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MRCOG PART 2 SBAs and EMQs

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I have rewritten the placenta previa topic. I look forward for your comments

I have rewritten the placenta previa topic. I look forward for your comments Posted by narmin B.
A 24-year old woman is known to have a placenta that is implanted over the internal os. She presents at 28 weeks gestation with vaginal bleeding. Justify your management.

Placenta previa is associated with increased rate of maternal and fetal mortality and morbidity. Its management depends both on the severity of bleeding and also fetal condition.

The patient should be admitted on the labour ward where maternal and fetal conditions can be assessed and appropriate care provided. Assessment of the mother includes: checking the blood pressure, pulse, estimation of blood loss, abdominal examination for identifying fetal lie and presentation and uterine contractions. Vaginal examination, either digital or by speculum, must be avoided, as it may provoke heavy bleeding. Cardiotocography is required for evaluation of the fetal well-being. Further management is directed by the results of this assessment

In the case of heavy bleeding an urgent review is needed by a senior obstetrician and anaesthetist. We need to start maternal resuscitation immediately. The patient must be placed in a head down position which improves cardiac output by increasing venous return. An open airway should be secured. Administration of oxygen is necessary, as reduced haemoglobin level will result in hypoxymia and acidosis. Insertion of two large bore cannulas is needed to provide venous access and for infusion of fluids. At this time blood sample can be taken to test blood group, rhesus and cross match of six units of blood and also for full blood count and clotting profile. Infusion of volume expanding fluids such as Hartmann?s, normal saline and group O negative blood, will increase blood pressure and prevent renal failure. Blood transfusion should be started to replace the blood loss. A central venous pressure (CVP) line may be required to monitor fluid infusion rate and prevent fluid overload and pulmonary oedema. If the patient continues bleeding urgent delivery is required.

The method of choice for delivery is caesarean section .Vaginal bleeding is contraindicated as it will result in massive bleeding. This should be explained to the couple and specific complications of the surgery like heavy bleeding during operation and the need for performing other procedures such as hysterectomy must be mentioned. Operation should be performed by an experienced surgeon as adherent placenta can be seen with placenta previa and also other interventions like hysterectomy and uterine artery ligation may be required. Vertical incision may be needed as lower segment at this stage of pregnancy has not been formed and malpresentation is common. Oxytocic such as syntocinone infusion must be given after delivering the baby as atonic uterus is one the common complications. General anaesthesia is the method of choice as regional anaesthesia can cause hypotension which is dangerous in an already hypotensive patient. This must be provided by an experienced anaesthetist Paediatrician is needed to attend in the theatre to provide care for the baby.

All the measures should be documented for record keeping and referral in future pregnancy. Patient must be seen after the operation in an appropriate time for an explanation of the management and answering her questions.

Howerver,If the assessment shows that the bleeding is mild and there is no fetal distress, conservative management is recommended. Patient should be kept on the labour ward until bleeding settles .Continuous monitoring of fetal heart during active bleeding is necessary to determine any fetal distress. She can be transferred to the antenatal ward where maternal bleeding can be checked and daily cardiotocography can be performed. Steroid must be given to the mother which reduces the rate of neonatal respiratory distress and intraventricular haemorrhage in case of a preterm delivery. Anti-D administration prevents isoimmunisation in a Rhesus negative patient. The patient can be discharged when there is no further bleeding for at least 48 hours. Follow-up appointment for the antenatal clinic must be arranged to check maternal and fetal conditions . For the last four weeks of pregnancy the patient is required to stay in the hospital as there is high risk of heavy bleeding with the start of labour. An elective caesarean section at 37 weeks should be booked as a change in the placental location is unlikely in this case.