed anomaly scan is counselled and carried out to identify any fetal anomaly. A transvaginal ultrasound scan is carried out at 32 weeks to confirm suspicion of major placenta praevia. Once confirmed a Doppler is carried out to map out the plane between the placenta and uterine wall and to check for placenta accreta or percreta. If confirmed she should be extensively counselled on high risk of surgery and possibility of hysterectomy as a life saving procedure if her placenta is adherent. Other options like role of methothrexate should be counselled on an individual basis based on unit protocol and guideline for management of placenta accrete. Her haemoglobin levels, blood grouping and antibodies are also checked. If she is anemia, her anemia should be treated and optimised as she will be undergoing a major surgery with high risk of bleeding. Her objections to blood transfusion should be asked and documented. If she has objections, should be asked on acceptability of blood products and cell salvage if expertise available. A serial scan is carried out from third trimester every 2 weekly to monitor for intrauterine growth restriction and to assess fetal wellbeing. Inpatient care till delivery should be discussed and arranged from 35 weeks onwards if she has not had any bleeding episode as the risk of a sudden bleed is unpredictable and can be life threatening. If she has had a bleeding episode, she should be admitted and antenatal steroids for fetal lung maturation should be given and paediatrician informed on her case and expectant care is carried out provided there is no maternal compromise. An early anaesthetist review during the antenatal period should be arranged and a plan for surgery documented in her notes so that her surgery can be optimised. Her caesarean section should be planned at 37-38 weeks. Prior to her surgery she should be asked about her completion of her family and whether she would like a tubal ligation during surgery if her surgery went well. She should also be counselled on the recurrence risk of this condition which is higher with those who had a previous caesarean. Her consent should be taken stating the high risk of hysterectomy, needing transfusion and her wishes about her surgery documented. Her caesarean should be an elective case which should be planned to be done in the morning when a senior obstetrician, senior anaesthetist should be present. The blood bank, hemaologist, paediatrician and high dependency unit should all be informed about the case. Interventional radiologist should also be informed if available and preoperative cannulation of uterine artery organised. Her bloods should be collected and kept in theatre and cell salvage organised if available. Oxytocic should be available in theatre and in adequate amount as part of active management for post partum hemorrhage. Timely decision for hysterectomy intraoperative should be made without delay.
Posted by zara A.
A]This is a high risk pregnancy due to previous three csections with low lying placenta [chances of persistence of placenta praevia ,placeta accreta].The maternal risks are antepartum haemmorhage ,intrapartum and postpartamhaemmorhage.The need of hospitalisation and blood transfusion .The need for c section, with increased complications due to previous surgery and possibility of placenta accreta ,risk of bladder ,bowel and ureteric injury.Risk OF hysterectomy and other interventions [uterine artery embolisation,]risk of thromboembolism ,needfor icu admission .The risk of recurrence of placenta in next pregnancy.THE fetal risks are prematurity [ DUE TO APH requirinq preterm delivery],NEED FOR icu admission ,and risk of anaemia ,perinatal mortality and morbidity increased.B]THE scan should be reviewed whether TVS OR TRANSABDOMINAL ,IF transabdominal REPEAT as TVS reclassifies low lying placenta diagnosed by transabdominal scan in about 60% cases in 2nd trimester .IF low lying confirmed she should be counselled about the diagnosis that placenta is lying in lower segment.The implication of this finding is that it will less likely to migrate because of previous c section and chances of placenta accreta are high.WHETHER placenta migrate or not mode of delivery willbe csection.This high risk pregnancy should be managed in consultant led unit with back up fascilities of blood bank .THE followup scan tvs should be repeated at 32 weeksin asymptomaic patient and if patient bleed then manage accordingly to clarify diagnosisand to plan further management .THE further imaging by colour flow doppler or MRI is planned to diagnose placenta accereta.THE patient with major placenta previa should be admitted at 34 weeks .IF ASYMPTOMATIC major placenta never bled ,and patient wants any home based care requires care ful counselling,constant presence of some one ,close proximity to hospital and informed consent .THe PATIENT and her partener should be told about the risk of haemmorhage ,need for blood transfusions and risk of emegency operative delivery if APH[ LIFE THREATENING],risk of hysterectomy ,and other interventions like uterine artery embolisation and intraoperative salvage therapy and any objections noted and dealt accordingly .THE PATIENT should told that if she noted any contraction s ,vague abdominal pain and any bleeding she should present immediately to hospital .THE patient HB OPtimised during antenatal period.THe blood group and atypical antibodies should be done ,if positive discuss with haematologist and involve blood bank.THe need for blood crossmatch during in patient stay depend on local blood bank service and individual patient factors, and unit protocol .cross matched blood replaced weekly.The inpatient isat risk of thromboembolism gentle immbobilisation and TEDstocking given and if high risk unfractionised heparin given.THE csection planned at38 weeks .IF preterm delivery required then administer corticosteriods.The planning of intrapartum care requires multidisciplinary approach ,involving interventional radiologist,consultant anaesthetist and consultant obstetrician should plan delivery .Choice of anaesthesia depend on anesthetist and woman chioce ,but regional anaesthesia safe .THE plan shold include about management of placeta accreta leaving or removing placenta,type of incision ,prophylactic arerial embolisation.PATient should be delivered in aunit with availibility of level2 critical care,with fascilities of intraoperative salvage therapy and arterial embolisation [espescially for patient who refuse blood transfusion].The blood bank notified about time of delivery and discuss need for blood and blood products.THE BLOOD SHOULD BEavailable in theatre .THE protocol to manage massive haemmorhage should available.THE consultant obstetrician and anasthetist should supervise delivery.The informed consent of woman taken and discuss if she want sterlization, discuss risks of csection and additional risk of hysterectomy,blood transfusion and other interventions intraoperative salvage therapy and uterine artery embolisation,and whether placenta left or removed.THE patient objection recorded.paedriatrician should present at delivery.
Posted by Bee N.
A healthy 37 year old woman with 3 previous caesarean sections attends the antenatal clinic at 20 weeks gestation. Ultrasound scan shows an anterior placenta covering the internal os and extending onto the posterior uterine wall. (a) Discuss the risks associated with these findings [5 marks]. (b) Discuss your subsequent antenatal care including planning for delivery [15 marks].

Bee

A)The risks associated with major placenta previa include antepartum haemorrhage. This can be a cause of significant morbidity to the fetus and also a significant cause of haemorrhage and anaemia to the patient. Fetal death is a possibility if bleeding is not promptly managed.The fetus may require early delivery due to heamorrhage leading to iatrogenic pre term delivery. Due to patients age, their is also slightlyrisk of spontaneous preterm labour. The patient is 37 years old and this is associated with increased chances of chromosomal anomaly which may manifest with structural anomaly and this has to be borne in mind when doing anomaly scan.There is also increased risk of structural anomaly even in absence of chromosomal anomaly. If the placenta remain a major placenta previa, delivery will have to be by ceasarean section without choice and this is associated with complications such as PPH, sepsis and increased chance of recurrence of placenta previa and accreta in future pregnancies. Bleeding associated with this especially if placenta accreta is present increases patient risk of venous thromboembolism.

