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Dr.Niraj Mahajan
Dr.Niraj Mahajan
Dr.Niraj Mahajan


Antepartum Haemorrhage : Placenta Previa & Abruptio Placenta

By AdminPosted On 05-Oct-2016

1. Speculum Examination

In a case of Antepartum Haemorrhage (APH), can we perform speculum examination?

a) Yes

b) No

Correct Answer: a) Yes. A speculum examination can be useful to identify cervical dilatation or visualise a lower genital tract cause for the APH. If the woman presents with a clinically suspicious cervix she should be referred for colposcopic evaluation.

2. Prophylactic Tocolysis

There is no place for the use of prophylactic tocolytics in women with placenta praevia to prevent bleeding.

a) True

b) False

Correct Answer: a) True. RCOG Green-top Guideline No. 27 indicates that there is no place for the use of prophylactic tocolytics in women with placenta praevia to prevent bleeding. (Evidence level 1+)

3. Abruptio Placentae

Placental abruption is a clinical diagnosis and there are no sensitive or reliable diagnostic tests available. Ultrasound has limited sensitivity in the identification of retroplacental haemorrhage.

a) True

b) False

Correct Answer: a) Yes. Ultrasound can be used to diagnose placenta praevia but does not exclude abruption. Women presenting with APH should have an ultrasound scan performed to confirm or exclude placenta praevia if the placental site is not already known. The sensitivity of ultrasound for the detection of retroplacental clot (abruption) is poor. However, when the ultrasound suggests an abruption, the likelihood that there is an abruption is high.

4. In Placenta increta; placenta is

a) Attached to the myometrium

b) Invading the myometrium

c) Penetrating the myometrium

d) None

Correct Answer: b) Invading the myometrium

To easily remember – accrete for attached to the myometrium; increta for invading the myometrium and percreta for penetrating the myometrium.

Morbid adherence occurs when the implantation site is lacking a sufficient amount of decidua basalis and imperfect development of the fibrinoid layer (Nitabuch layer).

5. Marginal placenta previa

An 18 year old woman is noted to have a marginal placenta previa on an US at 24 weeks gestation. Which of the following is the most appropriate management?

a) Schedule cesarean delivery at 38 weeks.

b) Schedule an amniocentesis at 36 weeks & delivery by C-section if the fetal lung is mature.

c) Reassess placental position at 33-34 weeks.

d) Recommend termination of pregnancy.

e) Reassess placental position digitally by vaginal examination 32-34 weeks.

Correct Answer: c) Reassess placental position at 33-34 weeks. RCOG Guideline - All women require follow-up imaging if the placenta covers or overlaps the cervical os at 20 weeks of gestation. Women with a previous caesarean section require a higher index of suspicion as there are two problems to exclude: placenta praevia and placenta accreta. If the placenta lies anteriorly and reaches the cervical os at 20 weeks, a follow-up scan can help identify if it is implanted into the caesarean section scar.

Placental ‘apparent’ migration, owing to the development of the lower uterine segment, occurs during the second and third trimesters, but is less likely to occur if the placenta is posterior or if there has been a previous caesarean section

6. Placenta Previa

Which of the following patients would be most likely to have a placenta previa?

a) 19-year-old G1, P0, Vertex presentation.

b) 24-year-old G2, P1, cephalic presentation, 2/5 palpable.

c) 34-year-old G5, P3+ 1(abortion), vertex presentation.

d) 36-year-old G3, Previous 2 LSCS, P2, transverse lie.

e) 28-year-old G3, P1+1(abortion), head at 0 station.

Correct Answer: d) 36-year-old G3, Previous 2 LSCS, P2, transverse lie. RCOG Guideline - Women who have had a previous caesarean section who also have either placenta praevia or an anterior placenta underlying the old caesarean section scar at 32 weeks of gestation are at increased risk of placenta accreta and should be managed as if they have placenta accreta, with appropriate preparations for surgery made.

Antenatal sonographic imaging can be complemented by magnetic resonance imaging in equivocal cases to distinguish those women at special risk of placenta accreta.

7. Complete placenta praevia

A pregnant woman presents with a complete placenta praevia and fetus has lethal congenital anomalies. Which of the following will be the best management?

a) Cesarean section

b) Oxytocin drip

c) Rupture of membranes

d) Induce with PG E2

e) Forceps delivery in the second stage to accelerate delivery.

Correct Answer: a) Cesarean section. RCOG Guideline (2011) - Complete placenta praevia can not be delivered vaginally. The mode of delivery in placenta previa should be based on clinical judgement supplemented by sonographic information.

A woman with a placental edge less than 2 cm from the internal os in the third trimester is likely to need delivery by caesarean section, especially if the placenta is thick.

As the lower uterine segment continues to develop beyond 36 weeks of gestation, there is a place for TVS if the fetal head is engaged prior to an otherwise planned caesarean section.

8. Previous Two Scar

A patient with two previous cesarean sections presents at 35 weeks of gestation with a painless vaginal blood loss of 400 ml. She is ‘unbooked,’ that is, she has not presented for any previous antenatal appointments so far in this pregnancy. Clinical finding are as follows: Blood pressure 120/75 mmHg, Pulse78 bpm, No clinical evidence of hypovolaemia, Urinalysis Normal, Examination Abdominal mass is soft, not tender, with a transverse lie, CTG Normal. What is the most likely cause of the blood loss?

a) Cervical fibroid degeneration

b) Likely abruption

c) Likely placenta praevia

d) Likely vasa praevia

e) Show

Correct Answer: c) Likely placenta praevia. The two previous caesarean sections are risk factors for placenta praevia. In addition the other factors all lead to the same diagnosis: the blood loss being painless, the amount of loss is in keeping with the degree of shock and the findings of a transverse lie.

9. Placenta Praevia with IUFD

16 weeks pregnancy with a complete placenta praevia with IUFD. Which of the following is the best management?

a) Caesarian section

b) Oxytocin drip

c) Rupture of membranes

d) Induce with PGE2

e) Hysterotomy

f) Induce with PGE1

Correct Answer: f) Induce with PGE1 (Misoprostol). b) Oxytocin drip also can be the answer but less commonly used these days because of availability of Misoprostol. Hysterotomy should be reserved for only when there is APH which is putting a woman at risk.

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Dr. Niraj Mahajan

MD- Gynecologist, Laparoscopic Surgeon, Uro-gynecologist , Infertility specialist & Cosmetic Gynecologist.

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