The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes336
EMQ1502
SBA2115
Do you realy want to delete this discussion?
Forum >>

Essay 215 - Placenta previa

Posted by Badi A.


the patient should be informed that this is a major placenta previa with a possiblity of morbidly adherent placenta which associated with increased morbidity and mortality and admission to the hospital is recommended.

the time of delivery will be between 37-38 weeks by a ceasarean section if remains stable.if she has a labour or p.v bleeding then emergency c/s will be done.

the patient will be conuselled about the risk of bleeding, hysterectomy and blood transfusion and cell salvage may be considered.

the patient should be informed about the risk of hysterectomy if all measures to control the bleedig fail and the consent for cesarean hysterectomy should be taken .

multiteam approach including a senior obstetrician , senior anesthetist and intensivest is recommended.
the measures to minimise the morbidity from pph include availability of blood and FFP, replacement of blood with fluids, plasma expanders and blood products .
interventional measures like over sewing the implantation site pre operative internal illic artery ballon, uterine artery ligation and finally hyterectomy if all measures failed.
admission to high dependency unit is recommended initialy post operative.
Posted by Srivas  P.
I will tell her that this low lying placenta if has been seen by Transabd US scan at 35 weeks, it is unlikely to be reclassified by TVS especially since she has previous caesarean section and she is most likely to remain as major degree placenta praevia. If these findings are reconfirmed by TVS which has good sensitivity of 88% and specificity of 99% in diagnosing a low lying placenta, she would need an Elective caesarean for delivery. But TVS is not very sensitive in diagnosing an adherent placenta for which she has 30% chances due to her having low lying placenta along with previous caesarean scar. This can be confirmed by Color Flow Doppler Ultrasonography. Other tests like MRI have low sensitivity and specificity in diagnosing adherent placenta. If these tests are not available, she should still be treated as a case of placenta accreta, unless proved otherwise. She could have sudden bout of bleeding and have emergency C.S and should preferably be admitted in hospital. She would need Elective caesarean section around 38-39 weeks if bleeding is

I would tell her that she would need C.S for delivery but she runs the risk of severe hemorrhage at caesarean from placental bed and may need massive blood transfusion. These could be controlled by medicines and utero tonics and uterine massage but may need additional surgical measures to control it and rarely may need even a hysterectomy as life saving measure. There is possibility of placenta being adherent which may have been detected prior to operation. The options of trying conservative treatment versus the other life saving measures if they fail should be explained and consent taken for all possibilities. Rarely facility for uterine artery embolisation maybe in place in some units and this may avoid hysterectomy. Her objection if any to blood transfusion should be recorded and in these cases early decision may be taken for hysterectomy.

She should be operated by senior obstetrician and 4 units blood should be kept booked and cross matched. Senior anesthetist should be present and hematologist alerted. Her pre anesthetic check up should be done and hemoglobin level should be optimum before surgery. Informed consent explaining the whole possibilities should be taken so that there are no delays in decision making. Protocols to deal with heavy hemorrhage should be in place with extra help available. In the event of haemorrhage, oxytocins, ergometrine and Prostaglandins should be tried and everything fails steps like uterine artery ligation, Brace sutures or internal iliac ligation should be taken without too much delay depending on surgeon?s expertise and response to various measures. Hysterectomy should not be delayed especially in life saving situations. She must have prophylactic antibiotics and thromboprophylaxis measures depending on risk profile. Post operative early mobilization and blood transfusion should be given depending on blood lost.
Posted by Olubunmi O.
This is major placenta previa, a condition which is unlikely to change at this gestation. There is a 30 % associated risk of haemorrage which could be unpredictable in volume and frequency as the lower segment develops in the 3rd trimester.
Admission to the hospital may be recommended after considering the patients proximity to the hospital, presence of a constant companion in case of sudden bleeding but the patients wishes should be taken into consideration
She will be delivered by planned elective CS at around 38 weeks or earlier if there is heavy bleeding with maternal and or foetal compromise.
Prophylactic corticosteroids should be considered in case she needs urgent delivery before term .She will need IV access while on admission, a constant crossmatch order in place according to local protocol and a FBC and coagulation screen if bleeding.Any atypical antibodies should be noted and appropriate blood requested .
A multidisciplinary team involvement is needed consisting of a consultant obstetrician, consultant anaesthetist and haematologist. An anaesthetic review should be arranged and the woman?s wishes regarding mode of anesthesia noted.
She should be told that there is a real risk of placenta accreta with in anterior PP with a previous CS and colour doppler should be arranged if not already done.
Her baby has a chance of being born prematurely although most will do well at this geastation and there is a risk of malpresentation and malposition.
She is at risk of intrapartum haemorrhage during CS and PPH with an attendant risk of blood transfusion and a possibility of hysterectomy if uncontrollable haemorrhage. The reoccurnce risk in her next pregnancy is between 4-8%.Leaflets should be given regarding this condition.
Her risk of VTE should be assessed and TEDS stockings and mobilization is important if admitted or prophylactic LMWH if at increased risk.
Informed consent for CS should include the name of the proposed procedure in full. In this patient with her real risk of haemorrhage any other procedure which may be necessary like external iliac or uterine artery ligation,uterine artery embolization and B Lynch suture should be discussed. Intraoperative management of a morbidly adherent placenta should also be explained . Hysterectomy should be discussed and consented for especially in the presence of accretta. Use of ambiguous terminology should be avoided and all dicussion documented clearly in the notes.
Commonly occurring complications should be discussed like haemorrhage, UTI and wound infection,and others like accidental injury to bladder and bowel.She is also at increased risk of VTE and may need prophylactic heparin.
CS could be technically difficult due to the position of the placenta and foetal malposition / malpresentation.
Risk of haemorrhage neccecitating blood transfusion should be explained and her wishes regarding blood products and blood transfusion clearly documented.Autologus blood transfuson may be considered.
The patient should be given an opportunity to ask questions and state procedures she will not like to be performed.
Leaflets should be given and the patient given time to digest all the information before consent form is signed
Measures to minimize morbidity from PPH would involve adequate pre operative preparation.LMWH should be omitted on morning of surgery.At least 6 units of blood should be crossmatched.The operation should be carried out by an experienced surgeon with a consultant obstetrician present in theatre. Heamatology services should be aware of surgery in case additional blood product is needed. Decision about method of anaesthesia should be made by the consultant anaesthetist who should be present. Inhalational agents should be avoided if GA is used as they may cause uterine atony. Careful surgical technique and fastidious heamostatasis should be employed Uterotonics should be used and IV infusion continued after delivery. Prompt treatment of haemorrhage should be undertaken by bimanual compression ,uterine packing or balloon, arterial ligation, B lynch suture or hysterectomy .A morbidly adherent placenta may be left in situ and treated by methothrexate. Intra operative antibiotic should be used with adequate correction of anaemia. In dwelling urinary catheter should be left in situ. Post operatively lochia should be observed, FBC and coagulation checked especially if there has been haemorrage and or transfusion.Post operative thromboprophylaxis should only be employed after coaguloathyhas been excluded.