B)If the patient had this diagnosis made by transabdominal USS, a pelvic USS will be needed as this can reclassify severity. If this is confirmed, an anomaly scan should be done to rule out structural anomaly. She should be informed of the diagnosis in a sensitive way as this may arouse anxiety. She is then informed of the risk of bleeding and need to inform hospital if she has any contraction and/or PV bleeding. She should be managed antenatally in a tertiary unit that has a Neonatal intensive care facility under a consultant led clinic. From 20 weeks gestation till 28 weeks she should be seen every 2weeks and weekly thereafter.
I will do growth scans at 24,28 and 32 weeks gestation to detect IUGR. If IUGR is detected, scans will be more frequent.
At 32 weeks a transvaginal scan should be repeated. If still a major placenta previa and have bled PV anytime after the diagnosis had been made, steroids can be considered and patient admitted at 34 weeks as in patient for observation during which time weekly crossmatch of maternal blood is done to make blood ready in case of bleeding. If asymptomatic till then, careful assessment need to be made before out patient management can be continued. Such assessment will include proximity to hospital, likelihood to bleed due to abdominal pain, if living alone or with someone. Patient must consent to this plan before it is embacked upon.
During antenatal period, discussion should be had with both patient and her partner concerning the high risk of bleeding and issues about tranfusion, emergency caesarean delivery of term or preterm baby and possibility of hysterectomy. Hysterectomy is especially a possibility considering the fact that she has had three previuos C/S. The haematologists must be informed about this patient so that arrangement is made to provide blood in case of presence of rare antobodies in maternal blood. The paediatricians and anaesthetist must be informed at every admission. Thromboprophylaxis with unfractionated heparin should be considered at every prolonged admission.
Delivery is planned in a tertiary center for 38 weeks in presence of placenta previa if bleeding does not warrant earlier delivery.Delivery will be by C/S and done by a consultant if patient remains with placenta previa.This is due to the high possibility of accreta and the morbidity associated with it. However if placenta is more than 2 cm from the internal cervical os vaginal delivery is possible. However due to the high risk of uterine rupture in this patient (appox 2%) I will offer her delivery by C/S if is she accepts. I will plan for active management of third stage of labour. There should be a clear documentation of all plans and discussions made with the patient and unit protocol should be considered in management. If adverse events such as heavy bleeding occurs, an incident form should always be filled.
Posted by sonu P.

a) The diagnosis is major placenta previa and the chances of migration are minimal. The associated risks are antepartum haemorrhage, postpartum haemorrhage, risks associated with blood transfusion, perinatal morbidity and mortality in the form of premature delivery and associated peoblems of RDS and sepsis, maternal morbidity and mortality in the form of placenta accreta and percreta, chances of caesarean hysterectomy, HDU/ITU admission.

b) The patient will be under consultant led care. I will explain the findings of USS to the patient and associated risks of perinatal and maternal morbidity and mortality. She should be seen 2-3 weekly in the antenatal clinic upto 28 weeks and 1-2 weekly thereafter. She will be advised to seek medical attention quickly in the event of vaginal bleeding. She should be offered growth scan according to unit protocol due to poor sensitivity of SFH measurement especially in cases of abnormal placentation. Inpatient care should be considered based on unit protocol even in the absence of history of APH.Generally, it is considered after 32 weeks of gestation when the lower segment is formed which may provoke the first bleed. Anaemia should be actively detected and treated appropriately. A group and save sample should be in the laboratory every 5-7 days and some unit keep units of blood cross matched in the delivery suit according to local maximum surgical blood ordering schedule(MSBOS) which is replaced as per protocol, usually every 7 days. An elective caesarean section should be planned@ 38-39 weeks and not early to reduce the risks of neonatal RDS.The gestation of delivery will also depend on the history of APH, previous obstetric history and available resources. Early involvement of consultant neonataologist, haematologist, anaesthetist and radiologist is advisable in formulating the timing of delivery. An USS Doppler flow studies or MRI should be done in the antenatal period to detect placenta accreta or percreta. If morbidly adherent placenta is confirmed antenatally, prophylacytic uterine artery embolisation before caesarean may be considered. The delivery should be done by a consultant obstetrician in presence of consultant anaesthetist or directly supervised by one. An informed consent should be taken in good time with special emphasis on chances of hysterectomy and risks of leaving the placenta in situ and possible use of methotrexate if fertility conservation is an issue.
Posted by H H.
A healthy 37 year old woman with 3 previous caesarean sections attends the antenatal clinic at 20 weeks gestation. Ultrasound scan shows an anterior placenta covering the internal os and extending onto the posterior uterine wall.
Discuss the risks associated with these findings [5 marks

Maternal risks are related to such placenta remaining in place and continuing into the third trimester as a placenta previa. Placenta being anterior , it would be implanted on the cesarean scar with high possibility of it being accrete. There is risk of bleeding which can be ante partum, intrapartum(in case she has contractions at home), intra operative or post partum, which can be so severe to cause shock and even death. There are risks of procedures used to stop bleeding, eg internal artery ligation with possibility of injury of internal iliac vein, injury of ureter or even ligation of external iliac artery. There is risk of performing a hysterectomy with associated risks of injury to surrounding structures,(ureter urinary bladder or bowel) and loss of fertility.There is risk of need for blood transfusion with its risks(transfusion reaction, transmission of virus, fluid overload,acute transfusion lung injury).
During her antenatal care there is risk of silent rupture uterus or scar dehescense,which can be catastrophic to her and her baby.
This patient had 3 cesarean sectionsC/S, and so during doing a 4th C/S there is risk of adhesions and possibility of injury to urinary bladder or bowel.
Fetal risks are related to prematurity( anemia,hypoglycemia,RDS, intaventricular hemorrhage, necrotizing enterocolitis, hypothermia, hyperbilirubinemia, cerebral palsy),should the patient have an early C/S due to bleeding compromising her or the fetus or should she enter into premature labour.There is also risk of congenital malformation which are increased in placenta previa.

b) Discuss your subsequent antenatal care including planning for delivery [15 marks].
This patient should be considered a high risk pregnancy. She should be followed in a consultant led unit. The ultrasound scan should have been a detailed anomaly scan as well to exclude obvious malformations. Should the scan have been an abdominal scan, a repeat transvaginal scan at 22wk would be safe and more accurate at detecting the location of placenta.
Patient is counseled regarding findings at the scan , risks associated with these findings and the follow up which would more frequent ante natal visits. An ultrasound scan is arranged at 32wk to, detect wether the placenta migrated up or not, though as there is a previous scar this is unlikely and this should include colour Doppler to detect placenta accreta.
Patient is told that she would need admission if she has bleeding at any time, but she will be admitted at 34wk till delivery . Refusal to do so is dealt with taking in consideration how far she lives from hospital and more counseling.
Risk assessment for venous thromboembolism done with each admission and follow local guide line protocols for thromboprophlaxis.
Patient view regarding blood transfusion is known and if Jehovha witness her view regarding cell salvage is taken and she can be transferred to centers who provide this service to have here elective C/S there.
Radiology department can be notified in case the patient has a placenta accrete to place their catheters into femoral arteries before doing the C/S for uterine artery embolisation in case of need.
Delivery will be by elective cesarean section planned at 38 wk, performed by consultant obstetrician with blood available in theatre. Consultant anesthetist to see patient during her antenatal care and before C/S. C/S be done at an earlier date if patient has bleeding compromising maternal or fetal condition or if she has preterm labour.
Posted by A A.
AA (SA)
(a) Placenta praevia is associated with increased risk of maternal and fetal morbidity and mortality. Risks are maternal and fetal. Maternal risk of placenta praevia (PP) with previous caesarean sections is placenta accreta / percreta. Risks of antenatal and postnatal bleeding. She need delivery by C/S and associated with C/S and anesthesia risks. Risks of hysterectomy and blood transfusion during delivery due to postpartum hemorrhage. Risk of admission to Intensive care after delivery. Risk of mortality associated with bleeding. Fetal risks are premature delivery due to antepartum bleeding and fetal distress. Congenital malformations with double risk of serious malformations. Risk of intrauterine growth restriction due to abnormal placenta. Risks of malpresentation and hypovolaemia due to bleeding during delivery.
(b) It is high risk pregnancy. She should be seen in consultant led clinic. If transabdominal (TAS) then further transvaginal scan (TVS) required as it has superior view than TAS in case of posteriorly situated PP. IN case of major placenta praevia repeat TVS should be performed at 32 weeks to make diagnosis and plan delivery as data suggest 50% chance of resolution if placenta cover internal os at 20 week scan. I will arrange color flow Doppler used to make diagnosis of placenta accreta if such scanning is not available than she will be managed as placenta accreta. Blood should be available based on local guideline and hematologist involved in case of atypical antibodies. There is risk of sudden heavy bleeding in major PP which should be managed as in patient. In case of heavy bleeding at any gestation consider resuscitation and delivery by c/s. If she remain asymptomatic consider admission at 34 to 36 weeks If she refused admission then ensure she have someone at home to help her and having ready access to hospital if she has bleeding. She should attend hospital immediately if she has bleeding, or pain abdomen. She and her partner should have antenatal discussion regarding delivery, possible transfusion in case of hemorrhage, and major surgery like hysterectomy. Informed consent should be taken and discussion should be documented in antenatal note record including any objections. There is no evidence to recommend cervical cerclage to reduce bleeding and prolong pregnancy. Tocolysis is contraindicated in antepartum hemorrhage. In case of bleeding give Anti D if Rhesus negative. Blood should be available during in patient stay. I will assess her for VTE during in patient in high risk thromboprophylaxis with LMWH will be started. Advice for mobilization and TED stocking. Fetus should be monitored by biometry and Doppler. In case of delivery before 34 weeks corticosteroid should be given to reduce fetal morbidity. Delivery should be planned by consultant and other specialist, hematologist; intensivist should alert and get ready to be available. Time of delivery is dependent on clinical circumstances but in asymptomatic aim of delivery by C/S at 38 weeks to minimize neonatal morbidity. Anesthetic choice depends upon final decision of anesthetist and woman. Wishes Ensure blood available before starting surgery. There is no evidence to support autologous blood because woman needs massive blood transfusion. Cell salvage may be considered if expertise available. Inform SCBU and neonatologist to attend delivery as there is risk of fetal blood loss and neonatal hypovolaemia.
Posted by F N.
a:
The risks can be divided into maternal and fetal.
maternal risks are:
As she has previous 3 ceasarean sections and now a low lying placenta covering the internal os at 20 weeks gives her an increased risk of placent previa,as the placenta is anterier,she is at increased risk of accreta.Her subsequent risks will be secondary to major placenta previa and accreta.
She has the risk of recurrent antepartum and post partum haemorrhage which can be life threatening.She is at increased risk to develop anemia and rarely DIC with massive haemorrhage.
She can have multiple blood and blood product transfusions and its sequale like anaphylaxis and development of atypical antibodies.she is at risk of having a ceasarean hysterectomy which can be quite difficult inveiw of her previous 3 sections.Therefore she is at increased risk of bowel ,bladder and ureteric demage and thromboembolisim.she is at risk of developing sheehan sydrome due to massive PPH.
And above all, she can suffer significant psychological morbidity as a result of difficult and stressful pregnancy and delivery.

