PLACENTAL

 ABRUPTION  
Placental  [Link]  (Abrup.o  Placenta)  
•  [Link]  of  the  placenta,  either  [Link]  or  
totally,  from  its  [Link]  site  before  delivery    
•  premature  [Link]  of  the  normally  implanted  
placenta    
•  perinatal  mortality  and  morbidity  are  more  
common  with  [Link]  occurring  at  earlier  
AOGs  
•  classically  presents  as  PAINFUL  uterine  bleeding  
•  associated  with  tetanic  uterine  contrac0ons  and  
increased  baseline  uterine  pressure  

 
 Pathogenesis  of  abrup.o  
Bleeding  into  the  decidua  basalis  (rupture  of  a  
decidual  spiral  artery)  
 
Decidual  hematoma  
 
[Link]  and  compression  of  the  adjacent  
placenta  
 
External  vs  Concealed  Hemorrhage  
•  Bleeding  typically  insinuates  itself  between  
the  membranes  and  uterus,  [Link]  
escaping  through  the  cervix  to  cause  external  
hemorrhage  
•  Less  oEen,  the  blood  is  retained  between  the  
detached  placenta  and  the  uterus,  leading  to  
concealed  hemorrhage  and  delayed  diagnosis.    
 Risk  Factors  for  Abrup.o  Placenta  
•  Age  >40  
•  [Link]  
•  Prior  [Link]  
•  Hypertension  –  most  frequent  [Link]  associated  
with  placental  [Link]  
•  Preterm  premature  rupture  of  membranes  
•  CigareSe  smoking  
•  Cocaine  abuse  
•  Lupus  [Link]  and  thrombophilias  
•  Uterine  leiomyomas  –  especially  if  submucosal,  behind  
the  placental  [Link]  site  
Risk  Factors  for  Abrup.o  Placenta  
•  Sonography  has  limited  use  because  the  
placenta  and  fresh  clots  may  have  similar  
imaging  [Link]  

•  [Link]  findings  with  sonographic  

[Link]  do  not  exclude  placental  
[Link].    

•  With  [Link],  intravascular  coagula@on  is  

almost  universal.  Thus,  elevated  serum  levels  
of  D-­‐dimers  may  be  [Link].  
 [Link]  of  Abrup.o  Placenta  
•  Hypovolemic  shock  secondary  to  [Link]  
bleeding  
•  Acute  kidney  injury  develops  if  treatment  of  
hypovolemia  is  delayed  or  inadequate  
•  Disseminated  intravascular  [Link]  
•  Couvelaire  uterus  ([Link]  of  blood  into  
the  uterine  musculature  and  beneath  the  serosa)  
•  Sheehan  Syndrome  (pituitary  failure  secondary  to  
severe  intrapartum  or  postpartum  hemorrhage)  
Couvelaire  Uterus  
 Management  of  Abrup.o  Placenta  
•  prompt  and  intensive  [Link]  with  blood  
plus  crystalloid    
•  manner  and  .ming  of  delivery  depends  
primarily  on  clinical  [Link],  the  [Link]  
age,  and  the  amount  of  associated  
hemorrhage    
•  with  a  living  viable-­‐size  fetus  and  with  vaginal  
delivery  not  imminent,  emergency  cesarean  
delivery  is  chosen  by  most  
 Management  of  Abrup.o  Placenta  
•  if  there’s  fetal  compromise,  CS  is  preferred  
•  if  the  fetus  has  died,  then  vaginal  delivery  is  
usually  preferred    
•  excep@ons  for  which  vaginal  delivery  may  not  
be  preferable  even  if  the  fetus  is  dead:  
•  hemorrhage  is  so  brisk    
•  presence  of  obstetrical  [Link]  that  prohibit  
vaginal  delivery  (ex.  Transverse  lie,  previous  CS,  
etc.)  
 Management  of  Abrup.o  Placenta  
•  Early  amniotomy  has  long  been  championed  
in  the  management  of  placental  [Link]  
•  achieves  beSer  spiral  artery  compression  that  
might  decrease  [Link]  site  bleeding  and  
reduce  thromboplas.n  infusion  into  the  maternal  
vascular  system  
PLACENTA  PREVIA  
 Placenta  Previa  
•  describes  a  placenta  that  is  implanted  somewhere  
in  the  lower  uterine  segment,  either  over  or  very  
near  the  internal  cervical  os    

 
 Classifi[Link]  
•  Placenta  previa  -­‐  the  internal  os  is  covered  [Link]  
or  completely  by  placenta.  In  the  past,  these  were  
further  classified  as  either  total  or  par@al  previa    
•  Low-­‐lying  placenta  -­‐  [Link]  in  the  lower  
uterine  segment  is  such  that  the  placental  edge  does  
not  reach  the  internal  os  and  remains  outside  a  2-­‐
cm  wide  perimeter  around  the  os.    
•  A  previously  used  term,  marginal  previa,  
described  a  placenta  that  was  at  the  edge  of  the  
internal  os  but  did  not  overlie  it.    

