MEDICAL TREATMENT :
For an uncomplicated pregnancy, continue expectant management until an episode of bleeding occurs. Studies have not shown any difference regarding maternal or fetal morbidity with home management versus hospitalization, prior to the first bleed. If, however, bleeding or contractions occur, the patient must rapidly go to the hospital for evaluation and the above mentioned testing. If bleeding persists, a double setup exam in preparation for immediate surgery is indicated. However, if bleeding is minimal and fetal reassurance is noted, expectant management may be considered to allow for fetal maturity. Additionally, tocolytics may also be considered in cases of minimal bleeding and extreme prematurity to administer antenatal corticosteroids. If more that one episode of bleeding occurs during gestation (at viability or >24 wk), the clinician should consider hospitalization until delivery given the increased potential for placental abruption and fetal demise.
Surgical Care: Cesarean delivery is the safest mode of delivery. Most often a low transverse incision is used; however, a vertical incision may be considered secondary to an anterior placenta and risk of fetal bleeding. If the patient is at increased risk for invasive placentation (accreta, increta, or percreta), then the patient and surgical team must be prepared prior to delivery. These invasive placentations carry a high mortality rate (7% with placenta accreta) as well as a high morbidity rate (blood transfusion, infection, adjacent organ damage).
These complicated pregnancies must have delivery plans that include patient-matched blood and informed consent for possible cesarean hysterectomy. Predelivery placement of balloon catheters for angiographic embolization of pelvic vessels is a technique described in reducing blood loss associated with cesarean hysterectomy. Other means to control hemorrhage include B-Lynch or parallel vertical compression sutures, uterine artery ligation, hypogastric artery ligation, and, of course, hysterectomy.
DRUG THERAPY : No medication is of specific benefit to a patient with placenta previa. Tocolysis may be cautiously considered in some circumstances. Encourage patients with known placenta previa to maintain intake of iron and folate as a safety margin in the event of bleeding.
1. TOCOLYTICS : -- Prevent preterm labor or contractions.
- MAGNESIUM SULPHATE : No medication is of specific benefit to a patient with placenta previa. Tocolysis may be cautiously considered in some circumstances. Encourage patients with known placenta previa to maintain intake of iron and folate as a safety margin in the event of bleeding.
PATIENT MONITORING
β’ Inpatient followup
β’ Outpatient care with frequent visits
PREVENTION/AVOIDANCE
β’ Decrease activity to avoid rebleeding
β’ All vaginal exams, sexual intercourse, douching, or other vaginal manipulation may cause rebleeding
POSSIBLE COMPLICATIONS
β’ Maternal mortality is rare with cesarean section available. Greatest fetal risk is preterm delivery.
β’ History of prior C-section and/or general anesthesia increases risk for need of transfusion
β’ Attempted tocolysis may compromise maternal status
β’ Rebleeding risk may be more risky than delivery and management
β’ If previa present after 30 weeks, there is greater risk of persisting previa
β’ Placental accreta strongly associated with placenta previa (up to 15% of patients). Higher incidence in
women with placenta previa and multiple prior cesarean sections.
β’ Vasa previa
β’ IUGR - 16% incidence
β’ Congenital anomalies: Most common major anomalies of the central nervous system, cardiovascular system,
respiratory and gastrointestinal tracts.
β’ Fetal anemia and Rh isoimmunization
EXPECTED COURSE/PROGNOSIS
β’ If term and complete or partial: Cesarean delivery
β’ If term and anterior marginal: Trial of labor may be okay
β’ If preterm and maternal and fetal status stable: May observe and delay delivery