ROLIM COLLEGE OF HYGIENE AND HEALTH SCIENCE MINNA, NIGER STATE

DEPARTMENT OF COMMUNITY HEALTH

JCHEW 200 LEVEL

GROUP ASSIGNMENT ON MATERNAL HEALTH

GROUP FOUR (4) MEMBERS

1. Usman idris
2. Umar kawu
3. Zainab Abdulkadir
4. Abdulkadir baba Mohammed
QUESTION DESCRIPTION
Discuss Abnormalities of The Placenta.

INTRODUCTION: Before we move in to the further explanation, we may like to define what
placenta is all about:The placenta is the organ that develops during pregnancy to nourish the baby. It
grows inside the uterine wall, connecting to the baby through the umbilical cord. The fetal side of the
placenta is called the chorionic plate, and the maternal side is called the basal plate. Throughout your
pregnancy, the placenta is responsible for getting nutrients and oxygen into your baby’s bloodstream, as
well as removing its waste products. Placental insufficiencies, intrauterine growth restrictions, and other
placental conditions can cause issues for both mother and infant. In rare cases, a pregnancy might take
on some additional risks, due to Placenta Abnormalities. We are asked to discus about the
abnormalities of the placent, whereby some of them will be discussed below:

(1)PLACENTA PREVIA

The term placenta previa describes a placenta that covers part or all of the internal cervical os. In normal
pregnancy, the placenta implants in the upper uterine segment. In the case of placenta previa, the
placenta is partially or totally implanted in the lower uterine segment.
Placenta previa is one of the most common causes of bleeding in the second and third trimester of
pregnancy. Studies in placental pathology suggest a placental attachment to the anterior wall is
associated with shorter gestational age, low birth weight, lower Apgar score, higher prenatal
bleeding rate, increased postpartum hemorrhage, longer duration of hospitalization, and higher
blood transfusion and hysterectomy rates compared to cases with lateral/posterior wall
placenta.
Placenta previa is a major cause of third-trimester bleeding and has been associated with
severe maternal morbidity including hemorrhage requiring a blood transfusion, disseminated
intravascular coagulation, and possibly, emergency hysterectomy.
Placenta previa is more commonly seen in early gestation and in many such cases, with advancing
gestation and growth of the uterus, the placenta is lifted into the upper uterine segment. This
mechanism of “placental shift/migration” is poorly understood but may be related to a preferential
growth of the placental towards a better-vascularized upper endometrium (trophotropism.)

Above is a picture showing placenta previa

RISK FACTORS OF PLACENTA PREVIA

An exponential increase in the incidence of placenta previa exists with increasing number of prior
cesarean sections. The presence of four prior cesarean sections increases the incidence of placenta
previa about 10 folds (5).

- History of prior cesarean delivery

 - Prior pregnancy termination(s)
- Prior uterine surgery
- Maternal smoking
- Advanced maternal age
- Multiparity
- Cocaine use in mother
- Multiple pregnancy

SIGN AND SYMPTOMS OF PLACENTA PREVIA

Placenta previa is often diagnosed in the third trimester, following an occurrence of bright red vaginal bleeding.
The bleeding can be heavy or light, and it usually stops on its own, only to return again within a few days or weeks. Most
women don’t experience any pain. If the placenta is found to be low lying at the routine second-trimester ultrasound
examination, further evaluation for placental cord insertion should be performed.

Complications placenta Previa

 Hypovolemic Shock due to severe bleeding
 Premature early rupture of membrane (PROM)
 Placenta accrete
 Death of the mother
 Fetal death
TREATMENT OF PLACENTA PREVIA

 Cesarean section
 Bed rest at home
 Regular medical check up
 Blood transfusion and intravenous fluids in case of heavy bleeding
 Tocolytic drugs (drugs that slow down or inhibit labour) such as magnesium sulphate or terbutaline etc
 Corticosteroids etc.

(2) VERSA PREVIA

Vasa Previa is a complication in which fetal blood vessels, either in the placenta or in the umbilical cord, are
trapped between the baby and the cervix. This can happen in a number of ways. One of the most common is when
the placenta develops a minor (succenturiate) lobe, joined to the main placental disc only by threads of blood
vessels, which cross the cervical opening. In cases of the bilobed placenta, there is no increased risk of fetal
anomalies. However, this type of placental abnormality can be associated with first-trimester bleeding,
polyhydramnios, placental abruption, and retained placenta.

