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ESSAY 144 - PLACENTA PREVIA

Posted by Sarwat F.
A woman with placenta previa having vaginal bleeding represents an obstetric emergency. Management will include stabilization of the condition of woman and delivery by caesarean section. Woman should be examined and her notes are quickly reviewed to ascertain the cause of her admission. Examination will include checking for anemia as well as abdominal examination palpating uterus for contractions and auscultation of fetal heart sounds. IV line is maintained with two wide bore IV cannulas. Senior obstetrician informed about womans condition. Blood is arranged at least 4 units after grouping and cross matching, more if the woman is anemic. At least 20 ml blood is drawn and sent for full blood count, urea, electrolytes and coagulation studies. Patient counseled about immediate need for delivery, risk of further hemorrhage intraoperatively, adherent placenta and informed consent taken for hysterectomy. A neonatologist should be present at the time of delivery as there is a risk of birth asphyxia for the neonate and SCBU must be informed. Before the caesarean, patients past obstetric history is checked to see if she has had any previous caesarean sections which increase the risk for placenta acreta, her most recent scan is reviwed to check if the placenta is anterior or posterior as an anterior placenta may be associated with more difficulty in operative technique. Senior most person available on the delivery suite should be doing the caesarean section. Anaesthetist will be informed regarding woman’s condition and vaginal bleeding as general anaesthesia is prefereed in this situation because of the risk of hypotension associated with regional blockade. A good assistant will be required. Intraoperative technique will differ from an ordinary caesarean section in the sense that there is more risk of hemorrhage and difficulty in delivering baby and giving uterine incision. Rarely a classical caesarean section may be required. Before uterine incision abdominal cavity may be packed to minimize risk of damage to adjacent organs. If placenta is encountered in uterine incision there arte two approaches, either to go in the plane between uterus and placenta or to cut through placenta which should be rapid enough to prevent fetal hypoxia. After delivery of the baby and placenta one of the most important approach to minimize hemorrhage is quick and secure closure of uterine incision. If however bleeding is present in the placental bed a figure of 8 stitch can be applied there. Intravenous syntocinon and ergometrine given as sometimes bleeding may occur due to coexistent uterine atony. In case of PPH not responding to syntocinon and ergometrine and Prostaglandin F2 alpha, uterine and ovarian artery ligation can be done. Quick decision is needed for intervention in case of PPH depending on the expertise present as if expertise for artertial ligation are not present hysterectomy maybe needed to save woman’s life. After delivery Patient may need HDU care. Post partun thromboprophylaxis may be required, anti D given if woman is Rh negative. Incident form is filled and risk management team notified. Patient will be counseled regarding the recurrence risk in future pregnancies.
Posted by Nibedita R.
This is an obstetric emergency. Prompt assessment of maternal and fetal condition to prevent morbidity and mortality from acute blood loss and its complications (CVS and respiratory failure, ARF, DIC and VTE), acute fetal hypoxia and stillbirth.

Haemodynamic stability is the first priority. Her vital signs such as pulse, BP and SO2 should be measured. A cardiotocography is done to assess fetal condition and also uterine activity.

If her condition is compromised, airway, breathing and ciculation have to be established first. Help from experienced midwife, senior obstetrician and anaesthetist would be sought. Maintenance of airway and oxygen by mask. Two wide bore cannula for venous access and blood collected for FBC, grouping and cross matching at least 4-6 units and kleihauer if Rh negative. Discussion with haematologist should be done regarding urgent need for blood transfusion. A review of the notes to look for any objection (Jehova?s witness) to blood or blood product transfusion. A CVP line should be placed and catheterisation to monitor urine output. Fluid infusion with colloid and O negative blood if severely compromised and blood still unavailable.
Monitoring of vitals every 15 minutes and urine output hourly should be done. Resuscitation and arrangement for emergency caesarean section should be done simultaneously. Theatre staff, senior anaesthetist, SCBU and consultant obstetrician should be informed.

If her condition is stable, a history and review of the notes done to assess risk: parity, previous CS and myomectomy (risk of morbid adherent placenta), other pregnancy associated complication like preeclamsia or PPH in past pregnancy which increases risk of haemorrhage. P/A to assess uterine activity (frequency of contraction), presentation and FHR. Speculum examination to assess blood loss and condition of cervix (dilated cervix increases risk of haemorrhage from placental separation). Vaginal examination should not be done.
She should be counselled regarding the urgent need for CS and associated complications such as PPH, postpartum endometritis, placenta acreta and the urgent need for hysterectomy.