the fetal and neonatal risks are:
There is an increased risk of miscarriage,preterm labour(iatrogenic/spontaneous) and intrauterine growth restriction and there subsequent implications.There is risk of intrauterine death/still birth as a result of massive APH.

B:she should be followed up in a consultant led clinic regularly.The probable diagnosis of placenta previa/accreta and its implications for her and the baby should be explained to her.She shouls be booked for 4 weekly scans from 24-28 weeks to moniter the growth of the baby,as placenta previa even without any APH may be associated with IUGR.The frequecy of scans can change according to clinical need.
The uss will also confirm the diagnosis of placenta previa after 28 weeks.Colour flow doppler uss may be help ful to diagnose accreta.MRI can be considered to help in diagnosis of accreta.
Offer admission for even mild APH,secure IV line,send FBC to check Hb and sample for group and save and kliehaur test.Administer Anti D if Rh negative.
Her heamoglobin levels should be optimised and anemia should be treateed aggressivly with oral/parentral iron.blood transfusion can be given nearer to the time of delivery for more rapid response.
jehowah witnesses should be managed as per depatmental guidlines,and should have a detailed intrapartum care plan in notes.
Review by the anesthetic team should be arranged in 3rd trimester.
Offer admission between 32-24 weeks till delivery if major placenta previa.However the woman social circumstances should be considered if she declines admission,and make sure she has some one available all the time and should report to the hospital even mild pain or bleeding.
Option of sterlisation at c/section can be discussed antenataly,if she has completed her family.however should be explained that it may not be performed in life threatening situations.
Delivery shold be planned between 36-38 weeks,administer steriods for fetal lung maturity preterm delivery is anticipated.
neonatal team shoud be informed.
Planning for c/section for placenta previa is of paramount imporatnce as it can improve maternal and neonatal outcome significantly.
She should be fully counselled about the risk of massive Haemorrhage needing blood transfusions and hysterectomy along with the risk bladder, bowel ,ureteric injury and thromboembolisim. She should be told about the option of leaving the placenta in situ and methotrexate injection as part of management strategy.a consent form should be signed.at least 4 units of blood should be cross matched and kept in the fridge on delivery suite.
Interventional radiologist should be informed before hand,as there may be need for prophylactic or theraputic embolisation.
Consultant anesthetist and obstetrician should perform the C/section or at least should be present in theatre.Regional anestehesia is recommended however it should be explained to the patient that there is a risk of GA with massive haemorrhage and prolong surgery.
Adequate theatre staff should be present.
Another Consultant obstetrician may be made aware before hand as well as his help may be needed for descision of ceasarean hysterectomy.
I/v antibiotics should be administered after the delivery of baby.
Asses risks for thromboembolisim and provide TEDS/prophylactic LMWH after ceasarean section if no containdication.
Postnatal followup should be arranged.Risk of Placenta previa and accreta discussed in future pregnancies,and adequate contraception couselling offered.
Posted by Im F.
a) She is elderly mother with 3 previous c-section. She is at high risk of major placenta previa and morbidly adherent placenta (15%). She is at risk of haemorrhage and ante partum haemorrhage at any time during her antenatal period ranging from minor bleed to major haemorrhage which can lead to mortality sometimes. She is at risk of post partum haemorrhage and sepsis as well. If she is Rh negative mother, there are chances of rhesus alloimmunization. There are chances of adhesion intra-abdominally in view of her previous surgeries. So chances of bladder and bowel injuries are also present. Fetal risks includes of prematurity and increased perinatal morbidity or mortality.she has risks of fetal anomalies as well in view of her age and lowlying placenta.

