Placenta Previa

Placenta Previa

Q. 1

All of the following are included in the expectant management of placenta praevia, except:

 A

Cervical Encirclage

 B

Anti-D administration

 C

Corticosteroids

 D

Blood transfusion

Q. 1

All of the following are included in the expectant management of placenta praevia, except:

 A

Cervical Encirclage

 B

Anti-D administration

 C

Corticosteroids

 D

Blood transfusion

Ans. A

Explanation:

The cervical encirclage operation given among the options, is mostly effective for cervical incompetence which usually occurs around 14 weeks of pregnancy.

It has no proven significant role in the treatment of placenta previa which occurs after the 28th week of pregnancy.

While the other three options are included in the treatment of placenta previa.

Ref: Dutta 6th edition Page 171 & Page 243; Obstetrics and Gynecology By Charles R. B. Beckmann, American College of Obstetricians and Gynecologists, Barbara M. Barzansky, Frank W. Ling, Douglas W. Laube, Page 208-209, Page 128


Q. 2

In Browne’s classification of placenta previa, the placenta covers the internal os when closed but not when fully dilated is:

 A

Type 1

 B

Type 2

 C

Type 3

 D

Type 4

Q. 2

In Browne’s classification of placenta previa, the placenta covers the internal os when closed but not when fully dilated is:

 A

Type 1

 B

Type 2

 C

Type 3

 D

Type 4

Ans. C

Explanation:

Browne’s classification for placenta previa:

Type 1 lateral

Placenta dipping into the lower segment but reached upto the os

Type 2 marginal

Placenta edge reached the internal os

Type 3

The placenta covers the internal os when closed but not when fully dilated

Type 4

The placenta covers the internal os even fully dilated

 


Q. 3

Which of the following statements concerning placenta previa is TRUE?

 A

Its incidence decreases with maternal age

 B

Its incidence is unaffected by parity

 C

The initial hemorrhage is usually painless and fatal

 D

Vaginal examination should be done immediately on suspicion of placenta previa

Q. 3

Which of the following statements concerning placenta previa is TRUE?

 A

Its incidence decreases with maternal age

 B

Its incidence is unaffected by parity

 C

The initial hemorrhage is usually painless and fatal

 D

Vaginal examination should be done immediately on suspicion of placenta previa

Ans. C

Explanation:

The initial hemorrhage in placenta previa is usually painless and rarely fatal.

If the fetus is premature and if hemorrhaging is not severe, vaginal examination of a woman suspected of having placenta previa frequently can be delayed until 37 weeks gestation; this delay in the potentially hazardous examination reduces the risk of prematurity, which is often associated with placenta previa.

Vaginal examination, when needed to determine whether a low- lying placenta is covering the internal os of the cervix, should be performed in an operating room fully prepared for an emergency cesarean section.

Increasing maternal age and multiparity are associated with a higher incidence of placenta previa. 

Also Know:
Placenta previa is used to describe a placenta that is implanted over or very near the internal cervical os. There are several possibilities:
  • Total placenta previa—the internal os is covered completely by placenta
  • Partial placenta previa—the internal os is partially covered by placenta
  • Marginal placenta previa—the edge of the placenta is at the margin of the internal os
  • Low-lying placenta—the placenta is implanted in the lower uterine segment such that the placental edge does not reach the internal os, but is in close proximity to it
Vasa previa—the fetal vessels course through membranes and present at the cervical os.
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 35. Obstetrical Hemorrhage. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.

Q. 4

A lady with 37 weeks pregnancy, presented with bleeding per vagina. Invetigation shows severe degree of placenta previa. The treatment is:

 A

Immediate C.S.

 B

Blood transfusion

 C

Conservative

 D

Medical induction of labour

Q. 4

A lady with 37 weeks pregnancy, presented with bleeding per vagina. Invetigation shows severe degree of placenta previa. The treatment is:

 A

Immediate C.S.

 B

Blood transfusion

 C

Conservative

 D

Medical induction of labour

Ans. A

Explanation:

A patient with 37 weeks of pregnancy and severe degree of placenta previa with bleeding per vagina, the next step of management should be immediate C.S.