CS should be done under general anaesthesia and halothane which causes uterine relaxation should be avoided. An experienced obstetrician should perform the operation and consultant must be readily available. Fetus is at risk of hypovolemia and anaemia, blood loss should be minimised. Cord blood should be collected for Hb estimation. Active management of thirdstage with oxytocin, ergometrine and carboprost to minimise blood loss. Manual removal of placenta should not be done as it increases risk of endometritis.

If bleeding is excessive, the obstetrician should consider other surgical procedures to arrest bleeding such as internal iliac ligation, B-Lynch suture or billings suture, or subtotal hysterectomy. Obstetrician if not competent enough to perform any of these surgical procedures should immediately seek assistance.

Antibiotic prophylaxis to reduce risk of infectious morbidity. Thromboprophylaxis by LMWH for 3-5 days or until full mobilisation along with adequate hydration and TED stockings.
Depending on the condition, patient may need care under HDU.

Post op monitoring of vitals, vaginal bleeding, uterine contractility and urine output hourly for 24 hours. Post op investigations include: FBC, U/E, Clotting factors (if massive haemorrhage with massive transfusion).

Consultant haematologist?s advice should be sought if transfusions of platelet, FFP or cryoprecipitate are required to correct haematological and biochemical abnormalities (arising out of massive transfusion) such as thrombocytopenia, hyperkalaemia and hypocalcaemia.
Anti D immunoglobulin 500iu im within 72hrs of delivery if mother is Rh negative with Rh positive baby. Extra dose should be calculated from Kleihauer count.

Clear documentation of urgency of CS, assistance and help sought, stepwise procedures performed and counselling of the patient if it could not be done before due to practical reasons.
Incident reporting form for risk management.
Information should be given about the risk of recurrence(4-8%) in future pregnancy.



Posted by velam K.

Management of this patient involoves basic resuscitation with simultaneous communication with senior colleagues and appropriate arrangement for delivery.
The patient should be given facial oxygen, and two large bore intravenous cannulas should be inserted. Blood should be obtained for full blood count , crossmatch 4 units, coagulation screen, urea and electrolytes. Her temperature, pulse blood pressure should be monitored. CTG should be started.
Consultant obstetrician,anaesthetist should be summoned, as this is a high risk situation. Theatre staff, paediatricians should be informed about the need for emergency delivery.The haematologist, laboratory and porters should be informed of the situation.
Her case notes should be reviewed to see for mode of delivery if she is a parous patient. This is important because there is a high risk for placenta accreta if it was a caesarean section. In that case her scan reports should be reviewed to look for any evidence of accreta or whether she has had any colour doppler carried out . If it is accreta then prophylactic measures like uterine artery catheterisation or plan to leave the placenta in situ are shown to be effective.
The patient and her partner should be explained about the need for delivery. she should be explained about the possibility of haemorrhage during or after the procedure. she should be explained about the need for blood transfusion and should be asked about if she is against it (like jehovahs witness). It should also be explained that she may need additional procedures like uterine artery or interna iliac artery ligation or very rarely hysterectomy.
The choice of anaesthesia depends on anaesthetist but regional anaesthesia is proven to be an acceptable method now. The caesarean section should be done by the senior obstetrician as it is shown to improve outcome. A dose of intravenous antibiotic should be given as it reduces the infectious morbidity. The obstetrician should be ready to resort to the following procedures like intramyometrial prostaglandin injection, B lynch brace suture, uterine artery ligation, internal iliac artery ligation or hysterectomy as required.It has been proven that earlier resort to any of these methods is shown to reduce maternal morbidity and mortality.
The patient should be monitored postoperatively for developing PPH. Blood transfusion or other blood products amy be necessary based on blood results after consulting with consultant haematologist. Anti D should be given if she is Rh negative after taking blood for kleihaeur. Thromboprophylaxis should be presribed according to national protocol as these patients are high risk for thromboembolism.
She should be explained about the recurrence of placenta praevia and risk for placenta accreta in next pregnancy, particularly if the interval between conception is short. contraceptive advice should be given..
Posted by narmin B.
The aim of the management in a woman with placenta previa is to prevent maternal and fetal mortality and morbidity due to bleeding. Therefore this woman should be seen urgently as she may lose large amount of blood in a short period of time.