Posted by Sreekala S.
The woman should be informed of the increased risk of a morbidly adherent placenta in view of the anterior placenta and previous caesarean section and should therefore be offered a colour Doppler. If there are no facilities for a colour Doppler, she should be managed as having a placenta accreta.
She should be informed of the increased risk of bleeding which may be sudden and heavy requiring an urgent delivery by a caesarean section and the need for blood transfusions. In the absence of any bleeding the aim would be to continue the pregnancy atleast until 38weeks and deliver by a planned caesarean section.
History of previous bleeding episodes should be taken and in the presence of previous bleeding episodes, she needs to be managed as an inpatient. Home based management should be considered in the absence of any previous bleeding episodes provided that she has an easy access to the hospital and has a constant companion. In such circumstances an informed consent should be obtained from the woman. She should be advised to report immediately to the hospital in the event of any bleeding, contractions or pain including vague supra pubic period like aches.

Mode of delivery by caesarean section, risk of haemorrhage and requirement of blood transfusions and need for additional interventions like hysterectomy should be discussed with the woman and her partner. The discussion should be documented. Any objections for blood transfusions noted and queries dealt with effectively. She should be informed that the most experienced obstetrician and anaesthetist on duty will be involved in the surgery with additional help from other specialities as required. The options for the treatment of adherent placenta like leaving the placenta insitu during the surgery, use of methotrexate, internal artery ligation, uterine artery embolization and hyseterectomy should be discussed in the event of an adherent placenta praevia.

6 units of blood should be crossmatched and caesarean section performed by the consultant obstetrician involving the consultant anaesthetist. Cell salvage should be considered in cases with high risk of haemorrhage. Early involvement of other specialities should be done. To minimize the morbidity from Post partum haemorrhage, all units should have protocols for the management of major Obstetric haemorrhage including early liaison with haematologist, giving warm blood rapidly, criteria for invasive monitoring and management of women who refuse blood products. Emergency clinical scenarios and fire drills for major obstetric haemorrhage should be undertaken and the practice audited regularly.