 
Ref: Obstetrics and Gynecology By Charles R. B. Beckmann, American College of Obstetricians and Gynecologists, Barbara M. Barzansky, Frank W. Ling, Douglas W. Laube, 2009, Page 208

Q. 5

Placenta previa is supected in a 26 year old primigravida who has attended the ante-natal clinic for a per vaginal examination.

 
Assertion: Per vaginal examination is contraindicated in a patient with placenta previa prior to term.
 
Reason: There may be torrential bleeding if PV is done in a patient with placenta previa.
 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Q. 5

Placenta previa is supected in a 26 year old primigravida who has attended the ante-natal clinic for a per vaginal examination.

 
Assertion: Per vaginal examination is contraindicated in a patient with placenta previa prior to term.
 
Reason: There may be torrential bleeding if PV is done in a patient with placenta previa.
 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Ans. A

Explanation:

Per vaginal examination if unavoidable should only be performed in an operation theatre when the patient has already got bleeding per vagina, is at term and immediate termination of pregnancy is about to be done.

Ref: Mudaliar and Menon’s Clinical Obstetrics, 9th Edition, Page 250.

Q. 6

A 32 week pregnant female is brought to the emergency department with sudden onset of painless vaginal bleeding. Ultrasonography shows placenta praevia. What is the expectant method of management in this patient?

 A

Brand-Andrews method

 B

Crede’s method

 C

Macafee & Johnson’s method

 D

Lilley’s regimen

Q. 6

A 32 week pregnant female is brought to the emergency department with sudden onset of painless vaginal bleeding. Ultrasonography shows placenta praevia. What is the expectant method of management in this patient?

 A

Brand-Andrews method

 B

Crede’s method

 C

Macafee & Johnson’s method

 D

Lilley’s regimen

Ans. C

Explanation:

Expectant management of placenta praevia by Macafee and Johnson method:

  • It is an attempt to improve the fetal salvage without increasing undue maternal hazards.
  • The aim is to continue pregnancy for fetal maturity without compromising the maternal health.
  • Suitable cases: Mother is in good health status, duration of pregnancy is less than 37 weeks, active vaginal bleeding is absent, and fetal well being is assured.

Ref: Textbook of Obstetrics by D.C. Dutta, 6th edition, Page 251.


Q. 7

A lady with placenta previa delivered a baby. She had excessive bleeding and shock. After resuscitation most likely complication would be:

 A

Galactorrhoea

 B

Diabetes insipidus

 C

Loss of menstruation

 D

Cushing’s syndrome

Q. 7

A lady with placenta previa delivered a baby. She had excessive bleeding and shock. After resuscitation most likely complication would be:

 A

Galactorrhoea

 B

Diabetes insipidus

 C

Loss of menstruation

 D

Cushing’s syndrome

Ans. C

Explanation:

Sheehan syndrome refers to panhypopituitarism.

It classically follows massive postpartum hemorrhage and associated hypotension. Abrupt, severe hypotension leads to pituitary ischemia and necrosis.

In its most severe form, these patients develop shock due to pituitary apoplexy.

In less severe forms, loss of gonadotrope activity in the pituitary leads to anovulation and subsequent amenorrhea.

Damage to the other pituitary cell types may present as failure to lactate, loss of sexual and axillary hair, and manifestation of hypothyroidism and adrenal insufficiency symptoms.
 
Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 16. Amenorrhea. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.

Q. 8

Placenta previa is characterized by all except ;

 A

Painless bleeding

 B

Causeless bleeding

 C

Recurrent bleeding

 D

Presents after first trimester

Q. 8

Placenta previa is characterized by all except ;

 A

Painless bleeding

 B

Causeless bleeding

 C

Recurrent bleeding

 D

Presents after first trimester

Ans. D

Explanation:

Ans. is d i.e. Present after first trimester

Blood turns yellow° (i.e. hemoglobin is denatured) Blood remains pink° (hemoglobin intact)

Maternal origin                      Fetal origin°

Antepartum hemorrhage is defined as bleeding from or into the genital tract after the 28M week of pregnancy but before the birth of the baby ( the first and second stage of labour included). The 28th week is taken arbitrarily as the lower limit of fetal viability.