First of all her homodynamic status (blood pressure and pulse) and the amount of bleeding should be assessed quickly. Resuscitation is the first step in a patient with heavy bleeding or compromised haemodynamic condition. Immediate help is required from a consultant obstetrician, and an experienced anaesthetist as emergency caesarean is required. A senior midwife and SHO also should attend to help with resuscitation and communication with haematology laboratory and blood bank. Two large bore canulaes should be sited to have easy venous access. Blood should be taken for group and save, full blood count, cross match of 4 units of blood and kliehaure test. These tests may have already been done since the patient has been in the hospital. Intravenous fluids such as Hartmann’s solution, gelofusin or group O negative blood should be administered until cross-matched blood becomes available. Objections to blood transfusuion should be considered and advice should be obtained from haematologist for blood substitues. The reason for replacement of blood is to stabilise the haemodymic condition and prevent haemorragic shock and acute renal failure. Theatre staff and paediatrician should be informed as an emergency caesarean section is required and baby needs attention at the time of delivery. The patient may be on the antenatal ward (as she is in-patient), initial steps of management should be taken on the ward and then she should be transferred to the labour ward where better facilities are available. The obstetric notes should be reviewed for previous pregnancies. If she has had previous caesarean sections, placenta may be adherent this time (accreta, increta and percreta). therefore Risks of sever bleeding and the need for other intervention such as hysterectomy is higher. Because she is contracting she may be in active labour or she may have an abruption. Digital examination should be avoided as it can cause severe bleeding. Fetal heart should be monitored. Presence of any fetal distress should be documented and parents should informed about fetal condition.

The situation and need for an emergency caesarean section should be explained to the couple. The risks of caesarean section with placenta previa such as severe intrapartum and post partum bleeding and the need for performing other procedures like uterine artery embolisation, hysterectomy and return to theatre also must be told. The patient should sign an informed consent form. Meticulous documentation is required as this is a very high-risk case and subsequent referral to the notes may be required.

An experienced obstetrician should perform the operation. As there can be difficulties in dealing with intrapartum complications. If bleeding occurs oxitocic agents such as Syntocinon, ergometrine and prostaglandin F2alpha must be given. However these agents are not very effective as the bleeding is from lower segment which contain small amount of muscle tissue to respond. Therefore using pressure, suturing the placental site, packing the uterus and Roush balloon should be tried. Occasionally there may be a need for other procedures such as B-Lynch suture, uterine artery embolisation and hysterectomy.

However if initial assessment and observation shows the amount of bleeding is small, there is no further contractions or fetal distress, observation on the labour ward should be continued. After the confirmation of the gestational age by reviewing early pregnancy scans, caesarean section can be arranged in an appropriate time.

Nevertheless the woman may have small bleeding but in the presence of regular contractions urgent caesarean is required, because vaginal delivery is contraindicated in placenta previa due to massive fatal bleeding.

Anti-D immune globulin should be given to Rhesus negative unsubsidised women after delivery to prevent fetal iso immunisation disease in future pregnancies.


Posted by Iman B.
A grade 4 placenta previa, means a major placenta previa, a placenta that covers the internal os symmetrically and this makes vaginal delivery impossible.

The first step is to assess the amount of bleeding, and ensure 2 patent cannulae and start an IV drip of colloid solution as ringers lactate.
At the same time send a midwife to call the most senior obstetrician available, the consultant on call, the senior anesthetist, the neonatology team and the OR that an emergency cesarian is due.

The patent is informed of the necessity for an emergency CS, and that should the blood be uncontrollable, further surgical intervention may be called for, these might include ligating some of the vessels that supply the uterus up to a hysterectomy of there is no other option to save her life and stop the bleeding. This should have been dicussed with her previously, and patients notes are checked for any signed objection to blood, or blood products, in the event of excessive blood loss, a plasma expander should be started, and the patient transferred to the OR, zantac intravenously will decrease the possibility of Mendelssohn?s syndrome.

From the time the patient started to bleed right up to the post operative period all medications and decisions should be carefully documented and a person assigned this task specifically, this will aid audit later on and decrease risks of future emergencies.

Ensure all relevant consent forms have been signed and her relatives informed.

The type of anesthesia will depend on the senior anesthetists who will be in charge of the anestheisa given to patient.
The operation should be performed by the most senior obstetrician, with the consultant in the delivery room on hand for any crisis.
A urologist should be on hand in the event of injury to bladder, ureters or need for internal iliac ligation.
The incision should be a high lower uterine segment or upper segment if the placenta is completely implanted in the LUS, this will obviate the very bloody process of cutting thru the placenta which might, if the patient were a previous cesarian section or had a high risk of placenta accreta or percreta mean massive hemorrhage.
Following delivery of the baby, give antibiotics as the incidence of infection is higher with emergency CS.
Various methods may be adopted to stop the bleeding,step by step: strong ecbolics should be admistered, syntocinon, methergine, and IV or intramyometrial prostaglandin F2 alpha analogue, if this fails then from ligation of the uterine arteries to internal iliac ligation. Catheterisation and selective embolisation of the uterine arteries in cases of placenta accreta have shown good success so far, and the placenta will either resolve within the next six weeks or be easily removed.