Posted by neera  B.
I would explain the diagnosis with a diagram to her. I would councel her about risk of bleeding during pregnancy which can be sudden severe and unprovoked. In view of previous caesarian the chances of adherent placenta exist which can be associated with severe bleeding after child birth. Hence there is need for hospital admission so that immediate treatement can be given if she bleeds. There is no test which reliably rules out adherent placenta, though colour dopler may be helpful. Need for blood tests (blood groub and Rh, FBC, Red cell antibodies) shall be told. The possibility of needing blood transfusion shall be emphasised. Cesarian section will be offered at 37- 38 weeks, earlier if she bleeds excessively. I shall reassure her that most patients would have no problems but occasionally an adherant placenta which is stuck to the wall of the woomb may necessitate massive blood transfusion or even removal of woomb
I shall inform her that a thin plastic tube will be put into her urethra and intravenus fluids would be given. Usually regional anaesthesia is given with an injection at the back. A horizontal incision is given in lower abdomen just above the hair line. There is a risk of plcenta being stuck to the uterine wall, making it\'s seperation difficult, so there can be excessive bleeding. This may make it essential to ligate uterine arteries, embolise them or even remove the woomb in order to save her life. Most patients would have urinary tube removed within 24 - 48 hours, would be walking, and eating by mouth within 48 hours. Usually the discharge would be on fourth day after operation . However if a hysterectomy is needed longer hospital stay with HDU care would be needed. I would invite her to ask questions.Leaflet would be given so that she can make an informed choice.
Multidisciplinary team consisting of senior obstetician, senior anaesthetist and hematolgist should be involved in her cesarian. It should be performed in a hospital equipped to do hysterectmy. massive blood transfusion and provide HDU care. Four units of blood are arranged preopratively. If red cell antibodies are present, a personal communication with the local blood bank is made. Auto transfusion is not recommended though cellsalvage is permissiable. If large vessles are present on anterior surface of uterus, they should be underpinned and ligated before making the uterine incision. Active management of third stage is done with oxytocin at delivery of anterior shoulder, placenta is delivered by controlled cord traction, completenes of placenta and membranes is checked. If the placental bed is bleeding ,figure of 8 stiches can be taken. Early recourse to internal iliac ligation or uterine artery ligation, hysterectomy or if facilities are available, uterine artry embolisation can be life saving. Subtotal hysterectomy may be preferable over total in order to save time and minimize bloodloss. If PPH occurs, HDU care should be provided. Fluid balance should be carefully maintaned, CVP line may be needed and urine output should be monitered. Oxytocin infusion sould continue for 4 hours post operatively.
Posted by Yasser S.
I will inform her that the ultrasound showing abnormal location of the placental implantation in the lower segment of the anterior uterine wall and we consider that as a major type of placenta previa , and ultrasound considerd as the optimal mode of diagnosis in such cases ,although transvaginal scan more accurate in those cases but for cases of posterior placenta.i will tell her also that there is added risk also in her case being with history of previous c/s and anterior placenta which expose her to a risk of having placenta adherent to previos scar site(placenta accreta)which can be diagnosed by colour flow doppler which has high sensitivity and specifity but cant exclude the diagnosis which only can be confirmed intraoperativily .all those finding will expose her to risk of having massive per vaginal bleeding either antepartum or intrapartum and post partum which is risky for her life as well as fetus . and other fetal risk as intrautrine growth restriction and prematurity.due to all those risk she should be oserved as inpatient especialy as this gestational age till the time of delivery with respect of patient wish.

I will tell her that she should be deliverd by elective caserean section at completed 37 weeks providing that there are no significant bleeding, labour or fetal reason till then.and here delivey should be done in tertiary hospital where facilities are availble . i should councel here that even with the delivery be ceaseran section there is a possibility of bleeding which is mainly from placental bed which can be controlled by utrotonics but it may nessiciate also other interventional method like ligation ot utrine or internal iliac vessels or embolization,which also need blood transfusion at that stage for massive bleeding.all those life saving method will be taken befor proceeding to hystrectomy as long as she wants to keep her fertility.i have to councel her also about both way of mangment in cases of placenta accreta either surgical removal or treatment with methotraxate later and risk of both ways and side effect will be explained all those measures after explain to couple conscent should be taken.and because of high risk of bleeding and need of massive transfusion if there is refusal of blood transfusion then early intervention will be indicated.the councelling should involve the partner n should use clear terminology with no much medical terminology so to avoide misunderstanding the situation.

