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Placenta previa (Clinical features, diagnosis, and course

)
INTRODUCTION
1. Placenta previa refers to presence of placental tissue that extends over or
lies proximate to internal cervical os. Sequelae include potential for severe
bleeding and preterm birth, as well as the need for cesarean delivery.
2. Placenta previa should be suspected in any woman beyond 20 weeks of
gestation who presents with painless vaginal bleeding. For women who
have not had 2nd trimester ultrasound examination, antepartum bleeding
after 20 weeks of gestation should prompt sonographic determination of
placental location before digital vaginal examination is performed because
palpation of placenta can cause severe hemorrhage.
PREVALENCE AND RISK FACTORS
1. In systematic review including 58 observational studies of placenta previa,
prevalence ranged from 3.5 to 4.6 per 1000 births. The prevalence is
several-fold higher early in gestation, but most of these cases resolve
before delivery.
2. Purported risk factors, some of which are interdependent.
A. Previous placenta previa
B. Previous cesarean delivery
C. Multiple gestation
D. Multiparity
E. Advanced maternal age
F. Infertility treatment
G. Previous abortion
H. Previous intrauterine surgical procedure
I. Maternal smoking
J. Maternal cocaine use
K. Male fetus
L. Non-white race
3. There is paucity of data regarding the prevalence of placenta previa in twin
pregnancies. In a retrospective study of natural history of placenta previa in
twins, the prevalence of placenta previa in twins was similar to that in
singleton pregnancies. However, dichorionic twins had statistically
increased risk of placenta previa compared with monochorionic twins (OR
3.3) or singleton gestations (OR 1.5).
PATHOGENESIS
1. The pathogenesis of placenta previa is unknown. One hypothesis is
that presence of areas of suboptimal endometrium in upper uterine cavity
due to previous surgery or pregnancies promotes implantation of
trophoblast in, or unidirectional growth of trophoblast toward, the lower
uterine cavity. Another hypothesis is that particularly large placental
surface area, as in multiple gestations or in response to reduced
uteroplacental perfusion, increases likelihood that the placenta will cover or
encroach upon cervical os.
PATHOPHYSIOLOGY
1. Placental bleeding is thought to occur when gradual changes in cervix and
lower uterine segment apply shearing forces to inelastic placental
attachment site, resulting in partial detachment. Vaginal examination or
coitus can also disrupt intervillous space and cause bleeding. Bleeding is
primarily maternal, but fetal bleeding can occur if fetal vessel is disrupted.
CLINICAL FEATURES

An additional 10 to 20% of women present with both uterine contractions and bleeding. The distance the placenta extends over internal cervical os is the best predictor of placenta previa at delivery. However. An additional 33% of patients become symptomatic between 30 and 36 weeks.1. distance over 20 mm is highly predictive of persistence. 40 to 100% of previas will be present at delivery. In the 3rd trimester. this group is more likely to require blood transfusions and is at greater risk of preterm delivery and perinatal mortality than women whose bleeding begins later in gestation. available data correlating gestational age. it is less likely to resolve. fetal anatomic survey. The lower uterine segment lengthens from 0. initial bleeding episode occurs prior to 30 weeks of gestation. and also dependent on gestational age of diagnosis. millimeters of extension over cervical os. and when distance is at least 25 mm. Bleeding A. If previa persists with advancing gestational age. i. previa was present at delivery in 12% of those identified at 15 to 19 weeks. Ultrasound presentation and course A. B. In one series of 714 placenta previa in singleton gestations with liveborn infant ≥ 25 weeks of gestation. 62% of those identified at 28 to 31 weeks. About 10% of women reach term without . at 18 to 23 weeks of gestation. 2. The majority of these women are asymptomatic and 90% of these early cases resolve. 1 to 6% of pregnant women display sonographic evidence of placenta previa between 10 and 20 weeks of gestation when they undergo obstetrical ultrasound for assessment of gestational age. The likelihood of resolution by the time of delivery is also high in twin gestations. the characteristic clinical presentation is painless vaginal bleeding. Progressive unidirectional growth of trophoblastic tissue toward fundus within relatively stationary uterus results in upward migration of placenta. while most of the remaining patients have their first bleed after 36 weeks. C. ii. or prenatal diagnosis. the more likely it will be present at delivery. distance of at least 14 to 15 mm appears to be associated with 20% risk of placenta previa at delivery. Placental atrophy may explain why portion of placenta that sonographically appeared to cover cervix resolves. An anterior placenta previa appears to resolve more often and more quickly than posterior placenta previa. D.5 cm at 20 weeks of gestation to > 5 cm at term. In approximately 33% of affected pregnancies. 49% of those identified at 24 to 27 weeks. Based on available data. This phenomenon has been termed trophotropism. and outcome are insufficient to make precise predictions. The later in gestation the previa persists. and 73% of those identified at 32 to 35 weeks. which occurs in 70 to 80% of cases. In 2nd half of pregnancy. which is similar to presentation of abruptio placenta. B. 34% of those identified at 20 to 23 weeks. Development of lower uterine segment relocates stationary lower edge of placenta away from internal os. Two theories have been put forth to account for resolution of previa.