Q. 9

The following is false of placenta previa :

 A

Associated with toxemia

 B

Painless recurrent bleeding

 C

Maternal blood loss

 D

Severe bleeding may occur

Q. 9

The following is false of placenta previa :

 A

Associated with toxemia

 B

Painless recurrent bleeding

 C

Maternal blood loss

 D

Severe bleeding may occur

Ans. A

Explanation:

Associated with toxemia


Q. 10

Placenta previa at 32 weeks, management of choice is :

 A

Oxytocin IN

 B

Ergometrine I/V

 C

Conservative treatment

 D

PN examination & ARM

Q. 10

Placenta previa at 32 weeks, management of choice is :

 A

Oxytocin IN

 B

Ergometrine I/V

 C

Conservative treatment

 D

PN examination & ARM

Ans. C

Explanation:

Conservative treatment


Q. 11

Expectant line of management in placenta previa is contraindicated in :

 A

Preterm fetus

 B

Live fetus

 C

Breech presentation

 D

Active labour

Q. 11

Expectant line of management in placenta previa is contraindicated in :

 A

Preterm fetus

 B

Live fetus

 C

Breech presentation

 D

Active labour

Ans. D

Explanation:

Active labour


Q. 12

All of the following are true of placenta previa except :

 A

Postpartum hemorrhage infrequent

 B

First trimester bleeding is not uncommon

 C

Premature labour is common

 D

a and b

Q. 12

All of the following are true of placenta previa except :

 A

Postpartum hemorrhage infrequent

 B

First trimester bleeding is not uncommon

 C

Premature labour is common

 D

a and b

Ans. D

Explanation:

a and b both`


Q. 13

The best way to diagnose the degree of placenta previa is

 A

Trans vaginal sonography

 B

Double set-up examination

 C

Observation during C.S.

 D

Examination of placenta after delivery

Q. 13

The best way to diagnose the degree of placenta previa is

 A

Trans vaginal sonography

 B

Double set-up examination

 C

Observation during C.S.

 D

Examination of placenta after delivery

Ans. A

Explanation:

Trans vaginal sonography


Q. 14

Placenta previa mouth is associated with all of the following except :

 A

Large placenta

 B

Previous C. S. scar

 C

Primigravida

 D

Previous placenta previa

Q. 14

Placenta previa mouth is associated with all of the following except :

 A

Large placenta

 B

Previous C. S. scar

 C

Primigravida

 D

Previous placenta previa

Ans. C

Explanation:

Ans. is c i.e Primigravida                             

Placenta previa is implantation of the placenta partially or completely over the lower uterine segment. Damage to the endometrium or myometrium due to previous surgery or infection can predispose to low implantation and placenta previa.

Risk factors for placenta previa :

  • Prior surgery° (cesarean section / Myomectomy Hysterotomy)
  • Previous uterine curettage°
  • Endometritis°
  • Increasing maternal age (>35 years)°
  • Increasing parity°
  • Placental sire –increased (as in multiple pregnancy)
  • Placental abnormality –Succenturiate lobe
  • Smoking (due to defective decidual vascularisation)

Note :

  • The probability of placenta accreta and need for cesarean hysterectomy is increased in patients with prior cesarean section and placenta previa.
  • Smoking increases the risk of placenta previa by two fold times.
  • Previous cesarean section increases the risk of placenta previa by 4 fold time.
  • According to the latest edition of Williams—Women with otherwise unexplained elevated screening level of maternal serum alpha feto protein are at a greater risk of placenta previa.