preoperative messures whould include multidisplanry involvement like senior obstetrician ,senior anesthesist,heamatologist.neonatologist and intencivist . need to have FBC coagulation status cross match of blood according to hospital policy.and if availble the facility of internal iliac balooning by interventional radiologist as prophylaxsis preop soo it can help intraop for help in minimise bleeding . cell slavage to be considerd in cases of massave haemorrhage.
Posted by Farzana N.
She should be informed that placenta covering internal os at 35 weeks of gestation is a placenta which is entirely in the lower part of the uterus ( major degree placenta previa ) and associated with risk of heavy bleeding at any time which may be life threatening. she will need multidisciplinary care with 24 hours facilities of consultant obstetrician , consultant aneasthatest,haematologist Nicu and blood transfusion .
she need hospital admission and in patient care until delivery .she should be informed that location of placenta which is in the lower uterine segment and anteriorly with previous caesarean section increase the risk of morbidly adherent placenta (accrete )and its associated risk of hemorrhage and need for hysterectomy.she should be informed that she will be delivered by elective caesaren section at 38 weeks in case she will not bleed during that period .she may have an emergency c/s in case she has bleeding and fetus has the risk of prematurity in that case need for steroid administration and Nicu admission of the baby.
.she should be informed that she my need blood transfusion therefore at least 6 units blood should be available all the time .she will be informed of the risk of thromboembolism and need for antepartum thromboprophylaxis according to the her risk assessment .
An informed consent should be obtained for elective caesarean section which will be planned at 38 weeks to avoid the risk of prematurity .The procedure and its associated risk of haemorrage ,infection and wound dehiscence and febrile morbidity should be discussed with patient and her partner . Risk of emergency caesarean section which has more operative risk than an elective procedure .
The technical difficulties of the procedure which may occur because of major degree placenta previa and risk of morbid adherent placenta .The type of uterine incision which is usually lower uterine segment but may need to be changed in case of increase vascularity to Delees incision or even to classical with increase risk of uterine rupture in subsequent pregnancies. There is risk of injury to ureter ,bladder or bowel and may need involvement of other specialties.The need for life saving procedure in case intrapartum haemorrage or post partum haemorrage occur like massive blood transfusion and blood products, uterine artery or internal iliac artery ligation or uterine artery embolisation ,or even hysterectomy .The alternative methods of fertiliative conserving surgery in case placenta will be morbidly adherent leaving plascenta in situe ,focal resscetion over sewing and medical management with methotraxate with its risk of infection , haemorrage and hysterectomy should be discussed.The type of anaesthesia and its risk should be discussed . The need of high dependency post operative care and post operative heparein thromboprophylaxis should be discussed.Her future risk of repeat elective ceasarean section in subsequent pregnancies after two caesarean section .
The measures taken to minimize the morbidity from pph include multidisciplinary care. 6 units blood should be available and haemotolgist should be informed of the need of more blood preoperatively.
preoperatively blood transfusion in case she is anemic.preoperative detection of morbidly adherent Placenta by color flow Doppler ultrasound and pre operative uterine artery catheterization for prophylactic or therapeutic uterine artery embolization.The caesaerean section should be performed by experienced consultant obstetrician so timely intervention should be taken incase haemorrage occur or placenta is found morbidly adherent.uterine incision should be planed by detecting the less vascular spaceby ultrasound. Consultant aneasthetest should be present at operation and other specialties vascular surgeon and urologist should be informed stand by .Baby should be delivered by passing hand around the marigineof placenta rather then incising the placenta or by grasping the foot and breech extractin in case of difficuty of delivering freefloating head.Placenta shoud be delivered by controlled cord traction and oxytocin shoud be given .oxytocin infusion should be started .in case of bleed from placental bed haemostatic suture ,local compression , uterine packing ,hydrostatic balloon ,intramyometrial pgf2 alpha ,B- lench suture, uterine artery embolization and internal iliac ligation and even hysterectomy as life saving procedure should not be delayed In case no line of cleavage is detected and no bleeding then consideration should be given to consertive management .Post operative antibiotic and thromboprophylaxis to reduce the post operative morbidty and need for intensive post operative monitoring in high dependency unit .

