Patient's question:
The patient is 27 weeks pregnant, and ultrasound shows a placenta previa. She started experiencing vaginal bleeding two days ago, and the bleeding has been significant. The patient also has iron deficiency anemia. From the perspective of fetal well-being, should this fetus be kept?First follow-up question: The patient is 25 years old and pregnant for the first time.
Doctor's answer:
Hello, in this case, the key points of treatment are as follows:(1) Observation and Waiting: If the pregnancy is less than 36 weeks and the bleeding is not severe, close monitoring can be performed. For partial or complete placenta previa, hospitalization is required for observation, allowing the fetus to mature and thus improving its survival rate. During this period, rest, antiviral treatment, anemia correction, and avoidance of sexual activity are recommended.
(2) Termination of Pregnancy
1. Cesarean Delivery
(1) If there is significant bleeding and the cervix is not dilated, pregnancy termination should be performed immediately, regardless of fetal maturity.
(2) If the pregnancy is near term and is complicated by obstetric complications or other risk factors for difficult labor (e.g., cephalopelvic disproportion, first-time pregnancy in older women, malposition of the fetus), surgery does not need to be delayed.
(3) During the operation, the lower uterine segment incision often encounters the placenta. The fetus should be quickly delivered by penetrating the placenta, or the classical cesarean delivery method may be chosen to avoid the placenta.
(4) Due to the poor contractility of the lower uterine segment, manual placental separation is necessary immediately after fetal delivery. At the same time, intravenous ergot preparations and uterine massage should be administered to reduce postpartum bleeding. If placenta accreta is present, hysterectomy may be required to stop the bleeding.
(5) Preoperative preparation for fetal rescue should be made.
2. Vaginal Delivery: For low-lying or marginal placenta previa with minimal bleeding and rapid labor progress, vaginal delivery may be attempted. During labor, artificial rupture of membranes should be performed early, and abdominal bandages should be applied to compress the bleeding site with the presenting part, promoting uterine contractions and accelerating delivery. If there is significant bleeding and surgical conditions are not available, the Willet clamp may be used for scalp traction to dilate the cervix and compress the bleeding site. For breech presentations, one fetal foot may be pulled out after membrane rupture to compress the bleeding site. Additionally, the bipolar inversion technique may be used to pull out one fetal foot to compress the bleeding site. However, this method causes severe harm to the fetus and is generally not used.
(3) Postpartum Care: Uterine contractions and antibiotics should be administered to prevent bleeding and infection caused by poor contraction of the lower uterine segment where the placenta is attached. If anemia is present, blood transfusions should be given promptly.