Q. 15

Placenta previa true are:

 A

Incidence increases by two fold after LSCS

 B

More common in primipara

 C

Most common in developed countries

 D

1 per 1000 pregnancies

Q. 15

Placenta previa true are:

 A

Incidence increases by two fold after LSCS

 B

More common in primipara

 C

Most common in developed countries

 D

1 per 1000 pregnancies

Ans. A

Explanation:

Ans. is a i.e. Incidence increaes by two fold after LSCS Ref. Fernando Arias 3/e, p 333-334; Dutta Obs. 6/e, p 243-244

Chances of placenta previa are increased in case of history of prior cesarean section

“The probability of placenta previa is four times greater in patients with prior cesareans than in patients without uterine scars.”                                                                                       
Therefore, option a is correct (partly though) because the option says two-fold increase As far as – other options are concerned

Option ‘b’ i.e. it is more common in primipara is absolutely wrong as – placenta previa is more common in multipara.

Option ‘c’ It is more common in developed countries.

Now that is incorrect because ‑

“Increased family planning acceptance with limitation and spacing of birth, lowers the incidence of placenta previa.”


Q. 16

Conservative management is contraindicated in a case of Placenta previa under the following situa­tions, except :

 A

Evidence of fetal distress

 B

Fetal malformations

 C

Mother in a hemodynamically unstable condi­tion

 D

Women in labour

Q. 16

Conservative management is contraindicated in a case of Placenta previa under the following situa­tions, except :

 A

Evidence of fetal distress

 B

Fetal malformations

 C

Mother in a hemodynamically unstable condi­tion

 D

Women in labour

Ans. C

Explanation:

Ans. is c i.e. Hemodynamically unstable condition

The aim of expectant management in case of placenta previa is to continue pregnancy for fetal maturity without compromising the maternal health.

Prerequisites for expectant management

  • Availability of blood for transfusion whenever required
  • Facilities for cesarean section should be available throughout 24 hours.

Candidates : Suitable for expectant management are :

  • Mother in good health status — Hemoglobin > 10 gm%

— Hematocrit > 30%

  • Duration of pregnancy less than 37 weeks
  • Active vaginal bleeding is absent
  • Fetal well being is assured by USG and cardiotocography.

The expectant management is carried upto 37 weeks of pregnancy until baby matures,

Indications for active treatment I contraindications for putting the patient to expectant management.

  • Bleeding occurs at or after 37 weeks
  • Patient is in Tabour-‘
  • Patient is in exsanguinated state on admission
  • Bleeding is continuing and is of moderate degree
  • Baby is dead or known to be congenitally deformed
  • Severe degree of bleeding
  • Fetal distress.”

Coming to option “c”i.e. hemodynamic unstable condition of mother — Hemodynamic unstable condition means there is a change in vital signs of the patient due to blood loss and approximate blood loss is 15-30% of the blood volume (Moderate blood loss).

Remember :

Mild bleeding

blood loss <15%

No charge in vital signs/ urinary output

 

Moderate bleeding

blood loss between 15-30%

Pulse rate ‘I/ B/P / cold clammy extremities

 

Severe bleeding

blood loss >30%

Patient in shock with decreased or unrecordable BP, Oliguria or anuria

 

So initial hemodynamic instability is not a contraindication for expectant management but if the condition remains unstable for 24 – 48 hours despite resuscitative measures, it is a contraindication for expectant management.

Note: Since in this question there is no other correct option, therefore, we are saying hemodynamic unstability of mother is not a contraindication for conservative management and finding out ways to support it but if there was a better option then I would have included hemodynamic unstability in the contraindication for conservative management


Q. 17

In placenta previa conservative treatment is not done in case of :

 A

Active labour

 B

Anencephaly

 C

Dead baby and Severe placenta previa both

 D

All of these

Q. 17

In placenta previa conservative treatment is not done in case of :

 A

Active labour

 B

Anencephaly

 C

Dead baby and Severe placenta previa both

 D

All of these

Ans. D

Explanation:

Ans. is a, b  and c i.e. Active labour; Anencephaly; Dead baby; and Severe placenta previa

Well friends, there is no need to “rattoo” the conditions where expectant management is required and where active management. For a while – forget all the lists and just think you are a gynae casualty medical officer and a pregnant female with vaginal bleeding in the late months of pregnancy comes to you (suspected case of

placenta previa). How will you manage if :

a. She is in active labour

Obviously you will either do cesarean section or if bleeding is not much and no other adverse circumstances are present, proceed with vaginal delivery but you will never think of arresting her labour and managing conservatively

b. If the patient is diagnosed of carrying anencephalic fetus.