Posted by Parveen  Q.
First of all, she has to be given an an expert and evidence based opinion, which will help her come to an informed choice. Her fears and anxiety should be dealt with sympathetically.All the information is best delivered with the partner\'s or a constant companion\'s presence, so they will be available when necessity arises. In third trimester, TV US can change the TA ultrasound diagnosis by only 12.5%, so i will explain to her it is a major placenta praevia, and there is an increase chances for maternal morbidity, fetal morbidity and mortality. Bleeding can occur anytime , which will be painless and if profuse will need emergency caesarean section, and chances of foetal anaemia, and due to prematurity, admission to neonatle intensive care unity becomes mandatory.If there is no bleeding, she could be manged in outpatient unit, provided she lives close to hospital, with a constant companion and has understood all the risks and gives a consent for the same. Incase therse is bleeding at present, she will be admitted and managed as hospital protocol. She may need blood transfusion and if there is an objection due to religious beliefs, her views will be accepted and documentd and need for alternate blood products, fresh frozen plama, cryoprecipitate will be discussed and consent documentd. She may have to remain an inpatient for a longertime than anticepated .Discussion should include about hysterectomy and other major procedures and future fertility .If she is Rh negative ,She will need additional Anti-D ,if she bleeds apart from her routine antenatal Rh prophlaxis .
Her chances of morbidly adhernt placenta is increased when she had previous caesarean section, especially if there is a short caesarean section to conception interval.Antenatal colourflow doppler ultrasound has sensitivity of 80%and sensitivity of 95% can diagnose accreta and consent should include hysterectomy , other proceduers like, internal iliac artery ligation, uterine artery emboliation, if intactable bleeding occurs peroperativley. she will be manged by consultant obstetrician,and anasthesia by consultant anasthetist and regional anasthesia is better than general due to the relaxing effect of the later and patient will be included in the decision making process. Intra and Postoperative care may involve the help of haematologist and best managed in the high dependency unit. Due to the risk category, she will be given prophylactic anticoaglulation in the form of unfractionated heparin ,and use of thrombo embolic stockings.
To minimise the morbity from PPH ,intial per operative maneouvres like uterotonics, bimanual compression, hydrostatic ballon cathetrisation, aortic compression in case of atonic uterus. B-lynch suture, uterine or internal iliac artery ligation, or hysterectomy are considered as additional procedures. Strict adhernce of hospital protocols, and calling for expert help in time, liasion with the haematologist , giving warm blood and managing patient who has refused blood transfusion. and there is no evidence to support the use of autologues transfusion in placenta praevia and cell salvage can be considered in massive PPH.Fire drills, emergency clinical scenarios should be run locally.
patient sould be given a leaflets and emerency number to be contacted.
Posted by Freha Z.
The diagnosis of major placenta praevia should be explained to the women and its risk of antepartum haemorrhage which is associated with fetomaternal mortality and morbidity. She should also know that at 35 weeks it is unlikely that the placenta will migrate. She should need admission and managed as inpatient upto 38 weeks when she would be delivered by caesarean section. If she has remained asymptomatic, careful counselling is required before contemplating outpatient care. Any home based care requires close proximity with the hospital, constant presence of a companion and full informed consent from the women and that she should immediately attend the hospital if she experience any bleeding, contraction or pain which would warrant urgent caesarean section. In her case previous caesarean and anterior placenta are likely to be associated with morbidly adherent placenta and its implications for which she can be offered colour flow doppler ultrasonography for diagnosis. Placenta accreta may lead to major surgical interventions such as hysterectomy and higher chances of multiple blood transfusions. There is also risk of recurrence(4-8%) of placenta previa in next pregnancy. She should also be warned against the risk of thrmboembolism because of prolonged bed rest and therefore encouraged to stay mobile and use thromboembolic deterrent stockings. All the discussion should be documented clearly and leaflets should be given.
Detailed explanation of indication and procedure of caesarean section should be done and inform that because of her high risk condition senior obstetrician would be performing the procedure.
Need for proposed emergency procedures such as B-lynh suture, Uterine artery ligation and eventual hysterectomy should be explained. Risks associated such as haemorrhage, infection and accidental damage to bladder and bowel should alsobe explained. Choice of anaesthesia must be made by anaesthetist in consultation with obstetrician and mother however regional blocade is safer. Because of higher risk of thromboembolism she may be considered for heparin therapy. Need for blood transfusion should be explained and querries should be dealt with.
To minimise the risk of postpartum haemorrhage every unit should have a protocal for management of massive obstetric haemorrhage which includes liasion with haematology, giving warm blood rapidly and management of women who refuse blood products. Post operative management in HDU and set criteria for invasive management. Multidisciplinary team involvement and urgent call for help impoves outcome. Caesaren section for placenta previa with previous caesarean section should be performed by consultant obstetrician according to most recent confidential enquiry into maternal death. Continous oxytocin infusion may reduce the risk of post partum bleeding. Infection is another risk factor for placenta previa which can be tackled by use of antibiotic prophylaxis before termination of pregnancy, caesarean section and manual removal of placenta.
Posted by Randa E.
This young lady should made aware that this is a major placenta praevia , a condition in which the placenta is wholly inserted into the lower segment of the uterus and covering the internal os. She should also be told that at her gestation and her previous history of caesarean section (c/s) the majority of cases remain as placenta previa and the placenta is less likely to migrate away from the internal os.
She should also be given the information that women like herself with an anterior placenta previa and have been previously delivered by c/s are at an increased risk of having a morbidly adherent placenta known as placenta accreta especially if there has been a short c/s to conception interval , and that she might need further antenatal imaging to establish a diagnosis in such cases. Techniques used include u/s imaging, power amplitude ultrasonic angiography, MRI and colour flow Doppler. The mother should be aware that images antenatally allows for preparation for surgery but false positives do occur and the diagnosis should be confirmed intra-operatively to avoid inappropriate treatment.
This lady should be told that the appropriate mode of delivery in her case and with her diagnosis would be an elective c/s at 38 weeks if all continues well, to try and minimize neonatal morbidity, but she must also be aware that she might also start to bleed suddenly and heavily requiring urgent delivary, and so hospital admission is usually preferable at this gestation. Any home-based care if chosen by her requires close proximity to hospital, the constant prescence of a companion with the full informed consent from her, and it should be made clear that if she experiences any bleeding , any contractions or any form of pain she should attend to hospital immediately. She must also be made aware that placenta previa comes with an increased risk of haemorrhage which possibly might need urgent blood transfusion and sometimes urgent surgical interventions such as hysterectomy which might be life saving.
To obtain an informed consent the following issues must be discussed with the mother in an appropriate manner with courtesy, respect and dignity maintained at all times, preferably in the prescence of her partner; Firstly I must make sure that she fully understands the nature of her condition and the name of the procedure she is undergoing , I will explain to her that she will be delivered by the abdominal route through an open insicion in the abdomen and uterus, and I will explain the procedure to her as described in her file and give her a leaflet explaining the procedure.
I will explain to her that the intended benefit of the c/s is to secure the safest and quickest route of delivary in the circumstances present. I will explain the serious risks of both the placenta praevia and the surgery itself .I will make sure that she understands that she has a higher risk of haemorrhage which might need blood transfusion and sometimes the bleeding will be life threatening and hysterectomy might need to be preformed to save her life. I will also explain general risks associated with the surgery like wound infection and thromboembolism.
She must also be made aware of the other procedures which might become necessary during the procedure like ligation of major vessels to stop the bleeding if need arise or repair of organs damaged if occurring.
I will explain to her the risks of not interfering and give her room to digest all this information and make her own descision and will take all her wishes and concerns into concideration.
I will then make a record of everything discussed prior to the surgery and discuss with her the form of anaesthesia planned giving her an opportunity to discess this with the anaesthist before surgery. Lastly any uncertainiinities must be discussed and any questions must be answered accordingly.
To minimize morbidity the surgery should be conducted by a consultant obstetrician with involvement of specialised multidisciplinary personel and should occur where there are facilities for high volume blood transfusion and availability of other blood products with ready available cross matched blood available.Calling for early extra help should be encouraged. Uterotonic agents such oxytocin may help in reducing blood loss, and also additional surgical manaeovers e.g b-Lynch suture, ligation of internal iliac artery, might be considered.
The units protocols for managing massive obstetric emergencies should be followed to the letter and should include early liason with haematologist, giving warm blood rapidly,criteria for invasive monitering and management of women who refuse blood products. Emergency firedrills and clinical scenarios surrounding issues of massive obstetric haemorrhage and obtaining blood products urgently should be run locally.

