Praevia

Question 1

Management of accreta (pre delivery)

Answer 1

If risk or clinical suspicion- treat as accreta
Optimize maternal Hb and iron stores
Planned delivery in appropriate unit with blood on hand and staff competent in cs hysterectomy
MDT approach
Should remain close to hospital of planned del in third trimester

Question 2

Surgical management options

Answer 2

Del of baby and placenta -high likelihood hysterectomy
Del of baby and uterine incision away from placenta, then close and en bloc hysterectomy
Del of baby and uterine incision away, close uterus and conservatively manage
-1/3 will still require a hysterectomy
-high risk of infection

Question 3

Risk factors for Praevia

Answer 3

Previous placenta praevia
Previous c/s - OR increases with # of cs
Previous TOP
Multip
AMA (>40)
Multiple preg
Smoking
Deficient endometrium due to: uterine scar, endometritis, MROP, curettage, submucous fibroid
Assisted conception

Question 4

When to rescan if praevia at anatomy scan

Answer 4

32 weeks

Question 5

When to give steroids

Answer 5

Single course of steroids 34-35+6 in women with a LLP or praevia
Earlier if higher risk of preterm birth

Question 6

When to deliver

Answer 6

Late preterm (34-36+6) to be considered if hx vaginal bleeding or other risk factors for preterm delivery

Uncomplicated 36-37+6

Question 7

Delivery management

Answer 7

Regional anaesthetic
Liars with lab
Rapid infusion and fluid warming devices available
Cell salvage
Consider classical if transverse lie (more so if <28)
Early recourse to hysterectomy

Question 8

Risk factors for accreta

Answer 8

Previous accreta
Previous c/s and other uterine surgery
Repeat d & Cs

Question 9

MRI for accreta

Answer 9

Similar to USS in dx

But can assess depth of invasion and lateral extension of myometrial invasion

Question 10

When deliver accreta

Answer 10

35-36+6 if no other risk factors

Try and leave placenta in

Question 11

Different types of accreta

Answer 11

Creta-adheres superficially to the myometrium (does not interrupt decidua)
Increta- penetrates down to the serosa
Percreta- through the uterine wall

Question 12

Cervical length and risk of haemorrhage

Answer 12

If <31mm: have a 16x higher risk of emcs due to massive haemorrhage

Question 13

Incidence of compications praevia
Hysterctomy
Massive Obs haemorrhage
Laparotomy repeat
Bladder or ureteric injury
VTE

Answer 13

Hyst 11% (27% w prior c-section)
PPH 21%
Lap 7.5%
Bladder or ureter 6%
VTE 3%