b) she is a high risk patient so her ANC should be in a consultant led unit.During her subsequent antenatal care, the first step should be to confirm the finding by using a transvaginal scan (in case it was diagnosed by transabdominal scan during her routine anomaly scan) because confirmation by TVS is more accurate and saves unnecessary visits. USG should rule out any congenital anomalies as well which are usually associated with p.previa. Her subsequent management depends on whether she bleeds (symptomatic) or not (remains asymptomatic). If she remains asymptomatic, the TVS should be repeated at 32 weeks. A Doppler scan should also be performed in order to rule out morbidly adherent placenta previa (placenta accreta). Patient should be counseled about findings of scan and need of frequent scans and hospitalization.
In case placenta migrates to upper segment, then recourse to normal antenatal care should be done. But if still major placenta previa, then she should be admitted in 3rd trimester (32-36 weeks) depending upon patient’s wishes, proximity to hospital and presence of family members at home. The rationale to admit such patient is risk of unpredictable bleeds.. In case of inpatient management, there should be availability of blood cross matched usually 2 pints according to local protocol. If there are abnormal antibodies in the blood, hematologist should be involved. Her haemoglobin level should be well maintained throughout her ANC.
If patient is symptomatic with active bleeding anytime during her antenatal period, she should be admitted to hospital and should be given antenatal steroids for fetal lung maturity . There are chances of thromboembolic disease, in view of her age and history of admissions, so thromboprophylaxis should be given in case of local protocol and TED stocking should be provided. If patient is asymptomatic after a minor episode of bleed, then she can be managed as out patient before 32 weeks but after explaining risks of rebleed. Delivery should be around 37-38 weeks to avoid complications of prematurity if managed conservatively. Risk of haemorrhage and need of blood transfusion should be explained to patient.In case placental edge is 2cm away in anterior and 3cm away in posterior previa and if placenta accrete has been ruled out, women can be delivered vaginally.
In case of placenta accreta, she should be managed by multidisciplinary team including consultant obstetricians, consultant anaesthetist, hematologist and ITU specialist. Blood should be available. There is no role of autologous blood transfusion. Cell salvage should be considered in women at high risk of massive haemorrhage especially if she is a jehova\'s witness. Traditionally, general anaesthesia has been used but if patient wishes regional, can also be used. Management options in case of placenta accreta are early recourse to internal iliac artery ligation, uterine artery embolisation and hysterectomy as last resort. Other options are leaving placenta insitu after c-section and medical treatment with methotrexate.Contraception or sterilization options should be discussed with patient before discharge.
Posted by A- N.
AA
a) The risks in her case may be either maternal or foetal. Antenatally she may be anaemic due to reccurrent bleeding. Severe antepartum haemorrhage may lead to maternal collapse. Unengaged presenting part, mal presentation are more common. Morbidly adherent placenta as placenta accreta, increta or percreta is common. There is a 40%chance of placenta accreta in 3 previous sections. The patient will require operative delivery with increased chances of blood transfusion, caesaerean hysterectomy which will increase the morbidity. With 3 previous caeserean sections there is an increased risk of scar dehescence.
Intrapartum duering caeserean section there are increased risks of bowel, bladder and ureteric injury due to the adhesions.
Post partum complications include Postpartum haemorrhage, endometritis, secondary Postpartum haemorrahage. There will be dealyed recovery.
There is always a risk of maternatal mortality due to antepartum haemorrhage.
Foetal risks include background risk of congenital abnormalities, risk of prematurity, intrauterine growth restriction and still birth.
b)
I would book her to be managed in a consultant led unit. I would explain that the placenta is localised abnormally and will need further evaluation.
I will arrange for a transvaginal scan at 32 weeks to confirm the major placenta previa. In this sitiuation its un likely that placenta will not migrate. Transvaginalscans are safe and more sensitive.
If the patient has reccurrent antepartum bleeds then she should be hospitalised for further observation and if needed, delivery by LSCS in case of major bleed
I would arrange for a colour doppler or MRI scan to check for morbidly adherent placenta.
I would regularly check for full blood count and give haematemics so as to optimise her haemoglobin levels prior to delivery.
Blood grouping and checking for antibodies is done at 28 weeks.
Blood group and cross matched everyweek from 36 weeks onwards in case she needs emergency caeserean sectioon.
The management of the this patient is asymptomatic, can be managed as an outpatient if she is living close to the hospital, having constant companion who can bring her to hospital as an emergency if there is bleeding.
I will counselthe patient regarding the risks of needing bloodtransfusion, additional procedures like hysterectomy as a life saving procedure during caeserean section and this I will document.
I would give antenatal steroids for foetal lung maturity in case of reccurrent APH.
I will arrange for regular foetal growth scans to check for fetal well being and growth.
I would arrange for an anaesthetic review for planning anaesthesia if she requires emergency delivery.
I would also infor the consultant haematologist and blood bank regarding the patient as she may require large amounts of blood during caeserean section.
I would explain the patient that she is to be seen in the hospital immidetialy if she has any bleeding, abdominal pain, rupture of membranes.,
I would arrange for an elective Lower segment caeserean section at 38 weeks gestation if asymptomatic.
Caeserean section should be performed by senior most obstetrician. Consultant anaesthetist and consultant ostetrician should be present in the theatre.
I would also arrange for cell salvage and interventional radiologist input if facilities are available.
I would explain the high likelyhood of blood transfusion and hysterectomy for bleeding while consenting for Caeserean section.
Posted by Aruna R.
Aruna
a) Discuss the risks associated with these findings.

The findings suggest the possibility of placenta previa with a risk of acreta due to anterior placenta. Maternal risks are Persistent findings leading to placenta previa with a risk of acreta due to anterior placenta. Frequent bleeding, which can be minor or major needing blood transfusion. May require in patient antenatal care from 32 weeks. Placenta previa is associated with unengaged head and malpresentation. It is associated with increased risk of venous thromboembolism. Risk of preterm delivery and Risk of operative interventions like uterine artery embolisation and hysterectomy. Placenta acreta /percreta may lead to mortality but is rare. Fetal risks include prematurity, fetal anaemia due to bleeding and fetal loss. This is associated with increased perinatal mortality and morbidity. All these leading to psychological problems including increased risk of postnatal mental health problems.


The care is by multidisciplinary team including obstetrician, anaesthetist, paediatrician, haematologists, and interventional radiologist. I will explain the possibility of persistence of the findings later in pregnancy and the need for rescan at 32 weeks to confirm the findings. I will check her haemoglobin results and treat with oral iron if necessary because of risk of bleeding.
I will confirm weather she has any objection for blood transfusion /blood products. If so I will document it in her notes and the additional precautions need to be taken once the diagnosis is confirmed.I will arrange growth scans at 26 and 32 weeks. At 32 weeks scan reconfirm the findings and discuss with the radiologist for further investigations like colour Doppler and MRI to rule out placenta acreta/percreta.
Once the diagnosis is confirmed ask for anaesthetic review and interventional radiologist to plan about prophylactic interventions like aortic/ uterine artery balloon prior to the time of caesarean section. Consultant obstetrician to discuss the risks including hysterectomy and death. If she had symptoms (bleeding) I will recommend inpatient treatment from 32 weeks till delivery. If asymptomatic ,I will offer outpaeint management provided she has good family support, living reasonably nearer to hospital, telephone facilities and transport available if needed. I will give her steroid (betamethsone 12gms x24 hours apart) after a bleeding episode or if asymptomatic at 32 weeks to improve the lung maturity.