In cases of vasa previa, velamentous cord insertion has been associated with low birth weight and an abnormal
intrapartum fetal heart rate pattern. Below is an image showing vasa previa of placenta:
RISK FACTORS OF VERSA PREVIA

Risk factors for vasa previa are presence of a second trimester low-lying placenta, or placenta previa is a
significant risk factor for vasa previa, and thus a follow-up transvaginal ultrasound with color Doppler at
32 weeks is recommended to screen for vasa previa. Below are some of the factors of versa previa:

 Resolving second trimester low-lying placenta

 Resolving second trimester placenta previa
 Presence of accessory placental lobes (succensuriate lobe)
 Velamentous or marginal cord insertion
 Multiple pregnancies
 Echogenic line(s) seen along the amniotic sac overlying the internal os

SIGN AND SYMPTOMS OF VERSA PREVIA

The signs and symptoms of versa previa may include the following:

 Painless vaginal bleeding that is dark in color

 Premature rupture of membranes
 Fetal bradycardia etc

COMPLICATIONS OF VERSA PREVIA

 The biggest complication of versa previa is rupture of the amniotic membranes. When the
amniotic sac breaks, this can cause the unprotected veins and arteries of the umbilical cord to
rupture as well as, leading to fetal hemorrhage.

MANAGEMENT OF VERSA PREVIA

Management of vasa previa relies on the prenatal diagnosis and a planned elective delivery by cesarean
section before the beginning of labor. This is typically accomplished around 36-38 weeks. The balance of
neonatal resuscitation capabilities with the risk of labor and rupture of membranes should be taken into
account when vasa previa is diagnosed in low-resource settings. The status of the cervix and prior
obstetric history may help in making such decision.

(3) ABRUPTION OF PLACENTA

Placental abruption is also called “abruptio placentae” is an uncommon yet serious

complication of pregnancy. The placenta develops in the uterus during pregnancy. It attaches to
the wall of the uterus and supplies the baby with nutrients and oxygen.

Placental abruption occurs when the placenta partially or completely separates from the inner
wall of the uterus before delivery. This can decrease or block the baby's supply of oxygen and
nutrients and cause heavy bleeding in the mother.

Placental abruption often happens suddenly and if it is left untreated, it endangers both the
mother and the baby. Below is an image showing placental abruption:
RISK FACTORS OF PLACENTAL ABRUPTION

Factors that can increase the risk of placental abruption include:

 Placental abruption in a previous pregnancy that wasn't caused by abdominal trauma

 Chronic high blood pressure (hypertension)

 Hypertension-related problems during pregnancy, including preeclampsia, HELLP

syndrome or eclampsia

 A fall or other type of blow to the abdomen

 Smoking

 Cocaine use during pregnancy

 Early rupture of membranes, which causes leaking amniotic fluid before the end of
pregnancy

 Infection inside of the uterus during pregnancy (chorioamnionitis)

 Being older, especially older than 40 etc.

SYMPTOMS OF ABRUPTION OF PLACENTA

Placental abruption is most likely to occur in the last trimester of pregnancy, especially in the
last few weeks before birth. Signs and symptoms of placental abruption include:

 Vaginal bleeding, although there might not be any

 Abdominal pain

 Back pain

 Uterine tenderness or rigidity

 Uterine contractions, often coming one right after another

Abdominal pain and back pain often begin suddenly. The amount of vaginal bleeding can vary
greatly, and doesn't necessarily indicate how much of the placenta has separated from the
uterus. It's possible for the blood to become trapped inside the uterus, so even with a severe
placental abruption, there might be no visible bleeding. In some cases, placental abruption
develops slowly (chronic abruption), which can cause light, intermittent vaginal bleeding. Your
baby might not grow as quickly as expected, and you might have low amniotic fluid or other
complications.

COMPLICATION OF PLACENTAL ABRUPTION

The complication may include the following:

 Antepartum hemorrhage
 Hypovolemic shock due to severe loss of blood
 Death if care is not taken
 Fetal distress
 Birth asphyxiation etc.

TREATMENT OF PLACENTAL ABRUPTION

It is not possible to reattach a placenta that’s separated from the wall of the uterus. Treatment options
for placental abruption depend on the circumstances:

 The baby is not close to full term. If the abruption seems mild, your baby’s heart rate is normal
and it’s too early for the baby to be born, you might be hospitalized for close monitoring. If the
bleeding stops and your baby’s condition is stable, you might be able to rest at home.
 You might be given medication to help your baby’s lung mature and to protect the baby’s brain,
in case early delivery becomes necessary.
 The baby is close to full term. Generally after 34 weeks of pregnancy, if the placental abruption
is minimal , a closely monitored vaginal delivery might be possible. If the abruption worsens or
jeopardizes your or your baby’s health, you will need an immediate delivery- usually by cesarean
section.