Posted by Sarwat F.
Anterior placenta covering internal os in a woman with previous caesarean section places woman at high risk. She should be informed about the risk of caesarean section with placenta previa. There is also a risk of adherent placenta and placenta acreta at the time of caesarean section. Various investigations like venous Doppler and MRI can be undertaken to identify adherent placenta. Caesarean section will be done at 38 to 39 weeks of gestation if patient is asymptomatic, however in case of any vaginal bleeding it can be done earlier. If patient has any vaginal bleeding she needs to be admitted in the hospital until the time of delivery. 4 to 6 units of blood will be crossmatched. Conservative in hospital management can be done in case the bleeding is light and stops after a single episode. She will be explained about the risk of fetal hypoxia and increased perinatal mortality with vaginal bleeding. There is a risk of antepartum and postpartum haemorrhage, maternal hypotension and shock associated with placenta previa.
Discussion for informed consent for caesarean section must include risks associated with the procedure which include haemorrhage, adherent placenta, and need for classical uterine incision. As placenta is implanted in the lower uterine segment, there is a high risk of haemorrhage at the time of caesarean section. Blood transfusion may be needed if there is heavy bleeding. Intravenous syntocinon infusion and intramuscular prostaglandins may be needed to control haemorrhage. Haemostatic sutures may be needed to control bleeding. In case bleeding is not controlled, other measures like major vessel ligation for example uterine and internal iliac artery ligation may be needed. In case these measures fail there is a risk of hysterectomy as a life saving procedure. There is a risk of maternal death with heavy bleeding and hysterectomy is done as a life saving procedure. Patient may need to be transferred to HDU for postoperative monitoring. Full blood picture is repeated to assess the degree of anemia and blood transfusion given if needed.
Measures to minimize morbidity from postpartum haemorrhage include correction of any anemia before delivery, senior input and early identification of complications at the time of caesarean section. 4 to 6 units blood should be crossmatched at the time of caesarean section. Patient must have wide bore intravenous line. A classical incision in uterus may be needed for delivery of baby. Adequate haemostasis should be achieved at the time of caesarean section. Patient will be transferred to HDU for postoperative monitoring.
Posted by Mary M.
(a) The information given that afterbirth is covering the mouth of womb & at this stage of gestation ,it will sit here,this is called major Placenta praevia & it has morbidity & mortality.Because of this it is unlikely that you will go into normaql labour, instead an elective C section will be arranged at 38-39 weeks. Even during rest of pregnancy, there is risk of bleeding. If it happens, you need admission or might be emergency C-Sectionis done . From 36 weeks onwards you need to be admitted and if it is not acceptable then you must have some responsible adult at home who will take you to hospital in case of emergency.There could be risk of adherent placenta and it can leed to casearean hysterectomy
(b)Potential risks are discussed. The risk of major haemorrhage & need of massive transfusion is discussed. Injury to surrounding organs like bladder & bowel isdicussed while operating . It could be due to adhesions of previos surgery.
If there is placenta increta or precreta,it could leed to severe haemmorhage and casearean hysterectomy is needed,it means no further children can be produced except surrogacy.
Risk of anaesthesia will be discussed such as dural tap, post dual headache,possibility of General anaesthesia & difficulty in intubation.
Potential risk of infection & need for antibiotics is discussed.There is risk of deathwith every surgery.
(c) Antenatally Hb is build up. Oral or intravenous iron is used. Blood is cross matchd & saved.In case of Jehovas witness other blood products & other measures are disussed.Consultant obstetrcian & anaesthetist will be present or surgery is performed under supervision.Other speciality is infomed aout surgery such as urologist & general surgeons.Immediate ressicitation is given in case of emergency & early intervention such as Caserean Hysterectomy is done in case of failed measures.
Posted by kiria O.
I would explain the diagnosis to her, that placenta is covering the entire lower part of the womb and its impossible to deliver normal. So the best and only option is elective caesarean at 38 weeks gestation however, emergency c.s is the other option if she get antepartum heamorrhage.