Cyclokapron may be given to stop bleeding from the lower uterine segment which may not respond so well to ecbolics, 1gm is given intravenously.

Uterine packing with gauze or insertion of a gastric sungstaken Blakemore tube may be used, filled with 300ml saline, which may be deflated slowly postpartum, or the B lynch suture may stop the bleeding, calling for extra help when needed, should be early to avoid excessive morbidity. If all methods fail, then hysterectomy may prove life saving.

In the event that the patient will refuse blood transfusion, cell salvage may be an alternative option and this should have been discussed previously at first booking prior to admission, and an attempt to deliver the patient in places offering this option sought.

If she is Rh negative, and non immunised, give her Anti D immunoglobulin.

The patient is transferred to the intensive therapy unit if the bleeding was massive to start treating side effects of massive hemorrhage as coagulopathy, thrombocytopenia, hypocalcemia, hyperkalemia.

A haematologist should be involved to ascertain risk factor of DVT and accordingly, heparin may be admistered either 3-5 days(low molecular weight heparin) postoperatively, or for six weeks(oral anticoagulant-warfarin) according to the number and degree of risk factors in the patient.
Explain to the patient once she is sufficiently conscious, the procedure performed, the chances of recurrence (4-8%) and the contraceptive method, or in case of retained placenta accreta, the use of methotrexate or conservative waiting for the resolution of placenta, under antibiotic cover.

Posted by Vaijayanti R.
This is an obstetric emergency , and can be asociated with fatal complications for the mother and the fetus.
Management is based on asssessment of blood loss,achieving hemodynamic stability,ensuring safe delivery and preventionof complications.
A quick review of her notes will indicate any factors that may modify treatment ( diabetes, renal disease, multiple pregnancy, Jehovahs wittness)
Examination will determine any hemodynamic instability ( tachycardia, hypotension,cold clammy extremities);attempt to distinguish whether she is in labour ( intermittent painful uterine contractions with adequate relaxation inbetween) or is having a placental abruption ( no relaxation inbetween contractions, hard woody uterus);fetal viability. Pelvic examination is contraindicated in major degree of placenta previa.
Hemodynamic instability is managed on the princliple of airway, breathng and circulation.help is requesteed from the SHO,anesthetic registrar, midwives, and porters.Inform the senior obstetrician, anesthetist, neonatologist,hematologist, blood bank,OT and the SCBU.
Oxygen is adminstered by face mask(8l/min),2 large bore IV cannulas are inserted and blood collected ( 30ml)for CBC, coagulation profile , cross matching, Keilhaurer Betke countAs she is an inpatient, it is likely that there would be blood reserved for her in the blood bank.Immediate infusion of Ringer solution /colloids is started. Bladder is catheterized,and if necessary a CVP line is inserted.Cotinuous monitoring of pulse , blood pressure, respiratory rate and oxygen saturation , hourly assessment of urine output.
If she is hemodynamically stable, immediate delivery is planned. The risks and possible complications( post partum hemorrhage, adherent placenta, hysterectomy) to her and the fetus ( hypovolemia, acidosis, hypoxia with its consequences) are explained to the lady and her companion and informed consent is taken( if not taken already as she is an inpatient)
Mode of delivery is by Caesarean section. This is done by an experienced obstetrician, the consultant must be available in case required.The choice of anesthesia depends on the senior anesthetist attending the case. Regional anesthesia may be used,if general anesthesia is given avoid halothane( myometrial relaxation increases bleeding). Anticipate postpartum hemorrhage, adherent placenta. Hemorrhage may be difficult to control as the placental bed here will not contract efficiently( poor musculature in lower segment) ? this may require other measures ? pressure application, placental bed packing,B-Lynch sutures, selective uterine artery embolization,uterine / internal iliac artery ligation, or hysteresctomy( subtotal).Neonatologist should attend the delivery.
Prophylactic antibiotics are given as there is a higher risk of postpartum endometritis.
Postoperatively she is nursed in a high Dependancy unit till stabilization. Thromboprophylaxis( low molecular weight heparin or warfarin ) is begun as she is at high risk for thromboembolism, along with other measures ? TED stockings, early ambulation.There is no contraindication to lactation.
Hematologist monitors any blood transfusion and associated complications ( hypocalcemia, hyperkalemia,thrombocytopenia). Fresh frozen plasma may need to be given ? risk of DIC is high
If indicated ( Rh negative; non immunized)Anti D ? 500 iu is given within 72 hrs, higher dose may be necessary based upon Keilhaure Betke count.
Clear and accurate documntation is essential. An incident form for risk management has to be filled.
The woman is counselled regarding the risk of recurrence (4 to 8%) and further implications on subsequent pregnancies.