The aim of conservative management is to continue pregnancy for attaining fetal maturity without compromising the maternal health. But in this case when fetus is anencephalic there is no point in continuing pregnancy i.e active management termination should be done.

c. If fetus is dead

Same is the case with dead fetus, there is no point in continuing pregnancy i.e. active management should be done

d. Severe placenta previa

Remember always A gynaecologists first aim should be to save the life of mother. If fetus can be saved nothing like it, but in order to save the fetus, mother’s life should not be put at risk. So, in this case expectant management (conservative management) should not be done. Immediate termination of pregnancy by cesarean section is the correct management.

e. Premature fetus If maternal condition is good. and fetus is premature. patient can be kept under observation. Betamethasone (to hasten fetal lung maturity) and blood transfusion (to raise mother’s hernatocrit), shoud be given i.e in this case conservative management can be done.

 

If fetus is dead


Q. 18

Termination of pregnancy in placenta previa is in­dicated in :

 A

Active bleeding

 B

Active labour

 C

Fetal malformation

 D

All of these

Q. 18

Termination of pregnancy in placenta previa is in­dicated in :

 A

Active bleeding

 B

Active labour

 C

Fetal malformation

 D

All of these

Ans. D

Explanation:

Ans. is a, b and c i.e. Active bleeding, Active labour and Fetal malformation


Q. 19

A 32 weeks pregnant women presents with mild uterine contraction and on examination her vitals are stable and placenta previa type III is present.

Best m/n is :

 A

Bed rest + Dexamethasone

 B

Bed rest + Nifedipine and Dexamethasone

 C

Bed rest + Sedation

 D

Immediate caesarean section

Q. 19

A 32 weeks pregnant women presents with mild uterine contraction and on examination her vitals are stable and placenta previa type III is present.

Best m/n is :

 A

Bed rest + Dexamethasone

 B

Bed rest + Nifedipine and Dexamethasone

 C

Bed rest + Sedation

 D

Immediate caesarean section

Ans. B

Explanation:

Ans. is b i.e. Bed rest, Nifedipine and Dexamethasone


Q. 20

A case of central placenta previa with anencephaly fetus should be delivered by :

 A

Cesarean section

 B

Induction of labour

 C

Hall breech extraction

 D

Application of Willet’s forceps

Q. 20

A case of central placenta previa with anencephaly fetus should be delivered by :

 A

Cesarean section

 B

Induction of labour

 C

Hall breech extraction

 D

Application of Willet’s forceps

Ans. A

Explanation:

Cesarean section


Q. 21

Vaginal delivery is contraindicated in :

 A

Central placenta praevia

 B

Previous LSCS

 C

Eclampsia

 D

Antepartum hemorrhage

Q. 21

Vaginal delivery is contraindicated in :

 A

Central placenta praevia

 B

Previous LSCS

 C

Eclampsia

 D

Antepartum hemorrhage

Ans. A

Explanation:

Central placenta praevia


Q. 22

Absolute indication for caesarean section is:

March 2013

 A

Previous LSCS

 B

Type IV placenta previa

 C

Fetal distress

 D

Breech presentation

Q. 22

Absolute indication for caesarean section is:

March 2013

 A

Previous LSCS

 B

Type IV placenta previa

 C

Fetal distress

 D

Breech presentation

Ans. B

Explanation:

Ans. B i.e. Type IV placenta previa

Caesarean section

Indications of classical caesarean section

  • Previous classical cesarean section
  • Neglected shoulder with anhydramnios
  • Structural abnormality making approach to lower segment difficult
  • Constriction ring due to neglected labor
  • Fibroids in lower segment
  • Anterior placenta accreta and praevia
  • Very preterm fetus, where lower segment is poorly formed.


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