I will discuss about cell salvage technique if it is available and consent for it. Autologous transfusion is of no value in this condition. I will book her for elective caesarean section at 37 weeks and consent her for caesarean section including ITU admission, interventional radiological procedures, and hysterectomy.I will inform the date of operation to haematologist, interventional radiologist and theatre staff to make necessary arrangements.I will cross match 6 units of blood on the day of operation.
Posted by Penelope T.
a) These findings show a low lying placenta, with a high chance that this will remain low when the lower uterine segment is formed and be a major placenta praevia. It may also be morbidly adherent (placenta accreta/increta/or percreta) given her history of 3 previous caesarean sections. Risks associated with these conditions include significant antepartum haemorrhage and transfusion. If she is rhesus negative there is an increased likelihood of isoimmunisation occurring. There is increased perinatal and maternal mortality and morbidity. The fetus has an increased risk of congenital anomaly. Delivery is necessarily by caesarean section, and has higher risks of intra-operative complications including bowel, bladder and ureteric injury. Emergency or planned hysterectomy is increased. Major obstetric haemorrhage may result in ICU admission, massive transfusion, infection and multiorgan failure.
b) Initially this lady requires a tertiary ultrasound. This should comprise detailed anomaly ultrasound and closer visualisation of the placenta (signs suspicious for morbid adherence including loss of bladder/placenta interface, placental lakes, and abnormal vascular flow on colour doppler). Subsequent ultrasound (ideally transvaginal) should be performed at 28-32 weeks once the lower segment has formed. If these fail to clarify presence or absence of morbid adherence, MRI should be performed.
FBC should be checked monthly and iron deficiency anaemia treated promptly with iron therapy and/or transfusion if appropriate. If rhesus negative and non-sensitised, she should have anti-D prophylaxis 500units at 28 and 34 weeks; should bleeding occur she should have a further dose.
The patient should be advised to avoid intercourse due to the risk of bleeding. She should be advised to present to hospital should bleeding occur. She should be counselled regarding the risk of major haemorrhage and should always have a phone and transport available.
In the third trimester if major placenta praevia or morbid adherence is confirmed she should be admitted from 34 weeks, and have a continuous crossmatch sample of 2 units packed cells available. Prior to this she should always be accompanied and be within easy reach of a hospital. If bleeding occurs prior to 34 weeks she should be steroid loaded. Any bleeding should prompt admission and large gauge IV cannula. Active brisk bleeding should prompt delivery at any gestation. Recurrent small bleeds should prompt serial growth ultrasounds.
Ideally planned caesarean should be performed at 37 weeks. This should be done by a consultant obstetrician with a second obstetrician or gynaeoncologist available. A consultant anaesthetist should be present. Spinal or general anaesthetic can be used. Pre-operative FBC and 6 unit crossmatch are important. Written informed consent including for caesarean hysterectomy should be obtained. If cell salvage is available this can be used intraoperatively should massive haemorrhage occur.
At Caesarean, uterine incision should be above the placental edge if possible and delivery expedited. Spontaneous delivery of the placenta with oxytocics is preferable. intraoperative bleeding can be treated initially with ergometrine, Bakri balloon +-compression sutures. If abnormal adherence is known pre-op and family is complete then planned caesarean hysterectomy can be performed instead. ICU bed should be arranged for postoperatively. TEDs and sequential compression devices should be used.
Posted by NIRMALA M.
Nirmala
a. The main risk is Major placenta praevia. However she is only in her 20 weeks of gestation now and migration of placenta might occur in II & III trimester as lower segment forms. But this is very unlikely in this woman as she had previous 3 Caesarean sections and the placenta is anterior. The other potential risks are placenta accreta, placenta increta and placenta percreta. Due to previous 3 operations, she is high risk for bowel, bladder, ureter injuries due to possible adhesions if she should have repeat LSCS. If she is having placenta praevia, she might have several bleeding episodes leading on to anaemia and blood transfusions and related risks. She might end up having preterm delivery if excessive bleeding occurs < 34 weeks. Intraoperatively, she could develop massive PPH and possible hysterectomy if PPH uncontrolled.
b. Her antenatal management should be in a consultant led clinic. She should be rescanned at 32 weeks to confirm the placental position. If still major placenta praevia, she should have colour flow dopplers/MRI to rule out placenta accreta/ percreta/ Increta. In the presence of placenta praevia and if the above investigations are not available especially in the presence of anterior placenta with previous Caeserean, should be treated as placenta accreta. If the placenta has been migrated but within 2 cms from the Internal os during the 32 weeks scan(minor placenta praevia), she should have another scan at 36 weeks to confirm whether the placenta is cleared of 2 cms from the internal os. If placenta praevia especially major type, patient should be advised to avoid intercourse, constipation, lifting heavy weights. Advised to get admitted if any contractions or vaginal bleeding occurs. She should be admitted from 34 weeks if any h/o previous bleeding episodes in major placenta praevia. Without any bleeding episodes, she could be managed as outpatient basis after proper counseling provided she lives in the close vicinity to the hospital, attendant available and patient consented for outpatient care. Bloods should be checked for atypical antibodies as prior notice required in emergency situations. Liasing with haematologist is necessary to arrange for blood and blood products when massive haemorrhage occurs. Atleast 2 units of blood should be cross matched and available all the time in the antenatal ward fridge since patients admission in the ward. Proper counseling before delivery regarding repeat elective Caesarean section, massive PPH, blood transfusions and hysterectomy. Elective LSCS should be planned at 38 weeks to reduce neonatal morbidity. If vaginal bleeding < 34 weeks due to contractions, tocolysis could be considered to gain time provided no maternal or fetal distress. Steroids could be considered before 34 weeks in major placenta praevia. If massive bleeding mandates delivery of the baby, emergency Caeserean section should be done after stabilizing the patient. Her care should involve multidisciplinary team involving Obstetrician, Anaesthetist, Paediatrician and Haematologist. If she progresses to term, Elective Caeserean section should be done by Obstetric Consultant and anaesthetized by senior anaesthetic colleague. 4-6 units of cross matched blood should be ready intraop. Autologous blood transfusion not advisable. Cell salvage pump could be used intraop. If placenta is adherent and no PPH, could be managed conservatively by methotrexate and serial B-HCG. If severe PPH, controlled by under running of the placental bed vessels, uterotonic drugs, IIA ligation. If uncontrolled PPH, subtotal hysterectomy done to prevent maternal mortality. Adequate documentation, Incident reporting if hysterectomy , debriefing, supporting the woman is necessary.
Posted by Tendai C.
TMC:A healthy 37 year old woman with 3 previous caesarean sections attends the antenatal clinic at 20 weeks gestation. Ultrasound scan shows an anterior placenta covering the internal os and extending onto the posterior uterine wall.


(a) Discuss the risks associated with these findings [5 marks].
Placenta praevia is associated with significant maternal and fetal morbidity and mortality. There is a high risk of antepartum haemorrhage. This may lead to preterm delivery if bleeding is heavy. There is a high risk of transfusion of blood and blood products in significant bleeding. The placenta praevia in this case is unlikely to resolve as it is major praevia at 20 weeks. Morbidly adherent placenta is a risk especially if there has been a short caesarean to conception interval from her previous caesarean. This results in an increased risk of haemorrhage, transfusion, hysterectomy and other surgical procedure which may become necessary if life threatening bleeding like internal iliac artery ligation. Is she is managed as an in patient there is a risk of thromboembolism from prolonged hospital stay and reduced mobility.

(b) Discuss your subsequent antenatal care including planning for delivery [15 marks].
This is a high risk pregnancy and should be consultant led care. It is managed with a multidisciplinary team including a consultant obstetrician, anaesthetist, haematologist, paediatrician, sonographers and radiologist. A transvaginal ultrasound scan is useful to confirm the placenta praevia after the anomaly scan. In view of her previous caesarean sections, this woman is at increased risk of placenta accreta so MRI and colour flow doppler scans may be considered to assess if there is evidence of this. I would explain the diagnosis with the patient and her partner and the implications of bleeding. While the woman is being manged at home, someone should be available at all times to help her if necessary and she should live close to the hospital. She should be able to attend the hospital immediately if she has any bleeding, contractions or abdominal pain. At 28 weeks gestation the woman would have the routine full blood count, antibody screen and Anti D immunoglobulin if she is rhesus negative. A repeat transvaginal scan should be arranged at 32 weeks gestation to clarify the diagnosis of placenta praevia. As she is still likely to have major placenta praevia at this stage I would arrange in patient management from 32 to 34 weeks gestation in this case. A discussion with the woman and her partner is important now to plan delivery aiming for elective caesarean section at 38 weeks gestation. I would also discuss haemorrhage, possible need for blood transfusion and major surgical interventions like hysterectomy. Any objections and questions will be dealt with effectively. During her inpatient care she will have a large bore intravenous cannula at all times with blood cross matched according to local guidelines and protocols. If she has atypical antibodies , the haematologist will need to be made aware of this. A thromboembolism risk assesment will be made on admission. She will be advised to gently mobolise while in hospital to prevent thromboembolism and shold wear thromboembolic stockings at all times and it may be necessary to give her prophylactic anticoagulation if she high risk. The timing of delivery is based on the clinical judgement of the consultant obsterician and involves the woman. In this patient she will be advised elecitve caesarean section at 38 week in view of her previous caesarean sections. Sterilisation may be discussed. Blood will be crossed matched according to local guidelines and protocols. The blood bank should be aware of any atypical antibodies present. The caesarean is expected to be under regional anaesthesia unless it is an emergency caesaeran. The woman will be delivered by the most experienced obstetrician and anaesthetist on duty or they will both be present on delivery suiye during the caesaern section. The consultant staff will be alerted if an emergency arises. There will be neonatologists present t delivery. The woman should be counselled on the risk of a morbidly placenta with her previous caeserean sections and anterior placenta. The risk of haemorrage, transfusion and hysterectomy should be included in the consent. If there is massive haemorrhage, this should be dealt with according to local guidelines and protocols. Practice drills should be run regulary to keep all staff trained in emergency scenarios. Careful documentation of all events and members of staff involved is vital. The woman should have anti D immunoglobulin as usual if she is rhesus negative unless she has a hysterectomy. She should be encouraged to breast feed as soon as possible and given prophylactic anticoagulation while in hospital. Contraception should be discussed if she declies sterilisation. She should be reviewed six weeks postnatally for debriefing.
Posted by R v P.
RVP

A healthy 37 year old woman with 3 previous caesarean sections attends the antenatal clinic at 20 weeks gestation. Ultrasound scan shows an anterior placenta covering the internal os and extending onto the posterior uterine wall.

(a) Discuss the risks associated with these findings [5 marks].

This is major previa. Anterior previa with uterine scar from C/S is assosiated with morbidly adherent placenta such as acreta, increta and percreta. She is at increased risk of antepartum haemorrhage due to placenta previa as well as morbidly adherent placenta. She is also at increased risk of bleeding at delivery(C/S) and PPH. She is at increased risk of requiring blood transfusion as a result of haemorrhage. Her risk of requiring intrapartum hysterectomy is also higher. She is also at higher risk of maternal death. Risk of fetal death, prematurity and need for admission to SCBU is also higher. Risk of vasa previa and velamentous insertion of the cord is also higher with placenta previa. She is at increase risk of venous thromboembolism from immobility, haemorrhage and her age.