Posted by SWATI M.
Painful contraction with fresh vaginal bleeding indicates that she is likely to be in spontaneous labour.Assessment of vitals and amount of blood loss is judged to establish haemodynamic status as woman with major degree previa may bleed profusely as cervix dilates with uterine contractions.If the woman is in shock,resuscitation should be started immediately with two wide bore intravenous lines.Summon midwives,SHO for help and porters to get blood bags.Since she is in-patient cross matched blood will be available and it should be started as soon as possible and alert blood bank as may need more blood bags if profuse bleeding.Collect blood for FBC,basic clotting profile and cross matching .Emergency caesarean delivery is recommended and arrangement should be made .Inform operating theatre,SCBU regarding patient.Senior obstetrician,senior anaethetist,neonatologist should be informed and involved in management.Review antenatal records,mode of previous deliveries in any,particularly previous caesarean section should be taken into account as placenta accreta may be associated which may lead to severe haemorrhage.Consent must be checked.Review ultrasound report to ascertain gestational age,placental localization and fetal presentation.Malpresentation is common with previa.
Clinical examination for fetal presentation,fetal heart rate is performed.Speculum examination is not indicated as cause for bleeding is known and will not gain additional information to influence management.Vaginal examination is contraindicated.Vitals are monitored every 15 minutes till start of caesarean.
Emergency caesarean delivery is recommended even if bleeding is not profuse since labour has started.At 37 weeks,there is risk of respiratory morbidity in caesarean delivery .But risks due to bleeding outweighs benefits of waiting further.
She must have been counseled prior, regarding maternal risks such as haemorrhage,PPH,need for emergency hysterectomy in event of uncontrolled bleeding ,acute renal failure and fetal risks of bleeding and neonatal shock.
Keep woman and her family members at all times .
Ensure availability of blood bags at start of caesarean section.Procedure should be undertaken by experienced person(particularly if placenta accreta) or under supervision as risk of intraoperative bleeding.Transverse incision on lower segment is preferred as bleeding can be controlled by haemostatic sutures under vision and risks of spontaneous rupture in future pregnancy is less than classical vertical scar.If tortuose vessels on anterior wall of uterus,haemostatic sutures are placed before incision.Delivery of baby may pose problem as presenting part may be floating or malpresentation and also risk of fetal bleeding.Risk of PPH as lower segment is less muscular , does not control bleeding from placental sinuses effectively , and may be due to placenta acreta.Oxytocics should be given and continued prophylactically for 4-6 hours post operative.If bleeding continues hemaostasis is achieved by placing sutures in lower segment/ hot water pack.If profuse PPH , may need internal iliac ligation / emergency hysterectomy depending on clinical situation.Thromboprophylaxis with adequate hydration,TED stockings and LMWH for 3-5 days should be offered .
Monitor vitals and per vaginal blood loss ,urinary output in post operative period. Patients to be explained of procedures undertaken on the following day . At discharge discuss contraception and risk of recurrence (4-8 %) and placenta accreta. Provide documents with procedures performed with recommendations for future pregnancy and inform the patients GP.
Posted by Sonali G.
Bleeding placenta previa is an obstetric emergency. Management aims at promptly assessing the maternal and fetal well being, stabilising the mother and then delivery of the baby. Pain associated with bleeding could be due to associated abruption (associated with 10% of placenta previa) or due to labour contractions. Vitals should be checked as tachycardia, sudden hypotension could be associated with abruption. Abdomen is palpated to rule out any abruption (feels like hard contracted uterus not relaxing) or to feel for any contractions. Pervulval ,amount of bleeding is assessed. Immediately, IV access with 2 wide bore cannula is secured (if already not in, as she is an inpatient) and simultaneously bloods are taken for full blood count, Group and save with 4 units cross matching, Urea, electrolytes and Coagulation profile. Simultaneously, Cardiotocography (CTG) is commenced to check for fetal well being as abruption can be associated with abnormal CTG or sudden bradycardia.
Patient needs to be transferred immediately to labour ward. Multidisciplinary involvement is essential with involvement of senior anaesthetist, senior most obstetrician, paediatrician, porter, haematologists and senior midwives. If there is any suspicion of abruption with fetal compromise on CTG, she needs urgent delivery by caesarean section.
Senior most obstetrician on the labour ward preferably consultant should be doing the caesarean section. Patient should be consented for hysterectomy & blood transfusion preoperatively as it might be the last resort to control bleeding in case of PPH associated with placenta previa or in presence of placenta accreta (associated with ~15%of cases). Chances of placenta accreta encountered is high especially if she has history of previous section. If it is not a crash section, then choice of anaesthesia is determined by the anaesthetist. Regional blockade is preferable.
During Caesarean section, quick delivery is needed as bleeding placenta may compromise fetal circulation. Due to failure of lower segment to contract properly chances of post partum haemorrhage is higher. Syntocinon is commenced with delivery of the baby to help contraction. If uterus is still flabby, the ergometrin or PGF2 alpha intramuscularly or intramyometrial may be given. If she is still bleeding options of internal iliac ligation, B-lynch suiture ,uterine artery embolisation can be used depending on the expertise and facilities available. Decision of undertaking hysterectomy should not be delayed if it is needed to save her life. Peri-operative antibiotics are given. Post-partum she might need further management in HDU. Thromboprophylaxis is considered to prevent DVT. Documentation of all the events is important and as important is the explanation of the events to the patient. She should be told about the recurrence risk of 4-8% before discharge.
Posted by Farzana N.
Bleeding in a case of known Placenta Previa is an obstetric emergency, which should be dealt with immediately. Management would include a quick assessment of amount of bleeding, resuscitation of patient if required and delivery by emergency caesarian section.
General condition of the patient assessed and vital signs taken. In case of mild bleeding
In presence of painful uterine contractions and gestational age 37 weeks, patient should be prepared for emergency c.s.Any delay would lead to profound bleeding with uterine contractions.
In case of moderate to severe bleeding, pt should be resuscitated first. Two wide bore canellas are inserted. Since the patient is admitted in the hospital, 4 units of cross-matched blood should be available. Blood should be collected for Hb, coagulation factors, urea and electrolytes.I.V fluids are given until the blood is available, patient should then be prepared for emergency caesarian section. .

