Actually I had a case of placenta previa for my case write up..
Madam S, a 39 y/o Malay housewife, diagnosed to have asymptomatic PP type III posterior at 28 weeks of POA, admitted to the ward for expectant management..
Placenta previae (PP) is a condition where there is low implantation of placenta in the uterus. The causes of this is unknown but there is some risk factors which might increase the incidence of placenta previa in the mother such as :
1. Advanced maternal age, which is more than 35 years old
2. Multiparity
3. Having history of placenta previae in previous pregnancy
4. Having previous history of cesarean section
5. Having surgical history which might affect the lining of uterus - dilatation and curettage (D&C), myomectomy
6. Multiple pregnancy
7. Smoking
Placenta previae are divided into four types which is PP type I, type II, type III and type IV.
In placenta type I which is minor PP, it is when the placenta is about 5 cm away from the internal os. It is safe for the mother with PP type I to undergo vaginal delivery at 38 week of POA.
For PP type II, it is when the placenta encroaches the internal os. This PP type II will be further divided as PP type II posterior and PP type II anterior.
For PP type II anterior, it is considered minor and patient is allow to delivered her baby via vaginal delivery. However, in PP type II posterior, it is considered as major and patient will undergo Caeserean section for delivery.
For PP type III where the os is partially cover the internal os and PP type IV is when the plancenta fully covered the internal os. Both of this type of PP is considered as major PP and patient are required to have cesarean section for delivery.
Patient usually presented with painless and causeless per vaginal bleeding in her pregnancy. The bleeding is usually bright red and the amount might varies from light to heavy bleeding. Patient with PP is easily bleed and thus it is important for a healthcare worker to monitor the pad chart and also the haemoglobin level in order to ensure, patient is not anaemic. In some women, they moght also experience pre-term contractions. Usually in PP, there is a malposition of the fetus. The fetus might be in oblique or transverse lie.
It is important to counsel the patient about some important things during her pregnancy with placenta previae such as :
- possible of per vagina bleeding.
- to avoid heavy works (have good rest), fall, trauma, massage to abdomen
- to come to hospital as soon as possible if there is any presence of contraction pain
- need to deliver at hospital and delivered via cesarean section
In order to diagnose a patient to have placenta previae, the doctor must wait until 28 weeks of period of amenorrhea as only by this time, the lower segment is fully formed. If the placenta is noted to be low lying before 28 weeks of POA, there is no need to manage the patient as PP as there is chance for the placenta to move to upper segment. By ultrasound, it may reveals the low lying placenta. In order to confirm the diagnosis, transvaginal scan should be done by localization of the placenta. TVS will give a good visualization of the placenta especially the posterior placenta and TVS is to be safer in presence of PP.
In managing patient with PP, we need to admit the patient for the expectant management, McAfee regime. McAfee regime is usually offered to patient when bleeding is not threatening and the baby is still premature. The McAfee consist of four components which are
1) Patient admission to the ward.
2) Close observation for further bleeding. For this, we were to monitor the pad chart.
3) There is availability of at least two unit of cross match blood (GXM). This is important as patient might have excessive bleeding especially during the operation.
4) There is availability of the operation theater (OT).
Usually in patient with PP, we plan for delivery at 38 weeks of POA because we don’t want to allow patient to go into labour.
Regarding the admission of patient to ward, patient is allowed to go home if :
1.
There is somebody who is taking care of her.
2.
She can have a good rest at home.
3.
If the house is not to far from the hospital and there is way for her to come to the hospital immediately if bleeding
4.
If the placenta previa is minor type
5.
Patient is well educated and know how to manage herself.
P/S : Dah lame tulis post ni (time posting O&G lagi) tapi x post untuk keselamatan Turn It In..