(b) Discuss your subsequent antenatal care including planning for delivery [15 marks].

Her ante natal care should be by a multi deciplinary team including consultant obstetrician, consultant anaesthetist, haematologist, radiologist and paediatrician. She may need to be referred to the regional tertiary centre if blood bank, cell salvage, expert radiology (MRI for accreta/uterine artery embolisation) fascilities are not available locally.
She should be offered all routine antenatal care. In addition, placenta previa should be confirmed/excluded at 32 weeks by TV scan (RCOG greentop). It is unlikely placenta would be moved away later, if major previa is still present at this gestation. MRI scan of uterus should be done and interpreted by an expert to exclude accreta. Alternative is colour doppler. Risk of bleeding should be explained to the mother and adviced to attend hospital if she starts bleeding. Written information should be provided. Her blood count should be optimised antenatally and anaemia treated with iron tablets, iron infusion or blood transfution. She should be offered admission to the hospital at 34 weeks if she has had any bleeding. Steroids for fetal lung maturation should be indicated if early delivery is antecipated. Her VTE risk should be calculated on admission and thromboprophylaxis should be offered to her. Uptodate group and save samples should be maintained at the lab. Some units keep two units of crossmatched blood on the ward due to the risk of bleeding.
If no bleeding during pregnancy, home management could be considered by the consultant and individualised. Exclusion of morbid adherence, proximity to the hospital and availability of another competent adult available with the patient at home are the factors considered for home management.
Written informed consent for C/S should be obtained antenatally. Risks discussed in the 1st part of the question should be explained to her. If she refuses blood products, this should be clearly documented and an advanced directive should be encouraged.
Anesthetic review to plan anaesthesia for C/S should be organised antenatally. Increasingly, regional anaesthesia is used for C/S with major previa. Cell salvage should be discussed with the patient and made available with staff trained to use it for delivery. Interventional radiology such as placement of uterine artery catheters for prophylactic embolisation by an interventional radiologist should be discussed with the patient if expertise is available. Haematologist and the lab should be informed about the planned date and time of surgery and available as blood and blood products may be needed urgently. Blood should be crossmatched and available (ie 6 units according to hospital protocol) at the time of surgery. Elective C/S is usually done at 38 completed weeks. Consultant anaesthetist and Obstetrician should be available to undertake the C/S or directly supervise the procedure.
Posted by Dr Dyslexia V.
X
a) Her main risks in this pregnancy include placenta previa major with possibilities of accreta or percreta and the risks of adhesion and possible intrabadominal injury such as bladder or bowel in view of 3 previous scars. She has high risk of having antepartum hemorrhage which could result in anemia which needs correction. She also has high risk of having postpartum hemorrhage which could result in hysterectomy. Other surgical risks are included as well such as blood transfusion and venous thromboembolism. There is also risks of intrauterine growth restriction of the fetus which are associated with placenta previa and it’s association risk of sudden intrauterine death.
b) Her management should be done by a consultant led unit with good accessibility for surgery and blood products. She should be seen regularly about 2 weekly for fetal growth and placental position. If anemia present it should be corrected with hematinics. An antibody screening should be done at about 24 weeks for availability of rare blood in case of transfusion. The issue of transfusion in this pregnancy must be discussed and her wishes should be acknowledged in terms of transfusion. Options of cell salvage and activated factor 7 and resort to hysterectomy should be discussed as well. She should be informed that an inpatient management will be preferred after 34 weeks of pregnancy and earlier if any major antepartum hemorrhage occurs. Transvaginal scan should be done with conjunction with Doppler to assess possibilities of accreta or percreta with additional use of a MRI if facilities permit. If accrete is suspected she should be managed with a multidisciplinary team which include surgeons, hematologist, radiologist and urologist. She should be informed the high risk of postpartum hysterectomy. The options of a classical caesarean section with leaving placenta insitu post delivery should be informed as it minimizes bleeding. She should be aware that this procedure is associated with high return to theater for hysterectomy, infection and increase blood transfusion. This management could be managed with in concurrent use of uterine artery embolization to arrest bleeding after leaving placenta insitu. The issue of postpartum BTL earlier in pregnancy should be discussed as well in view of high risk of future pregnancies if uterine conservation is successful. She should be given anti-D is she is rhesus negative in any episodes of antipartum hemorrhage and with use of Klihaeur test if she is keen for a next pregnancy. A clear plan of the pregnancy must be made so she would prepare her family and children for her management in this pregnancy.
Posted by millionaire2004 A.
Ag
healthy 37 year old woman with 3 previous caesarean sections attends the antenatal clinic at 20 weeks gestation. Ultrasound scan shows an anterior placenta covering the internal os and extending onto the posterior uterine wall. (a) Discuss the risks associated with these findings [5 marks].

There is risk of antepartum hemorrhage. This needs hospital admission. May need blood transfusion in severe cases. There is risk of blood transfusion such as alloimmunisation, transfusion related infection. Risk of placenta accereta. This can be predicted with colour Doppler study. Risk associated with delivery by caesarean section such as injury to bladder,bowel,ureter,massive hemorrhage (PPH) and risk of hysterectomy. Risk of post-partum sepsis. Risk of intrauterine growth restriction of fetus. Risk of major congenital anomalies doubled in fetus. There is risk of premature delivery due to APH. There is also risk of malpresentation.

(b) Discuss your subsequent antenatal care including planning for delivery [15 marks].

Low lying placenta should be confirmed by transvaginal ultrasound. This has been shown to reduce patient visits to hospital for subsequent scans. Reassure her that 50% of low lying placenta found at mid-pregnancy resolve by term . Antenatal care by a consultant obstetrician. Discuss with couple regarding risk of placenta praevia, especially massive hemorrhage,placenta accrete and risk of hysterectomy. Discuss regarding future fertility plan. Discuss regarding plan if she developed per vaginal bleeding. Plan includes immediate hospital admission, group and cross match blood, administration of antenatal corticosteroid, alerting neonatologist, intensive unit specialist, consultant obstetrician and consultant anaesthetist. Detailed anomaly scan and detailed cardiac scan between 20-24 week gestation. This is to rule out major congenital anomaly. Arrange ultrasound scan for fetal growth 2-4 weekly . Confirm placenta praevia by transvaginal ultrasound at 32 week gestation. Likelihood of placenta praevia predicted with colour Doppler of placental bed. If asymptomatic, she needs be managed as an in-patient from 32-36 weeks gestation in a tertiary hospital. The timing of admission depends on proximity of patients home to hospital, presence of companion at all time and patient’s wishes. Group ,save and hold and arrange for blood to be available at all time according to local protocol. If patient has atypical antibody, involve hematologist in her care. Optimise her Hb (>11 g/dl). Assess risk for venousthromboembolism and if she is in intermediate/high riskgroup, consider low molecular weight heparin . Advice her to mobilise and to wear TED stockings. Pre-operatively, discuss with the couple regarding risk of CS (injury to bladder,ureter,bowel), massive hemorrhage, need for blood transfusion, and hysterectomy. Document in the case note. Her delivery is by caesarean section. Offer bilateral tubal ligation. If she is asymptomatic, delivery by 38 weeks gestation. Arrange review by anaesthetist to discuss type of anaesthesia and take maternal wishes into consideration. Arrange for CS to be done/ directly supervised by consultant obstetrician. Group and cross match at least 4 units of blood. Arrange for cell salvage if facilities available. If she is on prophylactic LMWH, omit the dose in the morning of CS.
Posted by KWASI RICHARD A.
KRA
A. There is the risk of the placenta been morbidly adherent because of her previous caesarean section development of placenta accreta or percreta,therefore need to counsell her about the risk of hysterectomy if uncontrollable bleeding at caesarean section.
Antepartum haemorrhage may require admission and risk of blood transfusion if bleeding is life threating.Risk of repeat caesarean section include difficult Abdominal entry because of multiple adhesions, injury to bladder, bowel and postpartum sepsis. Repeated bleeding is associated intrauterine grouth restriction and placenta praevia is associated malpresentation and congenital malformations.