During the hospital stay, pt should have b even adequately counseled about the type of placenta, possibility of emergency c.s, hemorrhage,. During the surgery, presense of placenta accreta or percreta and hysterectomy if bleeding remained UN controlled. Consent should be obtained. USG should be reviewed to know if the placenta is anterior or posterior.
Senior obstetrician should do the operation with a senior anesthetist. Consultant presence is mandatory during the operation. A regional block has risk of hypotension, but is accepted in experienced hands with the provision that it can be converted to general anesthetic if necessary. Adequate venous access must be in place before surgery. A CVP line to aid fluid replacement should be considered. Antibiotic coverage should be given.

The incision is commonly transverse lower segment. If difficulty encountered it may be converted to inverted T, J or U shaped incision. If the incision is transverse and placenta anterior approach may be 1) going through the placenta, this requires speed and results in fetal blood loss.2) Defining the edge of the placenta and going above or below it. This may be associated with undue delay in delivery of the fetus, fetal blood loss and anoxia. Hemorrhage encountered during the procedure can be controlled by use of syntocinon or ergometrine to correct uterine atony. PG F2 injected to control bleeding due to in adequately occluded placental sinuses. B-LYNCH suture, internal iliac artery ligation, or UAE may be undertaken depending upon the expertise present. Care should be taken that too much time is not spent in these procedures before recourse to hysterectomy is taken. Post partum prophylaxis for VTE should be given. Patient should be transferred to HDU for close monitoring.