Also, woman need to be couneslled regrding in patient admission as the sever bleeding is un predictable and life threatining.

other information she need to know about the possible need for blood transfusion because she is at risk of intra and post partum bleeding and any objections or views need to be addressed.

The possiblity that placenta could be adherent(accreta) shoud be discussed with woman and doppler sonography may help in diagnosis.
woman should know that a hystrectomy maybe a neccessary if bleeding is uncontrallable.
Also, her CS would be performed or supervisied by consultant obstetrician and senior anasthatist would disscuse with her the most suitable form of anasthesia.
Pateint blood group and cross matched blood must be performed and heamatologist must be informed since admission.

To obtain informed consent from her clear information verbal, written must be provided to help her in understand the situation and give informed consent. Its important to discuse the intended benefit of CS is to deliver the baby as there is no possiblity of normal delivery.
The most serious complication is heamorrhage and its life threatining and may neccitate blood transfusion or in extreme cases hystrectomy.
Other morbidites and frequntly occuring complication must be discussed such as venous thrombosis,wound infection,urinray tract infection, longer hospital stay. However, those morbidites could be reduces by appropriate thromboprophylaxis and prophylactic antibiotics.
explanation of procedure and the possibility of upper segment incsion to avoid going through the anterior placenta.
Also, the fact that prvious two CS affect her future pregnancies and possiblity of a trial of two scars is still contraversial.

There are many mesures must be taken to minimise morbidity from postpartum heamorrhage including blood must be in theater before starting CS and keep heamtologist informed. Also.CS must be performed or supervised by consultant obestetrician, use of uterotonics and fastidious heamostasis. other measures such as using other option to control pph brace suture and decision for hystrectomy must be not delayed to avoid maternal mortality
Posted by M M A.
I should explain to her that the placenta cvers the enterance of the womb entirely and this may be complicated when the placenta is attached to the womb abnormally ,making separation at time of birth difficult and this is more commonly in women who have previously had caesarean section.
I would inform her about the risk of bleeding ,especially it may be severe , so,her admission to hospital should be offered ,even if she has no symptoms .Also,I would reassure her that Mortality from placenta praevia is rare in the UK,( 3 /600000 deliveries per year) . She should be counselled for possibility of peripartum blood transfusion .She should be offered elective caesarean section at 38 weeks to minimise
The neonatal morbidity.I would explain to her that her caesarean section would be conducted by the consultant obstetrician and the consultant anaesthetist on duty .
As this woman has increased risk of having morbidly adherent placenta, colour flow Doppler should be used to make diagnosis or should be managed ,as if she has placenta acreta until proven otherwise. I would to tel her that she has the right to be fully informed about her health care , and to share in making decisions about it .
She and her partner should have had discussions regarding delivery ,heamorrhage, possible blood transfusion and major surgical interventions such as hysterectomy ,and should be discussed with the patient as part of the consent procedure .
She should be discussed for use of thromboembolic prophylaxis.,Any home-based care requires close proximity with the hospital ,the costant presence of the companion and full informed consent from the woman.
The patient should be fully informed about the different conservative management strategies to retain her fertility , As leaving placenta undisturbed , Methotrexate , Interval placenta removal, and other strategies as wedge resection , Bilateral uterine artery embolisation, argon beam coagulator ,pelvic artery ligation ,but such techniques may be appropriate as long as bleeding remains minimal..
I have to ask her if she has fully understood the information and I have to answer her questions and finally making notes for the known risks and complications that she was discussed and information leaflet has been read and taken by the patient.
Measures to minimse massive postpartum haemorrhage , The delivery should be conducted by the consultant obstetrician and the anaesthetist and other specioalists ( haematologist and ITU ) should be alerted to assist if needed., also,blood should be available during in-patient stay based on local guidelines and the haematologist should be involved ,if the patient with atypical antibodies .
The risk of massive haemorrhage ,blood transfusion and hysterectomy should be discussed with the woman and her partner before delivery. There is no evidence to support the use of of autologous blood transfusion , but cell salvage should be considered . ,and call for extra-help from most experienced member of staff , with use of uterotonic agents and also,additional surgical management such as B-lynch suture and internal iliac artery ligation should be considered or arterial embolisation .
The unit protocol for m
anagement of massive obstetric haemorrhage ,should include early liason with haematologist ,giving warm blood rapidly, criteria for ivasive monitoring as CVP ,Swan-Ganz catheterization and management of women who refuse blood products .Emergency fire drills and clinical scenarios surrounding issues of obtaining blood products urgently should be run locally. And careful documentation and use of incident forms is strongly recommended.