B. She would be seen in a consultant led antenatal clinic, this is a high risk pregnancy. Repeat transvaginal ultrasound scan would be done at 36 eeks for placental localisation with ultrasound imaging with colour flow Doppler because of the risk of mobidly adherent placenta due to three previous caesarean section. If she bleeds I would offer admission from 34weeks or admit earlier if bleeds again or subsequent bleeding is heavy. If She is asymptomatic I would counsel and manage at home or in hospital. She should live in close proximity to the hospital with ready acess and constant presence of companion or any carer. Must attend hospital if experiences contractions, bleeding or ruptures of membranes.Prolonged inpatient care may increase risk of venous thromboembolism hence gentle mobile and consider throboprophalaxis.
Antenatal discussion regarding delivery about haemorrhage at delivery, blood transfusion, major surgical interventions like hysterectomy and any objections and queries dealts with effetivectively. Involves the blood bank if she has atypical antibodies.Delivery would be elective casarean section at 39weeks by the most experienced Obstetrician involving the Consultant anaethetist and Haematologist. Six units of blood need to be crossmatched and blood must be ready in the theatre before casarean section is commenced. Organise cell salvage facilities if available. Post delivery monitor on modified early warning score chart in high depending unit till full recovery.
Posted by Roba R.
Roba

A)

- Antepartum haemorrhage
- Increase risk of placenta accrete
- Preterm delivery
- Intraoperative bleeding
- Hystrectomy
- DIC
- Maternal death

B)
Management :
- Tertiary Hospital based Care
- Multidisciplinary care involve anaesthetist, neonatologist , haematologist, radiologist, mid wife , social worker.
- More frequent antenatal visits to high risk pregnancy clinic
- Second trimester: GCT, Blood group and antibodies at 26 weeks
Advised to contact the hospital if bleeding
AntiD at 28wk and 34 weeks if blood group negative
- Organise repeat Ultrasound at 26weeks, if confirmed findings ,request MRI to provide the level of placental invasion.
- Frequent fetal growth scans and Doppler as increase risk of Intra uterine growth restriction.
- If confirmed Placenta accrete, elective admission at 34 weeks.
- Plan of deliver:
Timing: at completed 37weeks or if develop vaginal bleeding prior to that
Mode: LSCS +/- Hysterectomy
_ Delivery: Consent form
Inform Radiologist: Intervention by uterine artery embolisation
Steroids as evidence showed increase risk of hyaline disease for elective lscs delivery before 39weeks.
- Inform blood bank/haematologist
- senior obstetrician
- inform urologist: possible stent prior to surgery to avoid uretric injury
- x match for at least 4 units of blood
Posted by A H.
AH

a) The maternal risks include persitent placenta preevia in up to 50%.This will predispose her to major and recurrent antepartum haemorrhage requiring blood transfusion and possible emergency caesareean section, both of which are associated with risks.
A history of 3 previous caesaren sections will increase her risk of having a morbidly adherent placenta. This increases her risk of major postpartum haemorrhage, which may necessitate a hysterectomy as a life-saving manouvre.
She is also at risk of postpartum sepsis and the condition may recur in a future pregnancy
The foetus is at increased risk of congenital malformation, abnormal lie and presentation and IUGR.
The risk of iatrogenic preterm delivery is increased predisposing the foetus to inreased risk of neonatal morbidity like respiraratory distress as well as neonatal mortality.

b)I will do a transvaginal ultrasound scan to confirm the diagnosis, as this is more accurate and is also safe. If confirmed a colour flow Doppler will be done to detect placenta accreta.
A detailed anatomy scan will be requested.
She will receive consultant-led care at a tertiary care centre with full blood banking failities.
She will be counselled about the diagnosis and advised to come to hospital if she bleeds.
If the placenta was found to cover the os, or if she experienced bleeding,she will be offered a repeat scan at 32 weeks to detect if there is placenta praevia so that subsequent care and delivery can be planned. If there is major praevia, she will be counselled and offered in patient care. Out-patient care will be allowed only after due counselling and documentation in the notes, that she will need to live close to the the hospital with a constant companion at home and easy quick access to the hospital if she bleeds.
She will informed that she will require caesarean delivery. She will be counselled about the risk of sudden heavy bleedig requiring blood transfusion and the possibility of emergency preterm delivery.
I will screen for atypical antibodies and if present will arrange with the haematologist and blood bank to have cross matched blood available for her. Her risk for DVT will be assessed and haematologist input will be sought to decide on thromboprophylaxis.
A meeting will be arranged for her to meet with the consultant obstetrician and anaesthetist to discuss type of anaethesia and plan her delivery. Clear documentation will be made in her notes.
If she is asymptomatic, delivery will be planned at 38 weeks.
Consultant anaesthetist and obstetrician will be present for the delivery. If placenta accreta is suspected and interventional radiology services are available they will be alerted prior to the caesarean section.
If the placenta was found to be encroachig the os, she will be managed as an outpatient after careful counselling. She will be offered caesarean section if the placenta is within 2 cm of the os.
This will be done at 38 weeks.
Posted by Bobey B.
The associated risks with placenta previa are antepartum haemorrhage. It is a major cause of maternal morbidity and mortality. There is an increased risk of placenta acreta and percreta in a woman who had uterine scarring (previous 3 CS). They are life-threatening complications with a high potential for caesarean hysterectomy .The following risks increasing with previous 3 CS like injury to bladder, bowel or ureter and the need for intensive care unit admission, duration of operative time and hospital stay. Postpartum sepsis is another frequent maternal complication. The findings represent significant fetal problem because of preterm delivery, IUGR, congenital malformations and perinatal mortality.
b) The ultrasound scan findings should be explained to the woman. The high risk of sudden haemorrhage associated with major placenta previa should be borne in mind and the appropriate management plan should be in place. Anomaly scan should be arranged at 22 weeks. Blood sample should be taken for FBC to identify anaemia early as possible and monitor haemogloblin levels at the upper end of the normal range. A kleihuer test should be performed if she is Rh negative . Serial fetal growth ultrasound scan to detect IUGR is important. The woman with previous 3 CS and anterior placenta previa is at increased risk of placenta accreta. Colour flow Doppler ultrasound or magnetic resonance imaging should be used to make diagnosis, or she should be managed as if she had placenta accreta.
The accepted approach to management of symptomatic major placenta previa is conservative and expectant involving possible long-term hospitalization , bed rest , blood transfusion where needed and fetal monitoring with an objective of reaching at least 37 weeks gestation.
Asymptomatic major placenta previa should be managed as inpatients from 32-34 weeks gestation. The decision on when to be admitted depends on home support, close proximity to a hospital and readily available transportation and telephone communication. She should be advised to attend hospital immediately if any bleeding or any pain (including vague suprapubic period-like aches). There is higher risk of preterm delivery and therefore she would benefit from close inpatient monitoring.
Prolonged inpatient care can be associated with an increased risk of thromboembolism and therefore thromboprophylaxis is recommended .Gentle mobility should be encouraged with use of prophylactic thromboembolic stockings. Corticosteroids should be given if she presenting with bleeding from 24-34 weeks gestation. In-utero transfer should be considered if facilities for neonatal intensive care is unavailable.Blood should available during inpatient antenatal care and should be based on local guideline and haematologist should be involved if she is with atypical antibodies. A \"group and save\" sample of blood should be adequate for case with no bleeding and no abnormal antibodies. However ,if she is refusing blood transfusion , she should be transferred to a unit with facilities for prompt management of haemorrhage , such as interventional radiologist , cell salvage and surgical expertise. Autologous blood transfusion should not be suggested .Absolute indication for delivery include bleeding after 36 weeks , fetal distress at a viable gestation and persistent haemorrhage causing maternal haemodynamic instability not readily corrected with volume replacement at any stage of pregnancy.
Management should concentrate on pre-operative counseling regarding the potential for uncontrollable haemporrhage , hypovolaemia , shock , coagulopathy , anaemia , venous thromboembolism and the risk of hysterectomy . Multidisciplinary joint plan with consultant anaesthetic , intervention radiologist , haematologist vascular surgeon , neonatologist and intensive care unit specialist should be done in advance. Informed consent should be obtained to perform elective CS at 37 weeks, the benefits, risks and alternatives of the planned procedure (like internal iliac artery ligation, B-lynch suture, prophylactic and therapeutic uterine artery embolisation and hysterectomy) should be discussed and documented.
Posted by S P.
hi Paul could you please mark my essay i posted it on time i think..
Posted by Bgk H.
bgk

a. The risks can be divided into antenatal, intrapartum and postpartum. There is a risk of antepartum hemorrhage which requires resuscitation and urgent delivery. This may need to undergo crash caesarean section and associated with increase in morbidity. There is also risk of fetal growth restriction because of abnormal placenta site and may need iatrogenic preterm delivery. Other risk is prolonged admission to antenatal ward for symptomatic patient and this associated with risk of deep vein thrombosis and hospital acquired infection. Intrapartum risk include need unplanned caesarean section if she is bleeding heavily. There is a risk of placenta acreta and increase risk of hysterectomy. She also has increase risk of blood transfusion. During postpartum period, she has an increased risk of postpartum hemorrhage.

