placentation issues

Question 1

What are RFs for placenta praevia? (3)

Answer 1

previous CS; ART, maternal smoking.

rcog

Question 2

Define placenta praevia and LLP?

Answer 2

When the placenta directly overlies the internal os.
LLP is used when the placental edge is less than 20mm from the internal os (on TAS/TVS, > 16 weeks gestation)

rcog

Question 3

If the placenta is thought to be LL or praevia at 20 week morph scan, when should you re-scan?

Answer 3

at K32 via TVS.

Rcog

Question 4

For women who have persistent praevia or LLP at K32, when should you rescan and what else should you do?

Answer 4

re-scan at K36 and discuss mode of delivery

rcog

Question 5

What do you need to counsel women with PP/LLP on? (2)

Answer 5

Preterm delivery + obstetric haemorrhage.

?need for blood products.

Question 6

When should women with LLP/PP be offered antenatal CCS?

Answer 6

Between 34+0 - 35+6 wks.
Or < 34 weeks in women at higher risk of PTB.

Rcog

Question 7

when is tocolysis indicated for women with LLP/PP?

Answer 7

to facilitate antenatal CCS

rcog

Question 8

At what gestation should planned delivery occur for women with PP/LLP?

Answer 8

Delivery timing should be tailored according to antenatal symptoms and, for women presenting with uncomplicated PP, delivery should be considered b/w 36+0 and 37+0 weeks of gestation.

Question 9

What do you need to ensure that you discuss with a woman with PP/LLP in the antenatal period?

Answer 9

Indications for blood transfusions and hysterectomy and any plans to decline blood or blood products.

Question 10

PP and which type of LLP are a/w higher risk of massive obstetric haemorrhage?

Answer 10

ant LLP.

Question 11

What type of anaesthetic procedure is most appropriate for women having a CS for PP?

Answer 11

Regional anesthesia is considered safe and a/w lower risks of haemorrhage than GA.

Need to advise that may be necessary to convert to a GA if required and gain consent.

Question 12

What are the RFs for placenta accreta?(3-4)

Answer 12

Previous accreta in previous pregnancy
Previous CS
Other uterine surgery including endometrial curettage.

Question 13

When should delivery be planned for women with placenta accreta spectrum?

Answer 13

In the absence of RFs for PTD in women with placenta accreta spectrum, planned delivery at 35+0 and 36+6 weeks gestation provides the best balance b/w fetal maturity and the risk of unscheduled delivery.

Question 14

What should be included in teh consent form for caesarean section in women with suspected placenta accreta spectrum?

Answer 14

risks of CS
Increased risk of lower urinary tract damage
Increased risk of need for blood transfusion and the risk of hysterectomy.

Can also counsel on additional interventiosn in case of massive haemorrhage such as: cell salvage and interventioanl radiology where available.

Question 15

What surgical approach should be used for women with placenta accreta spectrum?

Answer 15

caesarean section hysterectomy with palcenta left in situ (is preferable than attempting to separate it from the uterine wall).