🤰 Placenta Previa - सरल हिंदी में

पहले समझते हैं - Placenta क्या होता है?

Placenta Previa क्या है?

आसान भाषा में: बच्चा जब जन्म लेने के लिए नीचे आता है, तो उसके रास्ते में नाल आ जाती है - जैसे किसी दरवाजे के सामने कोई खड़ा हो जाए।

🏠 उदाहरण से समझें

• घर = माँ का गर्भाशय (Uterus)
• बच्चा = घर के अंदर रह रहा है
• दरवाजा = Cervix (गर्भाशय का मुंह, जहां से बच्चा बाहर निकलता है)
• नाल (Placenta) = बच्चे का खाना-पानी देने वाला साथी

तीन प्रकार (Types)

नोट: आधुनिक चिकित्सा में अब सिर्फ "Placenta Previa" (जब नाल os को ढके) और "Low-lying Placenta" (जब नाल os के 2 cm के अंदर हो) दो ही वर्गीकरण उपयोग होते हैं।

मुख्य लक्षण (Symptoms)

🔴 सबसे महत्वपूर्ण लक्षण:

• खून चमकीला लाल (bright red) होता है
• गर्भावस्था के दूसरे या तीसरे तिमाही (trimester) में होता है
• बार-बार हो सकता है

कारण (Causes / Risk Factors)

• पहले कभी सिजेरियन ऑपरेशन हुआ हो
• ज्यादा बच्चे हो चुके हों (multiparity)
• पहले भी Placenta Previa रहा हो
• गर्भाशय में ऑपरेशन हुआ हो
• धूम्रपान (smoking)
• बड़ी उम्र में गर्भावस्था

पहचान कैसे होती है?

⚠️ महत्वपूर्ण: Placenta Previa में हाथ से या किसी यंत्र से जांच (internal examination) बिल्कुल नहीं करनी चाहिए - इससे बहुत ज्यादा खून बह सकता है।

इलाज (Treatment)

एक और आसान उदाहरण

जैसे किसी बस का रास्ता बंद हो जाए क्योंकि कोई गलत जगह खड़ा हो - बस निकल नहीं सकती। ऐसे ही बच्चा नॉर्मल तरीके से नहीं निकल सकता जब नाल रास्ते में हो। इसलिए ऑपरेशन (C-section) जरूरी होता है।

🟡 याद रखें

• यह ~0.5% pregnancies में होता है (हर 200 में से 1 को)
• बिना दर्द के खून आना = तुरंत डॉक्टर के पास जाएं
• Ultrasound से पता चलता है
• C-section ही सुरक्षित डिलीवरी का तरीका है
• बहुत से मामलों में गर्भावस्था के मध्य में दिखा placenta previa अपने आप ठीक हो जाता है जैसे-जैसे गर्भाशय बड़ा होता है

Important Note: DC Dutta's Textbook of Obstetrics is not available in this medical library. The content below is drawn from Creasy & Resnik's Maternal-Fetal Medicine (the standard international reference for obstetrics, equivalent in depth to Dutta for MBBS) and covers all the same topics Dutta discusses on placenta previa.

Placenta Previa - MBBS Level

Definition

Classification

For MBBS exams, the older classification may still be tested:

• Total/Complete Previa - covers the os completely
• Partial Previa - partially covers os
• Marginal Previa - placental edge reaches the os

Incidence

• Affects approximately 0.5% (1 in 200) of all third-trimester pregnancies
• Diagnosed in 10% of mid-trimester sonograms (most resolve by term)
• Incidence is increasing, likely due to rising cesarean section rates

Pathogenesis

1. Endometrial damage / scarring from prior surgeries or curettage leads the trophoblast to implant in the lower uterine segment where endometrium is less damaged
2. Trophotropism - the placenta grows toward the fundus (better blood supply), causing the lower portion near the cervix to atrophy. This is why most early placenta previas "migrate" away by term

• As the lower uterine segment elongates and thins in late pregnancy, placental villi are torn from the decidua
• During cervical effacement and dilation in labor, the placenta is forcibly separated
• Intercourse, vaginal examination, or uterine contractions can also precipitate bleeding

Risk Factors

Clinical Features

Classic Presentation:

Painless, bright red, recurrent vaginal bleeding in the second or third trimester

• Bleeding is painless (distinguishes it from placental abruption, which causes painful bleeding)
• Blood is bright red (fresh)
• Bleeding may begin as small "herald bleeds" before a major hemorrhage
• In ~10% of cases, no bleeding occurs until labor
• Uterus is soft and non-tender (unlike abruption)
• Fetal lie may be abnormal (oblique or transverse) because the placenta prevents the fetus from establishing normal polarity
• Fetal parts are easily palpable (no tense uterus)

Diagnosis

1. Ultrasound (Investigation of Choice)

• More accurate than transabdominal ultrasound
• Safe - does not provoke bleeding (fears are unfounded)
• Can precisely measure the distance between placental edge and internal os

2. Double Setup Examination (historical/rare)

• Used only when ultrasound is unavailable and significant bleeding is present
• Done in OT, fully prepared for emergency cesarean
• Begin in vaginal fornices, avoid direct cervical palpation
• Rarely needed in modern practice

⚠️ CONTRAINDICATED:

"Placental Migration" - Resolution in Early Pregnancy

Follow-Up Protocol (Asymptomatic Women)

• If low-lying or previa found on early scan: follow-up at 32 weeks
• If still low-lying or covering os at 32 weeks: follow-up TVUS at 36 weeks
• Final decision on delivery route made at 36 weeks

Management

Acute Management (bleeding episode)

1. Admit to labor and delivery unit
2. Two large-bore IV lines
3. Electronic fetal monitoring (continuous)
4. Blood for: Hematocrit, type and cross-match (2-4 units), coagulation studies (PT/PTT/fibrinogen)
5. Rh immune globulin (300 mcg) for Rh-negative women
6. No vaginal examination until placenta previa excluded
7. If stable and <36 weeks: expectant management

Antenatal Corticosteroids

• Betamethasone/dexamethasone given for gestational age <37 weeks to reduce neonatal respiratory morbidity

Delivery Planning

Route of Delivery

• Cesarean section is mandatory for placenta previa
• Normal vaginal delivery is impossible as the placenta blocks the os
• Hysterotomy incision should be fundal (avoiding the placenta) if accreta suspected

Complications

Maternal:

• Postpartum hemorrhage (PPH)
• Placenta accreta / increta / percreta (especially with previous cesarean)
• DIC (disseminated intravascular coagulation)
• Hysterectomy (if uncontrolled hemorrhage)
• Death (in severe cases)

Fetal/Neonatal:

• Prematurity (most common cause of neonatal morbidity/mortality)
• Fetal growth restriction (possible, disputed)
• Abnormal fetal lie
• Higher rates of fetal anomalies
• Neurodevelopmental delay (reported in studies)

Associated Conditions to Know

Key Exam Points (MBBS)

• Classic triad: painless + bright red + recurrent bleeding after 28 weeks
• Investigation of choice: Transvaginal ultrasound
• Avoid: digital examination
• Delivery: always by cesarean section
• "Placental migration" occurs in most mid-trimester cases
• Most dangerous complication: placenta accreta (especially with prior cesarean scar)
• Blood loss requiring transfusion needs fresh frozen plasma if coagulopathy develops