This document discusses obstetrical hemorrhage from placenta previa and placenta accrete syndrome. It begins with an introduction and overview of placenta previa, including risk factors, clinical features, diagnosis and management. It then discusses placenta accrete syndrome in more detail, including pathogenesis, risk factors, ultrasound and MRI findings for diagnosis, and recommendations for management. The recommendations are that placental accrete syndrome should be ruled out using Doppler ultrasound in this patient, and preparations should be made for potential hysterectomy due to the high risk.

1. Obstetrical Hemorrhage: PPH
Hale T., O & G Resident,
Mekelle University,
College of Health Sciences, Dep't of OB-GYN
May 26, 2016

2. • Contents
– Discussion on
• Placenta Previa
• Placenta Accrete Syndrome• Placenta Accrete Syndrome
– Comments and Recommendations
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3. Introduction
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4. • Any degree of bleeding in a pregnant
mother is pathologic; excluding
– Implantation bleeding
– Bloody show– Bloody show
– Bleeding in the third stage of labor
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6. • Placenta Previa
– Placenta goes before the fetus into the birth
canal
– Implantation of a placenta in the lower uterine– Implantation of a placenta in the lower uterine
segment (adjucent or over the internal Os)
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7. • New classification of placental
implantation
– Normally implanted
– Placenta previa– Placenta previa
– Low lying placenta
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8. • Degrees of Placenta Previa
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9. Ultrasound in Obstetrics & Gynecology_ A Practical Approach - Clip 10.6.mp4
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13. • GA greater than 16 weeks
– Placenta > 2 cms away from Os - Normal
– Placenta < 2 cms but not covering - PP
• Follow up U/S at 32 weeks
– Placental edge > 2 cms– Placental edge > 2 cms
» Do color dopler U/S at 32 weeks to rule out vasa
previa
– Still less than 2 cms
» Follow up U/S at 36 weeks
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14. Placenta Previa
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15. Ultrasound in Obstetrics & Gynecology_ A Practical Approach - Clip 13.1.mp4
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19. • Placental Migration
– Apparent movement of the placenta away
from the internal os
• Imprecision of two-dimensional sonography• Imprecision of two-dimensional sonography
• Differential growth of the lower and upper
uterine segments
– A low-lying placenta is less likely to “migrate”
within a uterus with a prior cesarean
hysterotomy scar
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20. • Also
– Lengthening of the lower uterine segment
– Progressive unidirectional growth of
trophoblastic tissue toward the fundustrophoblastic tissue toward the fundus
– Placental atrophy
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23. • Predictors of hemorrhage in PP
– Placentas that cover the os
– Placentas near the Os have a greater risk of
bleeding if the placental edge is thick (>1 cm)bleeding if the placental edge is thick (>1 cm)
– Identification of an echo-free space in the
placental edge covering the internal os
– Cervical length ≤3 cm
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24. • Admission
– After 28 weeks
– Before 28 weeks
• If there is bleeding or contraction• If there is bleeding or contraction
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25. • Classification
– Placenta Previa
• Internal os is covered partially or
completely by placenta
– Low lying placenta
• Placental edge does not reach the internal
os and remains outside a 2-cm wide
perimeter around the os
– Somewhat but not always related is vasa
previa, in which fetal vessels course through
membranes and present at the cervical os
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26. • Incidence
– 0.3% or
– 1 per 300-400 deliveries
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27. • Risk Factors
1. Maternal age
• Age above 35 years
2. Multiparity
• Para 5 and above (80% of cases of PP are
multipara)
3. Prior Cesarean deliveries / Myomectomy /
Hysterectomy / Prior curretageHysterectomy / Prior curretage
• 8 fold if they had more than 4 CD
4. Cigarrete Smoking
• Compensatory placental hypertrophy
• Decidual vasculopathy
5. Elevated Prenatal Screening MSAFP Level
• increased risk for previa and a host of other
abnormalitiesHale T., M.D., Resident Physician 27