Patient should be explained that .the condition might recur in future pregnancies.
Posted by SWATI M.
Dear Dr.Paul,
Do we need to fill incident form for all patient who bleeds?
Or only if haemorrhage is >1000ml / require additional surgical procedures to control it?
Posted by Rani M.
As this woman has painful uterine contractions and bleeding prompt assesment of her vitals, general condition and amount of bleeding should be done.If the bleeding is significant, I.V. line is started with two large bore cannulae(16 gz.). Ringer lactate is started and blood is requested from the blood bank which may be already arranged as she is inpatient.. Samples are taken for Hb%,and for X match of more blood. Meanwhile help is summoned and seniors are informed.
Her antenatal records are reviewed to confirm gestational age, history of any previous uterine surgeries which increases the risk of morbidly adherent placenta significantly.
If gestational age is confirmed 37 weeks or if bleeding is persisting or is severe, emergency ceasarean section should be performed by the most senior obstetrician .Consultant should be readily available.During C.S vascularity of the lower uterine segment may be highly increased .Also in the case of anterior placenta one may need to cut the placenta to deliver the baby, therfore speed in delivery of baby is required.There is also risk of intraoperative haemorraghe from the atonic lower uterine segment and from the placental implanation site. Ligation of the isolated bleeders, use of utertonic agents, bimanual compression and packing of the uterus , all have been found to be useful and can be tried tilll senior help arrives.
Persistent bleeding may require ligation of the uterine/ internal iliac artery, use of B Lynch suture or hysterectomy. Early resort to these procedures may be life saving.Uterine artery emblisation has been reported to be useful and safe but radiological team should be ready and available.
Post op. she is monitorred carefully for vitals, vaginal bleeding and urine output. Blood loss should be adequately replaced.
Anti D should be given if woman is Rh negative, baby is Rh positive and direct coomb test is negative.Prophylactic antibiotics are given to cover the emergency cesarean. postpartum heparin thromboprophylaxis can be started 6 hours after the surgery if there is no PPH.
All the events, procedures done and steps taken should be carefully documented for risk management and future audit.
Posted by Rani M.
As this woman has painful uterine contractions and bleeding prompt assesment of her vitals, general condition and amount of bleeding should be done.If the bleeding is significant, I.V. line is started with two large bore cannulae(16 gz.). Ringer lactate is started and blood is requested from the blood bank which may be already arranged as she is inpatient.. Samples are taken for Hb%,and for X match of more blood. Meanwhile help is summoned and seniors are informed.
Her antenatal records are reviewed to confirm gestational age, history of any previous uterine surgeries which increases the risk of morbidly adherent placenta significantly.
If gestational age is confirmed 37 weeks or if bleeding is persisting or is severe, emergency ceasarean section should be performed by the most senior obstetrician .Consultant should be readily available.During C.S vascularity of the lower uterine segment may be highly increased .Also in the case of anterior placenta one may need to cut the placenta to deliver the baby, therfore speed in delivery of baby is required.There is also risk of intraoperative haemorraghe from the atonic lower uterine segment and from the placental implanation site. Ligation of the isolated bleeders, use of utertonic agents, bimanual compression and packing of the uterus , all have been found to be useful and can be tried tilll senior help arrives.
Persistent bleeding may require ligation of the uterine/ internal iliac artery, use of B Lynch suture or hysterectomy. Early resort to these procedures may be life saving.Uterine artery emblisation has been reported to be useful and safe but radiological team should be ready and available.
Post op. she is monitorred carefully for vitals, vaginal bleeding and urine output. Blood loss should be adequately replaced.
Anti D should be given if woman is Rh negative, baby is Rh positive and direct coomb test is negative.Prophylactic antibiotics are given to cover the emergency cesarean. postpartum heparin thromboprophylaxis can be started 6 hours after the surgery if there is no PPH.
All the events, procedures done and steps taken should be carefully documented for risk management and future audit.
Posted by Rani M.
As this woman has painful uterine contractions and bleeding prompt assesment of her vitals, general condition and amount of bleeding should be done.If the bleeding is significant, I.V. line is started with two large bore cannulae(16 gz.). Ringer lactate is started and blood is requested from the blood bank which may be already arranged as she is inpatient.. Samples are taken for Hb%,and for X match of more blood. Meanwhile help is summoned and seniors are informed.
Her antenatal records are reviewed to confirm gestational age, history of any previous uterine surgeries which increases the risk of morbidly adherent placenta significantly.
If gestational age is confirmed 37 weeks or if bleeding is persisting or is severe, emergency ceasarean section should be performed by the most senior obstetrician .Consultant should be readily available.During C.S vascularity of the lower uterine segment may be highly increased .Also in the case of anterior placenta one may need to cut the placenta to deliver the baby, therfore speed in delivery of baby is required.There is also risk of intraoperative haemorraghe from the atonic lower uterine segment and from the placental implanation site. Ligation of the isolated bleeders, use of utertonic agents, bimanual compression and packing of the uterus , all have been found to be useful and can be tried tilll senior help arrives.
Persistent bleeding may require ligation of the uterine/ internal iliac artery, use of B Lynch suture or hysterectomy. Early resort to these procedures may be life saving.Uterine artery emblisation has been reported to be useful and safe but radiological team should be ready and available.
Post op. she is monitorred carefully for vitals, vaginal bleeding and urine output. Blood loss should be adequately replaced.
