Obstetrics 9

• Oral glucose tolerance test  (typically at 24-28 weeks) 
• Complete Blood count  -  for anemia 
• Atypical antibody screen  -  to give RhoGAM 
• GBS (Group B strep) vaginal culture  -   to give prophylactic penicillin in Labor

• A. Cervical causes - Erosions, polyps, cancer
• B. Vaginal causes - Varicosities, Lacerations
• C. Placental causes - Abruptio, placenta previa, vasa previa

• Abruptio placenta:
• – 1%  of pregnancy  
• - painful 

• Placenta Previa:
• - 0.5%  of pregnancy
• -  painless  
• - typical h/o is wakes up in the middle of night with pool of blood.

• Vasa previa:
• - rare  
• - painless
• - Fetal blood  [AIIMS 91] 

• Uterine rupture:
• - rare
• - painful
• - there is loss of station of fetal head

• Abruptio placenta - Most common cause 
• Amniotic  fluid embolism
• Retained dead fetus
• Second trimester abortion

• [Note: Abruptio placenta is the most common cause of
• - Late pregnancy bleeding
• - Painful late pregnancy bleeding and
• - Obstetric DIC]

• Overt bleeding
• Concealed bleeding 

• Abruptio placenta – Normal position 
• Placenta previa – abnormal  - low segment

• HTN - most important  risk factor. [IOM 09] 
• Maternal blunt trauma 
• Cocaine - is a potent vasoconstrictor
• Folic acid deficiency
• Prevalence is more with high birth order, previous abruption,  advancing maternal age, malnutrition

Couvelaire uterus (also known as uteroplacental apoplexy)  is a life threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity. 

It is also associated with concealed  accidental hemorrhage. [UP 94]

• 16 weeks – 20%
• 40 weeks  -  0.5%

• Tropho – placenta, tropism – movement.
• It is the movement of placenta. In early pregnancy, about 20% of cases have placenta, the placenta is close to cervical OS. Over time, the lower part will atrophy and the higher part hypertrophies. This is because the blood supply to the placenta is from the lateral part of uterus ant there is less blood supply to the lower placenta. This process further occurs thus, placenta position is above.  
• 

• Avulsion of villi due to stretching of lower uterine segment. As the lower uterine segment stretches with effacement in later part of pregnancy, there is bleeding.  
• There is no bleeding in early pregnancy in placenta previa because there is no formation of lower uterine segment.

• Type I - Low lying
• Type II - Marginal, placenta in lower uterine segment, not in OS 
• Type III - Partial, Placenta partially in Inner OS
• Type IV - Total central, completely covers the  OS.

• Previous placenta previa 
• Multiple pregnancy – the more the number of  placenta, the more the chance 
• Artificial reproductive techniques  increases  the risk of placenta previa by 5 times.

In normal pregnancy, the sperm goes up and fertilizes in fallopian tube and the formed morrula  descends  and gets implanted in upper uterine segment. In artificial reproductive techniques, the fertilized zygote is placed in the uterus  descends a little and implants in lower uterine segment, and thus there is more risk. Now a days, the specialists are more careful to  keep the zygote as high as possible to prevent placenta previa.

Sonography provides the simplest, most precise and safest method of placenta localization.

• Maternal and fetal jeopardy - Emergency CS
• Preterm stable mother and fetus - Conservative management in hospital. 
• Marginal placenta >2cm form OS - Vaginal delivery 
• Term stable mother and fetus - Scheduled CS. 

Per vaginal examination is contraindicated in placenta previa. [IOM 09]

• Rest. Absolute bed rest for upto 72 hours after bleeding stops. 
• Careful monitoring - Clinical, laboratory, USG every 2-3 weeks. 
• Blood tranfusion and hematinics. Maintain Hb at least 10 g/dl and hematocrit of 30%. 
• Antenatal steroid for fetal maturity between 24-34 weeks of gestation. There is no evidence to support the use of antenatal steroids after 34 weeks of gestation. 
• Anti D immunoglobulins to all Rh negative women. 
• Use of tocolytics (controversial). 
• Cervical encirclage not currently recommended.

If placenta is present over a previous uterine scar, the villi may invade beyond Nitabuch Layer resulting in Placenta Accreta.

Hysterectomy - but in patients desiring to have a child, conservative attitude may be taken.

• It is the layer of fibrinoid degeneration which separates the superficial layer of decidua basalis from the deeper layer of deciduas basalis.
• The normal placenta does not go beyond the Nitabuchs layer.

• Accreta – villi invade deep basalis layer 
• Increta – villi invades partial myometrium 
• Percreta  - vlli invades to serosa/bladder. 

• [@Pacental attachment:
• Accreta- Attaches
• Increta - Invades
• Percreta - Penetrates]

D) Previous placenta previa

• Risk factors of placenta accreta are 
• - Placenta previa (present pregnancy) 
• - Previous C/S
• - Previous curettage 
• - Previous myomectomy 
• - Multiparity 
• - Advanced maternal age (≥35 years) 

Presence of placenta previa in the present pregnancy forms the most important risk factor. Placenta accreta should be suspected in all women with placenta previa.

B) Placenta  previa

C) Uterine septum

• The fetus is going to have its feet where the space is more. Normally, more space is in the fundus of uterus and thus, the foot is present in the fundus of uterus normally.
• If the fundus  of uterus is limited either by septum or uterine anamaly,  the fetus is going to have its feet down and is going to be in  breech presentation.

Abruptio placenta

Though she has higher risk of placenta previa, but now the bleeding is painful, so abruption-placenta.

• The  blood vessel connecting the main placental disc and the accessory placental disc,  if overlies the cervix, it is called as vasa previa.
• These vessels are not protected by umbilical cord and thus more chance of bleeding.
• The bleeding is from fetal blood vessles.  The bleeding is painless and the placenta location is normal.
• The treatment  is immediate cesarean.
• The complication is fetal hypovolemia.    
• 

• 1. Rupture of Membrane  followed by
• 2. Vaginal bleeding followed by 
• 3. Fetal Bradycardia

• Velamentous cord 
• Accessory placental lobe 
• Multiple gestation

• Normally the umbilical cord origins  from  the disc of placenta,
• In velamentous cord insertion,  the cord takes its origin  on the membranes

Previous classical uterine incision

• 1. Painful bleeding 
• 2. Loss of fetal heart rate 
• 3. Loss of station of fetal head