1. Management of Type II Placenta Previa

2. Dr. Geetha Balsarkar, Associate Professor and Unit incharge,
Nowrosjee Wadia Maternity Hospital,
Seth G.S. Medical college, Parel , Mumbai
Joint Asst. Secretary to the Editor,
Journal of Obstetrics and Gynecology of India,
Secretary, AMWI, Mumbai branch

5. Classification
Type I or low lying: The placenta encroaches the lower segment of the uterus but does not infringe on the cervical os
Type II or marginal: The placenta touches, but does not cover, the top of the cervix.
Type III or partial: The placenta partially covers the top of the cervix
Type IV or complete: The placenta completely covers the top of the cervix

6. Diagnosis DO NOT DIAGNOSE via vaginal exam! (Exception-”double setup”)
Ultrasound is the easiest, most reliable
way to diagnose (95-98+% accuracy)
False positive- ultrasound with distended bladder
Transvaginal or transperineal often superior to transabdominal methods

7. Migration
Clinically important bleeding is not likely before weeks gestation
The clinically important diagnosis of placenta previa is therefore a late second or early third trimester diagnosis
Migration is a misnomer- the placental attachment does not change, the relative growth of the lower segment does

8. Intervention
Although mothers used to be treated in the hospital from the first bleeding episode until birth, it is now considered safe to treat placenta praevia on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the fetus are in distress.
Bedrest probably indicated
Antenatal testing probably indicated

9. McCafee regime of expectant management

10. Evaluation
Evaluation for possibility of accreta needs to be considered
Consideration for RHIG in rh negative patients with bleeding
Episodic AFS testing with bleeding events
Vigilance regarding fetal growth
Follow up ultrasound if indicated

11. Associated conditions
Abnormal presentation (placenta raises presenting part)
Oblique lie
Transverse lie
Placental abruption
Placenta accreta (especially if prior ceserean section)
Postpartum hemorrhage

12. Think Accreta Previous cesarean scars Previous myomectomy scars
Twins or multiple gestation
Grand multipara

13. Counseling Risk of severe life-threatening hemorrhage
Risk of fetal death
Risk of maternal death
Blood transfusion may be necessary
Hysterectomy may be needed to control bleeding

14. Conservative measures
If the bleeding is not life threatening or, if initially severe but begins to settle, then there is a place for conservative measures
If the fetus is still preterm and the bleeding is under control, a policy of conservative management should be followed, at least until fetal maturity is achieved.

15. Management Protocol Late pregnancy bleeding
Ceserean delivery indications
37 weeks or
Unstable: Heavy bleed, hypotension, fetal distress

16. Delivery Delivery should depend upon type of previa
– Complete previa = c/section
– Low lying = (probable attempted vaginaldelivery
– Marginal/partial = (it depends!)
Consider “double setup” for uncertain cases

17. Delivery
Immediate delivery of the fetus may be indicated if the fetus is mature
If the fetus or mother are in distress.
Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary in a bleeding episode

18. Vaginal delivery Tertiary center Blood crossmatched and ready
Fetal monitoring
Gentle PV examination ???? To assess progess of labour
Everything ready for LSCS

19. Thank you