28. • Also...
– Multifetal gestation
– Infertility treatment
– Uterine instrumentation– Uterine instrumentation
– Abortion
– Male fetus
– Nonwhite race
– Previous placenta previa
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29. • Pathogenesis
– Suboptimal endometrium in the upper
endometrial cavity
• Droping down theory• Droping down theory
– Large placenta
– Defective decidualization
– Persistence of chorionic activity
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30. • Pathophysiology
– Changes in the cervix and lower uterine
segment apply shearing forces to the
inelastic placental attachment site,inelastic placental attachment site,
resulting in partial detachment
• Lower uterine segment - Soft and friable
– Vaginal examination or
– Coitus
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31. • Clinical Feature
– Asymptomatic
– Vaginal bleeding
• Painless• Painless
• Without warning
– Sentinel bleed
• Ceases and recurs
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32. • Sequele
– Severe bleeding
– Preterm birth
– Cesarean delivery– Cesarean delivery
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33. • Other associated problems with PP
– Preterm labor and rupture of the membranes
– Malpresentation
– Intrauterine growth restriction– Intrauterine growth restriction
– Vasa previa and velamentous umbilical cord
– Congenital anomalies
– Amniotic fluid embolism
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34. • Coagulation Defects
– Placenta previa rarely complicated by
coagulopathy
• Placental thromboplastin readily escape through• Placental thromboplastin readily escape through
the cervical canal
• Paucity of large myometrial veins
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35. • Diagnosis
– Historical presentation
– Double set-up technique
• Almost obsolete
– Sonographic placental localization
• 96% accuracy,• 96% accuracy,
• 100% negative predictive value
– Transabdominal
– Transperineal
– Transvaginal
– MRI
• For evaluation of placenta accreta
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36. Management
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38. • Expectant management
– Candidates?
– When should termination be effected?
– Home or Hospital?– Home or Hospital?
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39. Placenta Accrete Syndrome
• Abnormally implanted placenta
– Placenta Accrete Syndromes
• Placenta accreta, increta, percreta
– Abnormally firm placental attachment– Abnormally firm placental attachment
– Poorly developed decidua that lines the lower uterine
segment
– Previa overlying a prior cesarean incision conveys a
particularly high risk for accreta carries a major risk
of placental accrete Syndrome
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40. • Abnormality of placental implantation
– Anchoring placental villi normally attaches to
the decidua
• Accreta• Accreta
– Anchoring placental villi attach to myometrium
• Increta
– Anchoring placental villi penetrate into the myometrium
• Percreta
– Anchoring placental villi penetrate through the
myometrium to the uterine serosa or adjacent organs
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42. • Incidence
– Increasing at an alarming rate
– Accreta > Increta > Percreta
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43. • Pathogenesis
– Defective decidualization
– Excessive extravillous trophoblastic invasion
– Defective maternal vascular remodeling in the– Defective maternal vascular remodeling in the
area of a hysterotomy scar
– Partial or complete dehiscence of a uterine
scar
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44. • Risk Factors
– Placenta previa
– Placenta previa after previous CD scar
– Adavanced maternal age
– Multiparity
– Endometrial ablation– Endometrial ablation
– Prior endometrial irradiation
– Leiomyomas
– Uterine anomalies
– Smoking
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48. Risk of Placenta Accreta Syndrome - In the absence of PP
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49. • Clinical Presentation
– Life threatening torential bleeding during an
attempt to separate the placenta manually
– No plane of separation– No plane of separation
– 2/3 of peripartum hysterectomies
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50. • Sequeae
– Unplanned surgeries / Hysterectomies
– Death
– ARDS– ARDS
– DIC
– PPH
– Preterm birth
– SGA infants
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51. • Ultrasound Predictors of PPH in a patient
with APH (Placenta Previa)
– If there is placenta accreta syndrome
– Thickness of the lower edge > 1 cms– Thickness of the lower edge > 1 cms
– If placenta covers the internal Os
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52. • Imaging
– Sonography
• Conventional
• 3-D Ultrasound• 3-D Ultrasound
• Color dopler
– MRI
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53. Ultrasound Diagnostic Findings in Placenta Accreta
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A. Normal Placenta B. Placenta Accreta

55. Ultrasound in Obstetrics & Gynecology_ A Practical Approach - Clip 12.3.mp4
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60. • MRI Diagnositc Features of Placenta
Accreta
– Uterine bulging
– Heterogenous signal intensity– Heterogenous signal intensity
– Dark intraplacental bands
– Abnormal placental vascularity
– Focal interruptions in the myometrial wall
– Tenting of the bladder
– Invasion of nearby organs
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63. • Lab
– Elevated maternal serum AFP
– Hematuria
– Histology– Histology
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64. • Management
– Team work
– Always CD
– Hysterectomy Vs Conservative– Hysterectomy Vs Conservative
– Leaving the placenta for natural resoprtion
– Use of systemic methotrexate
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65. Recommendations
• In this patient
– Placental Accreta Syndrome should be rulled
in or out with dopler study
– Infraumblical midline abdominal incision– Infraumblical midline abdominal incision
should be planned
– Mother should be counseled on histeroctomy
and OR materials should be prepared for
hysterctomy
– The most senior person in the labor ward
should be involved in the OTHale T., M.D., Resident Physician 65

66. REFERENCES
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67. REFERENCES
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68. REFERENCES
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69. Thank you for listening!
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