b. Her management should be consultant led and jointly manage with the anesthetist. She needs to be informed regarding the finding of the low lying placenta. The consequences of the finding such as bleeding (antenatal and postpartum) need to be informed. Advise on urgent attention on PV bleeding, sign and symptoms of labour and avoidance of sexual intercourse needs to be given. If asymptomatic, she can be managed as outpatient provided that she lives nearby and having someone to bring to hospital if needed. A repeat scan should be done at 32 weeks gestation unless she is symptomatic. If the placenta remain low at 32 weeks gestation she should be manage as in patient from 34 weeks onwards. She should be aimed to deliver as an elective caesarean section by 37 weeks if she remains asymptomatic.

Before caesarean section, placenta acreta need to be ruled out. This can be done by ultrasound Doppler. Appearance such as bladder invasion and loss of space between lower segment and urinary bladder may suggest placenta acreta. If placenta acreta suspected, MRI can be done to confirm it. For caesaren section in suspected placenta acreta, early anesthetic referral needed and blood group and cross match must be available at least 4 units. The operation should be done by most senior obstetricians available. Intraoperative cell salvage can be considered in anticipation of blood loss of more than 1.5 liters. If there is expertise available, interventional radiology can be involved in placement of uterine artery catheterization. This can be used for embolisation of the artery in intractable uterine bleeding following delivery of the placenta. During postpartum period a close observation needed as she has the tendencies to bleed afterward. Oxytocin infusion can be given if not contraindicated. Patient management plan should be clearly documented in the notes. Patient information sheet regarding placenta praevia need to be given.
Posted by HM ..
HM

a) This is a case of major placenta praevia with previous Caesarean section(CS). This case is generally associated with increased maternal and perinatal morbidity and mortality.There is increased risk of antepartum haemorrhage and thus preterm delivery and risks of prematurity if early delivery required. The increased risk of placenta accreta predisposes to increased risk of intraoperative haemorrhage and postpartum haemorrhage. Intraoperatively there is an increased risk of injury to viscera like bowel, bladder, ureters because of adhesions and risk of hysterectomy if bleeding is uncontrolled. There is also risk of hysterectomy if bleeding is uncontrolled. There is also risk of antepartum stillbirth if masive bleeding occurs before delivery of fetus.

(b) The ultrasound scan shows a major placenta praevia. If this was performed transabdominally then it can be repeated transvaginally, once there has been no pv bleeding as it will reduce the false positive finding of placenta praevia. The rest of the mother\'s antenatal care will be clinically dependent on the situation and most importantly on the occurrence of any bleeding. Any such bleeding and she she should be managed as an inpatient. If asymtomatic, outpatient management adequate till about 34 weeks gestation. A repeat ultrasound should be done at 32 weeks, as well as a colour flow Doppler to determine the presence of placenta accreta, which is very likely. When admitted at 34 weeks or earlier, this should be in a consultant led unit in a facility which has access to readily available haematology services and emergency operating theatre. Blood should be taken for group and Xmatch and at least 2 units of packed cells should always be available. Her CBC should be checked and ensure optimization of Hb level. Anaesthetic consult should be made early. A discussion with respect to the timing of delivery and risks of repeat CS with patient and her partner should be done early.They should be informed of risks increased for visceral injury, intraoperative/ postoperative haemorrhage and possible need for hysterectomy. I would discuss her reproductive ambitions at this point and if there is any objection to receipt of blood/ blood products as blood transfusion is very likely.
During her hospital stay, thromboprophylaxis should be aided by adequate hydration, ambulation and use of TED stockings. There is also possible need for corticosteroids to aid fetal lung maturity if delivery likely before 34- 35 weeks gestation.
Delivery should be done ideally at 38 weeks if asymptomatic or earlier if there were any incidents of antepartum haemorrhage. A consultant should be doing the CS or least be present in the operating room.Active management or third stage should be intiated. After delivery of the fetus and placenta accreta encountered the choice to leave placenta in situ will be guided by maternal reproductive ambitions and amount of bleeding at the time. It can be left in situ and removed at a leter date, either vaginally or surgically or treatment administered with methotrexate. If possible, intraoperative arrangements may be done in advance for uterine artery embolization if facilities available or internal iliac artery ligation performed. Early resort to hysterectomy should be cosidered if blood loss incontrollable.
Posted by Mohamed D.
Mohamed
A) Risks related to placental location include persistent placenta previa major degree in the third trimester. Risk of morbidly adherent placenta (accrete or percreta). There is a risk of severe antepartum haemorrhage that can affect both the mother and the baby. Anaemia from recurrent or severe bleeding. Blood transfusion related risks as infection, incompatibility and abnormal antibodies, although rare to occur. There is a risk of hysterectomy with severe bleeding and future effect of fertility. There is a risk of difficult surgery from the previous surgeries with increased risks of bowel and urinary injuries.

B) Consultant led care should be arranged for the ANC follow up. Multidisciplinary care with anaesthetic review by consultant for the risks associated with surgery and the possibility of a GA for her section. If she has not had any bleeding, ultrasound should be repeated at 32 weeks to plan management and delivery early in the third trimester. If she has any antepartum haemorrhage, ultrasound should be repeated earlier for placenta localisation and fetal growth. If major placenta previa is suspected; Doppler ultrasound or MRI should be arranged to rule out morbidly adherent placenta. If she had any bleeding she should be manged as an inpatient. When no bleeding occurred, she should be counselled for admission to hospital as there is increased risk of bleeding. FBC should be sent to check anaemia at 28 weeks as normal and optimization of her haemoglobin should be done. Group and serum save, and if there is abnormal antibodies, another sample for cross matching should be sent earlier if admitted and bleeding. If she is inpatient, 2 units of cross matched blood should be available in the fridge, or according to the local blood bank guidelines. These should be changed on weekly bases. During hospitalization advise mobilisation and adequate hydration. TED stockings should be put on to reduce the risk of thromboembolism. If there is any antepartum haemorrhage prior to 34 weeks, steroids should be given to promote lung maturity and to reduce the risk of TTN in case of preterm delivery. Written information and discussion antenatally with the consultant about risk of bleeding, blood transfusion, CS morbidity, and possibility of hysterectomy. Delivery should be conducted by the consultant obstetrician and she should be advised to have a GA for risk of bleeding during the CS (as regional anaesthesia may be associated with drop in blood pressure which would worsen the condition if she bleeds). Anaesthetic consultant should be in theatre, as there are high risks of morbidity with bleeding and further surgery may be needed. Delivery should be planned by elective caesarean section at 37-38 weeks unless bleeding, it may be needed earlier. Consent should be signed prior to surgery and hysterectomy should be included. Blood bank should be notified on admission and a fresh blood sample should be sent for cross matching if needed. Haematology consultant should be involved if abnormal antibodies or need rFactor VII injection in post partum haemorrhage.
Posted by R v P.
Hi Paul, To answer your question

should there be an obstetric unit in a hospital without a blood bank

Try Liverpool Womens Hospital. The largest maternity unit in europe with close to 10000 deliveries per year. They dont have a blood bank and have to blue light to Royal Liverpool hospital for blood. I think there are few other large \"womens\" hospitals without inhouse bloodbanks. This was highlited in the TOG article on care bundle for placenta accreta as well.