Posted by SWATI M.
I will tell her that she has major degree placenta previa , it is unlikely to migrate and remain so until delivery.It is associated with increased maternal morbidity and mortality and perinatal morbidity.She can bleed per vaginaly due to her condition which is unpredictable in time,amount and unpreventable.She will need to be admitted in the hospital until delivery sothat haemorrhage can be dealt immediately to optimize maternal and perinatal outcome.She may need blood transfusions. She may need urgent and early delivery in case of bleeding even though the fetus is not mature but the chances of survival at or after 35 weeks are good.Mode of delivery would be by caesarean section since major degree previa.It is likely that the placenta can be adherent ?acreta- since she had previous caesarean and now placenta is anterior.Colour Doppler may give an idea about adherent placenta but can not rule out placenta acreta 100% antenataly and sometimes diagnosis is made intraop.She may have massive bleeding in case of placenta acreta and may need additional procedure which may compromise her fertility. She is at increased risk of having postpartum haemorrhage & VTE.

To obtain the informed consent for caesarean section, preferably discussion should be done in presence of her partner. I will tell her that this is the safest way of delivery. The optimum time would be at 38 weeks to optimise perinatal outcome if she does not bleed and in case of bleeding it will be done urgently.The procedure would be performed by senior personnel. The type of anaesthesia would be decided by the anaesthetist but regional anaesthesia would be preferred if performed electively and patient is haemodynamically stable.She should discuss it with the anaesthetist and the appointment would be arranged.Transverse abdominal incision would be made. She may need blood transfusions ,ask if she has any objections to it and document accordingly in her notes.She may bleed excessively during procedure since anterior placenta previa.Also placenta can be adherent contributing to haemorrhage . She may need additional procedures in case of massive haemorrhage to save her life . The procedure may include uterine or internal iliac ligation , B ?Lynch sutures or even emergency hysterectomy which will compromise her fertility. Baby can have complications such as neonatal shock or anaemia and neonatalogist would be present at the time of delivery. Baby may need admission to SCBU if born premature or develop complication.She may need admission to HDU in case of massive haemorrhage.Postop she will need intravenous fluids for 24-48 hours depending on amount of bleeding and urinary catheter until she mobilises.She will have to stay in hospital for 3-4 days if she has no complications .She should avoid heavy work and driving for 4-6 weeks postop. She should be given the information leaflet to make the informed choice and document all the discussion in her notes.

To prevent the morbidity from PPH, manage third stage actively which includes administration of oxytocics and continue oxytocin drip 4-6 hours postpartum. Adequate amount of blood should be available in blood bank and in operating theatre before the start of procedure. Do not pull or try to separate the placenta if adherent.Senior personnel should perform the procedure and decision about the additional procedure should be taken timely.Replace the amount of blood lost intra and postop and supplement with oral iron postpartum if anaemic.Careful monitoring especially 4-6 hours postpartum for PPH and nurse in HDU in case of massive PPH with involvement of Consultant obstetrician, haematologist and intensivist.
Posted by Srivas  P.
Sir

Do we need to explain to this woman about what a caessarean section is about ,type of incisions, especially as she has undergone a same operation before? Just highlighting why it could be different from last time, extra risks involved now especially due to the low lying placenta posssibly abutting on the scar, possibility of a classical caessarean/ hysterectomy and other likely procedures of dealing with an adherent placenta is not enough?
Posted by TAIWO NURENI Y.
I will let her know that she has a major placenta previa which makes normal delivery impossible as the route of delivery is covered by the placenta.Also ,there are associated risk of haemorrhage which could happen antepartum,intraoperatively or postpartum.She will have to be admitted to the hospital till delivery which is going to be by c/s at 38 weeks or sooner if major bleeding occured.The fact that she has had a c/s before also increases the possibility of adherent placenta which contributes to the morbidity associated with this condition.Issue of blood transfusion will be discussed in case she has any objection.
For the consent ,I will explain the procedure of ceasarian section to her and let her know that experienced obstetrician will be in charge of the c/s.The possible complication of severe heamorrhage which may neccesitate massive blood transfusion,difficult surgery because of adhesion from pevious surgery,ureteric/bladder damage and need for some other measures will be mentioned.Life saving operation like hysterectomy will be discussed as a possibility.The arrangement to see anaesthesisit for discussion will be mentioned and that she may end up in ICU as well.All these will be documented in her note and information leaflet issued to her prior to the consent.
The morbidity from PPH could be minimised by ensuring that the haemoglobin status is optimised prior to c/s and also 6units of blood to be crossmatched and made available.The laboratory as well as haematologist to be aware of the case while on admission and when going for surgery.Operation should be performed by senior and experienced obstetrician and consultant anaesthetist at the operation.Early and judicious use of uterotonics as well as surgical intervention to control hamorrhage during operation.In cases of morbidly adherent placenta ,it could be left behind and treated with methotrexate