Previous placenta

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I- INTRODUCTION-DEFINITION :

that & rsquo we said, is a placenta previa when & rsquo; s it & rsquo; wholly or partially inserted on the lower segment The frequency of the ulcerative placenta previa is 0.28% pregnancy

II- ETIOLOGY :

A- AVERAGING PLACENTA ON SEGMENT LOWER :

The placenta is overflowing on the lower segment to increase the surface d & rsquo; maternal-fetal exchanges due to multiple pregnancies, Advanced maternal age, smoking and drug abuse.

B- LOW implantation PRIMITIVE :

  • uterine abnormalities (uterine malformations, fibroma, adenomyosis…)
  • Assisted reproduction
  • Endometrial weakened by multiparity, endometritis, Caesarean scar, ATCD d & rsquo; abortion, récidive of PP

III- ANATOMICAL CLASSIFICATION :

There are four stages in the classification MacAfee

  • Stage IV : Total central placenta praevia or : covering entirely the & rsquo; internal cervical os
  • Stage III : PP part where only a portion of the neck is covered by the placenta
  • Stage II : PP marginal here affleure the & rsquo; internal cervical orifice
  • Stage I : PP side whose lower edge remains at a distance due the & rsquo; internal cervical os < 5cm

IV- PATHOLOGICAL ANATOMY :

A- MACROSCOPIE :

The PP is generally more spread out and thinner than normal placenta, it shows a small side of the membranes, at this level of villous degeneration zones (fibrin)

In case of fetal death : the placenta shows a decrease 30% placental weight with hematoma associated with death

B- MICROSCOPY FOR DEATH FETAL :

necrosis decidua, Marginal thrombosis with stromal fibrosis detached placental tongue

V- PATHOPHYSIOLOGY :

  • During pregnancy bleeding occurs during uterine contractions that cause a tugging on the lower edge of the placenta
  • When working : I cervical dilatation causes detachment of the placenta
  • L & rsquo; origin of the bleeding is dual maternal and fetal

WE- CLINICAL STUDY :

A- FUNCTIONAL SIGNS :

  • L & rsquo; hemorrhage : made of red blood, franc, appear spontaneously or at the & rsquo; uterine contraction during physical exertion or. It is often recurrent.
  • The pain kind of uterine contractions

B- GENERAL SIGNS :

Pallor, rapid pulse, low TA.

C- PHYSICAL SIGNS :

  • Palpation : flexible uterus outside contraction, with high and mobile presentation
  • Auscultation : BCF good or altered
  • Examination under speculum : checks the & rsquo; origin endo-uterine bleeding
  • Televisions : cervical intra looking placental mattress is formally against indicated

VII- ADDITIONAL TESTS :

A- BIOLOGY :

  • GR HR and NFS
  • Results of the blood erase : TP, fibrinogen, soluble complexes, PDF and D.dimères
  • Search fetal red blood cells by the Kleihauer

B- cardiotocographic REGISTRATION :

  • Highlights uterine contractions with normal fetal heart rate
  • Signs of suffering in case of & rsquo; maternal shock (fetal tachycardia, restricted or late decelerations oscillations)

C- ULTRASOUND :

For abdominal and vaginal way above : allows the diagnosis of placenta previa and to classify as classified by BESSIS :

  • Placenta praevia Antérieur :

– Type 1 : not exceeding the upper third of the bladder
– Type 2 : between the 1/3 and 2/3 upper bladder
– Type 3 : flush with the collar
– Type 4 : is located at 4cm back of the neck

  • Placenta praevia postérieur :

– Type 1 : is located at 4 cm back of the neck
– Type 2 : flush with the collar
– Type 3 : reached the lower third of the bladder
– Type 4 : exceeds the lower third of the bladder

VIII- EVOLUTION- COMPLICATION :

In the absence of treatment : maternal mortality is 25 for miles case (disorders & rsquo; hemostasis, anemia, endometritis, accident thrombo embolique, renal failure, or pituitary necrosis syndrome SHEEHAN)

Fetal mortality is 90% ; it is linked to prematurity, RCIU, especially heart defects)

When Active Management, l & rsquo; evolution marked by PP :

  • The rebleeding
  • RPM risk with chorioamnionitis or prolapsed cord
  • Premature delivery

IX- CLINICAL FORMS :

  • asymptomatic
  • early form of 1is and 2th trimester
  • Forms associated :

– and HRP
– placenta accreta
– Out d & rsquo; a vessel previa (vasa praevia)

X- DIAGNOSTIC DIFFERECIEL :

  • Any extra genital bleeding (hemorrhagic cystitis, anal fissure or haemorrhoids)
  • vulval bleeding, vaginal or cervical
  • During the 2th trimester : basal decidual hematoma, late ABRT, or hydatidiform mole
  • During the 3th trimester : decidual or marginal hematoma, uterine rupture, placenta circumvallata, Intra uterine melaena.

XI- TREATMENT :

  • Hospitalization in the presence of & rsquo; a multidisciplinary team (obstetrician, anesthetist, pediatrician)
  • maternal resuscitation : two broad ways d & rsquo; first, decubitus left lateral, oxygen 6 81 / m transfusion & rsquo; albumin, PFC, blood group iso iso rhesus
  • Conservative treatment :

– Toccolyse : antagonists to the & rsquo; oxytocin (atosiban*), AINS, (3against mimetic indicated if bleeding PP
– lung maturation of corticosteroids : 12Betamethazone mg to 24 d & rsquo; interval
– Prevention of & rsquo; allo immunization HR

  • treatment obstetrical :

– caesarean : if emergency : massive hemorrhage with & rsquo; admission or not responding to treatment, or if the presence of signs of fetal distress

Outside of & rsquo; if PP covering emergency or pathological presentation

– low life : PP non-overlapping with cephalic presentation, artificial rupture of membranes early is advised with strict monitoring of BCF, natural or placenta, infusion & rsquo; oxytocic maintained in the puerperium.

XII- CONCLUSION :

If placenta previa, Perinatal mortality has decreased significantly due to the prolongation of pregnancy, l & rsquo; extraction by caesarean, Prenatal steroids and neonatal resuscitation

Maternal mortality has decreased considerably due to blood transfusions and & rsquo; extraction by caesarean.

Course of Dr A. ABSURD – Faculty of Constantine