Placenta Previa and Placenta Abruption

What is the clinical presentation of Abruptio Placentae?

- *Dark red bleeding and intense abdominal pain* with painful uterine contractions - Hemorrhage into the decidua basalis, leading to premature seperation of the placenta and further increase in bleeding - bleeding into the basalis stimulates painful contractions and the uterus will be painful to the touch

How is Placenta Abruption diagnosed?

- Classic findings of painful dark bleeding - U/S to exclude placenta previa - Increase in uterine fundal height due to expanding hematoma - Uterus may be firm and demonstrate tetanic contractions - Signs of fetal distress: decreased variability, late decelerations - 50% abruption is enough to cause fetal death - Signs of Hypovolemic shock may present; 50% abruption is equivalent to 2000-2500 cc of blood loss

How is Placenta Previa diagnosed?

- Diagnosis via u/s: often will find an abnormal fetal presentation since the placenta is occupying the lower uterine segment (breech, transverse lie) - If a pt in her third trimester presents with bleeding, 1st stabilize the pt - no vaginal exams until the diagnosis of previa is made or excluded

What are the risk factors for component transfusion?

- Hep C - Hep B - HIV - CMV - parvovirus - EBV

What can cause bleeding during the third trimester?

- Intercourse - Vulva: varicose veins, tear and lacteration - Vaginas: tears or lacterations - Rectal: hemorrhoids - Cervix: polyps, glandular tissue, cervicirtis, carcinoma - Intrauterine: placenta previa, placental abruption, vasa previa

What is the clinical presentation of placenta previa?

- Usually visualized by U/S early in pregnancy - Spontaneous bright red bleeding around 28-30 wks gestation with no apparent warning - No pain unless accompanied by mild contractions - Bleeding is usually self limited "painless, bright red bleeding"

What are the risk factors for Abruptio Placentae?

- chronic HTN - preeclampsia - cocaine use - abdominal trauma - polyhydraminos - multiple gestaions

What is the medical management for Placenta Previa?

- hemodynamic stabilization - CBC, type and screen, Rho-gam - steroids for fetal lung maturity - bed rest with assessment for further bleeding - C.section

What are the complications of performing a C.section for placenta previa?

- incisions into the uterus that go through the placental tissue - after delivery of the placenta, lower uterine segment will not contract as well as the upper uterine musculature, and increased bleeding may occur - association of previa to placenta accreta, which usually necessitates a hysterectomy

What are the risk factors for placenta previa?

- increase parity (# of past pregnancies) - increasing age - previous cesarean section - previous placental previa

What is the treatment and managment for Placental abruption?

- stabilization of pt: IV, transfusion - if fetal distress is present perform a C.section - if fetus has expired, vaginal deliver is preferable - if fetus is tolerating the abruption vaginal deliver can often be undertaken - monitor HCT, platelets and clotting factors

What is Placenta Previa?

Abnormal placentation over the internal cervical OS or in close proximity to the internal OS

What is Couvelaire Uterus?***

Bleeding in abruptio placentae can espace into the uterine musculature to such an extent that a portion or all of the uterus develops a *purplish apperance* owing to the extravasation of blood

When does the bleeding during Abruptio Placentae not become apparent?

If the margin of the placenta remains attached to the underlying uterus, the bleeding may not escape the vaginal vault leading to concealed abruption

What is the most common cause of coagulopathy in pregnancy?

Placenta Abruption - which causes DIC, consumptive coagulopathy - hypofibrinogenemia - increased fibrin split product - thrombocytopenia - increase PT and PTT

What is Complete Placenta Previa?

Placenta covers the entire OS

When does Vasa previa occur>

Results in a triad of membrane rupture, painless vaginal bleeding and fetal bradycardia - Filamentous umbilical cord insertion (cord inserts into chorioamniotic membrane rather than placenta)

What causes bleeding in placenta previa?

Small separation of part of the placenta from the lower uterine segment

When does bleeding during Abruptio Placentae become apparent?

The bleeding can be readily apparent if the separation permits access to the cervical OS

What is Marginal Placenta Previa?

The edge of the placenta lies just adjacent to the OS

What is Low lying Placenta Previa?

The edge of the placenta lies near, but not directly adjacent to the OS

What is Partial Placenta Previa?

The margin of the placenta extends over a portion of the OS

How is a baby delivered with placenta previa?

c.section

What is Abruptio Placentae?

the premature seperation of a normally located placenta from the uterine wall

What is Vasa Previa?

the presence of placental blood vessels from the fetal circulation crossing the internal OS of the cervix

What is the migration of the placenta?

this occurs with low lying placenta previa, as the uterus grows and stretches it caries the placenta up with it moving it away from the OS