Anti D should be given if woman is Rh negative, baby is Rh positive and direct coomb test is negative.Prophylactic antibiotics are given to cover the emergency cesarean. postpartum heparin thromboprophylaxis can be started 6 hours after the surgery if there is no PPH.
All the events, procedures done and steps taken should be carefully documented for risk management and future audit.
Posted by Rani M.
As this woman has painful uterine contractions and bleeding prompt assesment of her vitals, general condition and amount of bleeding should be done.If the bleeding is significant, I.V. line is started with two large bore cannulae(16 gz.). Ringer lactate is started and blood is requested from the blood bank which may be already arranged as she is inpatient.. Samples are taken for Hb%,and for X match of more blood. Meanwhile help is summoned and seniors are informed.
Her antenatal records are reviewed to confirm gestational age, history of any previous uterine surgeries which increases the risk of morbidly adherent placenta significantly.
If gestational age is confirmed 37 weeks or if bleeding is persisting or is severe, emergency ceasarean section should be performed by the most senior obstetrician .Consultant should be readily available.During C.S vascularity of the lower uterine segment may be highly increased .Also in the case of anterior placenta one may need to cut the placenta to deliver the baby, therfore speed in delivery of baby is required.There is also risk of intraoperative haemorraghe from the atonic lower uterine segment and from the placental implanation site. Ligation of the isolated bleeders, use of utertonic agents, bimanual compression and packing of the uterus , all have been found to be useful and can be tried tilll senior help arrives.
Persistent bleeding may require ligation of the uterine/ internal iliac artery, use of B Lynch suture or hysterectomy. Early resort to these procedures may be life saving.Uterine artery emblisation has been reported to be useful and safe but radiological team should be ready and available.
Post op. she is monitorred carefully for vitals, vaginal bleeding and urine output. Blood loss should be adequately replaced.
Anti D should be given if woman is Rh negative, baby is Rh positive and direct coomb test is negative.Prophylactic antibiotics are given to cover the emergency cesarean. postpartum heparin thromboprophylaxis can be started 6 hours after the surgery if there is no PPH.
All the events, procedures done and steps taken should be carefully documented for risk management and future audit.
Posted by vijaya L.
Grade IV placenta previa with bleeding is an obstetric emergency, associated with massive blood losses and shock. The principles underlying the management of this woman are resuscitation, arranging for emergency caesarean section(as the fetus crossed 34 weeks), taking an informed consent and involving the consultant obstetrician and senior anesthetist in the surgery.
This woman has probably developed spontaneous labour pains, resulting in effacement of the cervix. This would involve separation of the placenta resulting in bleeding. Rarely placenta previa can be associated with abruptio placentae with pain abdomen and bleeding per vagina.
In the history previous history of uterine surgery would be of help in predicting the placenta accreta.
I would check airway, breathing and circulation and execute resuscitative measures like left lateral position, oxygen and large bore IV lines. Blood would be taken for FBC, clotting profile, RFT and group and crossmatch at least 6 units (if not already done). I would try to asses the amount of blood lost by the extent of soakage of pads and linen, as this gives a fare idea about the severity of the situation and the volume of resuscitative fluid required (usually 3 times the expected volume lost).
An abdominal examination would identify the contracting uterus of spontaneous labour and the position and presentation of the fetus. Fetal heart tones are usually heard well unless the mother is in shock or in case of abruptio placentae.
Consultant, senior anesthetist, theater staff and neonatologist are informed about the emergency situation anticipating the intra-op complications like PPH, placenta accreta and some times hypovolaemic neonate.
Informed consent is taken after explaining her about the seriousness of the situation, necessity for the immediate surgery as a life saving measure, need for blood transfusions (noting if she has an reservations about it), and the need for extra procedures like internal artery ligation and rarely hysterectomy.
The uterine incision is planned such that cutting thro the placenta is avoided and the fetus delivered as fast as possible prevent the exsanguination the fetus.
PPH is the most common complication of placenta previa. It is managed initially by the oxytosics (oxytocin20iu/500ml of normal saline over an hr, ergometrine 0.25mg IM, prostaglandin f2 alpha 25micro grams IM or intra myometrially). Haemostatic sutures in the placental bed or uterine packing can be of particular help because placental bed is situated in the non-contractile portion of the uterus and oxytosics might not be as efficient on this segment of the uterus.
Ligation of uterine artery, B- lynch suture and internal iliac artery ligation and if necessary hysterectomy are done as uterus saving or life saving measures.
In case of accreta the placenta should be left in place and postoperative methotrexate treatment can be initiated. If the bleeding is heavy the hysterectomy will be necessary.
Antibiotic prophylaxis is necessary to decrease the postoperative infective morbidity. High dependency care is necessary for those with PPH till continuing blood loss can be excluded.
Thromboprophylaxis is usually started once bleeding is controlled as massive blood loss can by itself increase the thrombosis potential. If the woman is RH negative klehier?test should be employed to calculate the amount of anti D to be given, as the fetomaternal hemorrhage will be more than a usual caesarean section.
In the post operative ward woman would be explained about the intra-op problems and counseled about the recurrence of 3 to 4 % in the next pregnancy and possibility of caesarean section again
Incident forms should be filled in case of PPH or accreta or Caesarean hysterectomy.
Contraception is advised for at least 2 years to allow for healing and strengthening of the lower segment of the uterus.