 
Total  Placenta  Previa  
 Placenta  Previa  
•  the  classifi[Link]  of  some  cases  of  previa  will  
depend  on  cervical  [Link]  at  the  .me  of  
assessment    

•  Digi@al/Internal  exaina@on  is  contraindicated  in  

placenta  previa  –  causes  severe  hemorrhage  

 
 Risk  Factors  
•  Age  >35  
•  [Link]  
•  Prior  cesarean  delivery  
•  CigareSe  smoking  –  carbon  monoxide  
hypoxemia  causes  compensatory  placental  
hypertrophy  
•  Elevated  prenatal  MSAFP  levels  
 Clinical  Features  
•  Classically  presents  as  PAINLESS  bleeding,  
usually  near  the  end  of  the  2nd  trimester  or  
later  
•  begins  without  warning  or  without  pain  (called  
sen@nel  bleed)  
 Pathogenesis  of  Placenta  Previa  
uterine  body  remodels  to  form  the  lower  uterine  
segment  
 
internal  os  dilates  
 
implanted  placenta  separates  
 
bleeding  ensues  and  is  augmented  by  the  inherent  
inability  of  myometrial  fibers  in  the  lower  uterine  
segment  to  contract  and  thereby  constrict  avulsed  
vessels    
 [Link]  
•  Placenta  accrete  syndromes  
§  arise  from  abnormal  placental  [Link]  and  adherence  
§  classified  according  to  the  depth  of  placental  ingrowth  into  
the  uterine  wall:  
§  Acrreta  
§  Increta    
§  Percreta  
§  more  commonly  seen  among  women  whose  placenta  
previa  is  implanted  anteriorly  at  the  site  of  a  prior  uterine  
incision  
§  DIC  rarely  occurs  
§  Placental  thromboplas.n,  which  incites  the  intravascular  
[Link]  seen  with  placental  [Link],  is  presumed  to  
readily  escape  through  the  cervical  canal  rather  than  be  forced  
into  the  maternal  [Link]    
 Diagnosis  
§  Sonographic  placental  localiza@on  
§  transabdominal,  transvaginal  or  transperineal  
§  previa  should  not  be  excluded  un.l  sonographic  
[Link]  has  clearly  proved  its  absence    
§  Diagnosis  by  clinical  [Link]  is  done  using  the  
double  set-­‐up  technique    
§  a  cervical  digital  [Link]  is  done  with  the  woman  
in  an  [Link]  room  and  with  [Link]  for  
immediate  cesarean  delivery    
§  should  not  be  performed  unless  delivery  is  planned  
§  rarely  necessary  because  placental  [Link]  can  almost  
always  be  ascertained  sonographically    
 Management  
§  always  via  cesarean  delivery  
§  Timing  of  delivery  depends  on:  
§ fetal  age/maturity  
§ labor  
§ severity  of  bleeding  
§  If  the  fetus  is  preterm  and  there  is  no  persistent  
[Link]  bleeding,  management  favors  close  
[Link];  otherwise,  emergency  CS  is  
performed    
§  [Link]  may  be  given  as  necessary  
 Management  
§  For  women  who  are  near  term  and  who  are  not  
bleeding,  plans  are  made  for  scheduled  cesarean  
delivery.    
§  [Link]:  at  36-­‐37  completed  weeks  
§  if  with  associated  placenta  accrete  syndromes:  34  to  35  
completed  weeks  
§  Type  of  uterine  incision:  low  transverse  
§  a  ver@cal/classical  incision  may  be  done  if  the  placenta  
is  anteriorly  located  
PLACENTA  ACCRETE  SYNDROMES  
 Placenta  Accrete  Syndromes  
§  include  any  placental  [Link]  with  
abnormally  firm  adherence  to  the  
myometrium  because  of  [Link]  or  total  
absence  of  the  decidua  basalis  and  
imperfect  development  of  the  fibrinoid  or  
Nitabuch  layer  
§  histological  diagnosis  cannot  be  made  from  
the  placenta  alone  
§  the  uterus  or  cureengs  with  myometrium  are  
necessary  for  histopathological  confi[Link]    
 Classifi[Link]  
§  Placenta  accreta  indicates  that  villi  are  
aSached  to  the  myometrium  
§  Placenta  increta  -­‐  villi  actually  invade  the  
myometrium  
§  Placenta  percreta  defines  villi  that  
penetrate  through  the  myometrium  and  to  
or  through  the  serosa    
 Classifi[Link]  
§  Total  placenta  accreta  –  involves  all  lobules  
§  Focal  placenta  accreta  –  involves  only  1  
lobule  
 Risk  Factors  
§  similar  to  those  for  placenta  previa  
§  2  most  important  risk  factors  are:  
§  an  associated  previa  
§  a  prior  cesarean  delivery  
(more  likely  a  [Link]  of  the  2)  
 Diagnosis  
§  Clinical  [Link]:  
§  antenatal  bleeding  as  a  consequence  of  [Link]  
previa  
§  adhered  placenta  encountered  during  the  3rd  
stage  of  labor  
§  usually  iden.fied  antepartum  by  sonography    
§  abnormal  intraplacental  venous  lakes  are  seen  
§  Doppler  color  flow  mapping  is  highly  [Link]  of  
myometrial  invasion  
 Management  
§  Exigencies  to  be  considered  are  appropriate  
surgical,  anesthesia,  and  blood  banking  
[Link]    
§  Timing  of  delivery:  34  to  35  completed  weeks  
§  aEer  fetal  delivery,  the  extent  of  placental  
invasion  is  assessed  without  aPempts  at  
manual  placental  removal    
§  If  confirmed,  HYSTERECTOMY  is  performed  and  
the  placenta  is  leE  in  situ