(4) MORBIDITY ADHERENT OF PLACENTA

The term morbidly adherent placenta implies an abnormal implantation of the placenta into the uterine
wall and this term has been used to describe placenta accreta, increta, and percreta. Placenta accreta is
a placenta where the placental villi adhere directly to the myometrium, placenta increta is a placenta
where the placental villi invade into the myometrium, and placenta percreta is a placenta where the
placental villi invade through the myometrium and into the serosa. About 75% of morbidly adherent
placentas are placenta accretas, 18% are placenta incretas, and 7% are placenta percretas . Placenta
accretas can be subdivided into total placenta accreta, partial placenta accreta, or focal placenta
accreta based upon the amount of placental tissue involved in their attachment to the myometrium.
Pathogenesis of placenta accreta is not currently clear. It is theorized to result from abnormal
vascularization resulting from the scaring process after surgery with secondary localized hypoxia, leading
to both defective decidualization and excessive trophoblastic invasion. The presence of any type of
placenta accreta can be catastrophic to the patient especially in a low-resource setting given the
potential need for massive blood transfusion and possibly emergency hysterectomy. Prenatal diagnosis
and a planned delivery are therefore essential for optimizing the maternal and neonatal outcome.
Below is an image showing placenta accrete:
RISK FACTORS OF PLACENTA ACCRETA

- Placenta previa and prior cesarean section

- Advanced maternal age
- Multiparity
- Prior uterine surgery
- Prior uterine irradiation
- Endometrial ablation
- Asherman’s syndrome
- Leiomyomas
- Uterine anomalies
- Hypertensive disorders in pregnancy
- Smoking

SIGN AND SYMPTOMS OF PLACENTA ACCRETA

Placenta accrete, increta and percreta typically have no outward symptoms. Your doctor can
catch the condition during a regular ultrasound, MRI, or blood test. Complications of this
condition can include third trimester vaginal bleeding, severe postpartum hemorrhage,
cesarean delivery, and subsequent hysterectomy.
COMPLICATIONS OF PLACENTA ACCRETA
Complications of placenta accreta are many and include:
  Damage to local organs
 Postoperative bleeding
 Amniotic fluid embolism
 Consumptive coagulopathy
 Transfusion-related complications
 Acute respiratory distress syndrome
 Postoperative thromboembolism
 Infectious morbidities
 Multi-system organ failure
 Maternal death etc

MANAGEMENT OF PLACENTA INCCRETA

Successful management of placenta accreta is dependent on its recognition prenatally and a planned
delivery with the best available resources. When resources are limited such as in a low resource
(outreach) setting, the authors recommend the following management steps, which may help to
optimize outcome of the mother and the newborn:

 Ensure availability of blood ahead of scheduled surgery. The blood should be immediately
available for transfusion in the operating room
 Plan your surgery with a multidisciplinary team approach, even in low-resource settings. Ensure
your best nursing team, anesthesiologist, surgeons and allied health care team are involved in
the management of the patient.
 Obtain consent for hysterectomy prior to initiating surgery.
 Most favor general anesthesia as the anesthesia method of choice and preparation should
include large bore intravenous access with central lines, compression stockings, padding and
positioning to prevent nerve injury, and avoidance of hypothermia (33, 34).
 Map the placental localization using ultrasound and plan the uterine incision to avoid entry
through the placenta if possible.
 The use of compression sutures, such as the B-Lynch suture may be helpful in tamponading
bleeding and has been used in cases of placenta accreta. The physicians caring for pregnancies
with placenta accreta should familiarize themselves with these compression sutures prior to the
cesarean delivery.
 If blood is available and there is a need for massive transfusion of patients with placenta accreta
when a hysterectomy is preformed to reduce morbidity and mortality

 The successful management of placenta accreta relies heavily on the prenatal diagnosis of this
entity. It is thus critical to identify the at-risk pregnancy, recognize the diagnostic capabilities of
ultrasound, and carefully prepare for the surgical management by ensuring that the most skilled
multidisciplinary team is available. It is through this approach that the outcome is optimized for
the mother and newborn.

REFERRENCES:

1- www.webmd.com
2- www.draliabadi.com
3- www.google.com
4- www.mayoclinic.org
5- my.clevelandclinic.org
6- https://www.glowm.com/pdf/Ultrasound_in_obstetrics_and_gynecology-
chapter8.pdfwww.glowm.com
7- Medical dictionary 2020 android app