C. and postpartum bleeding. In one large series. Population-based cohort studies have reported an increase in overall rate of neonatal congenital anomalies in pregnancies . and almost all of excess composite maternal morbidity in women with prior cesarean was related to complications associated with placenta accreta. E. or frequency of bleeding. The presence of placenta previa and one or more cesarean delivery scars places woman at very high risk for placenta accreta and need for cesarean hysterectomy: one previous cesarean birth (11 to 25%). Vasa previa and velamentous umbilical cord i. and identification of echo-free space in placental edge covering internal os or cervical length ≤ 3 cm are predictive of hemorrhage. and ≥ 4 previous cesarean births (50 to 67%). Placenta accreta i. it is likely to be mild or due to confounding factors. The large volume of placenta in lower portion of uterine cavity predisposes fetus to assume non-cephalic presentation. 2. Although the magnitude of risk may differ according to previa characteristics. The most serious and best supported of these complications is placenta accreta. Placenta accreta complicates 1 to 5% of pregnancies with placenta previa and unscarred uterus. or 3 prior cesarean deliveries was 15. but when present they are often associated with placenta previa. Associated conditions A. and 83%. bleeding. nor gestational age. Further study of patient-specific risk factors for bleeding is needed. B. 1. volume. Antepartum bleeding from any cause is risk factor for preterm labor and PROM. 23. investigators. but not all. ii. Authors have reported that placentas that cover os bleed earlier and more than placentas that are proximate to os. C. two previous cesarean births (35 to 47%). it is not possible to predict whether bleed will occur. Congenital anomalies i. all patients with placentas covering or in close proximity to cervical os are at risk of significant antepartum. placentas near os have greater risk of bleeding if placental edge is thick (> 1 cm). For individual patient. Preterm labor and rupture of membranes i. three previous cesarean births (40%). Vasa previa and velamentous umbilical cord insertion are uncommon. Intrauterine growth restriction i. and remains controversial. Noncephalic presentation at delivery is also related to increased risk of delivery before term. Placenta previa has been associated with increased risk of several other pregnancy complications. D. composite maternal morbidity in women with placenta previa and 0. Malpresentation i. 59. when non-cephalic presentations are more common. G.3. intrapartum. If reduction in fetal growth occurs. An increased risk of IUGR has been reported by several. F.

parasagittal. H. TVU should be performed to better define placental position. A previa can be missed near term if fetal head is low in pelvis since acoustic shadowing from or compression of placental tissue by fetal skull may obscure placental location. 2. For women who have not had second or third trimester ultrasound examination. and amniotic fluid embolism. ii. TAU is used for initial placental localization. A large population-based cohort study reported strong association between placental pathology. Transabdominal i. Specific points that should be appreciated when performing sonographic examination for placenta previa. In these cases. but no single anomaly or syndrome was associated with disorder. internal os. typically ultrasound. The diagnosis of placenta previa is based on identification of placental tissue covering internal cervical os on imaging study. TAU is performed as initial examination. Placenta previa should be suspected in any woman beyond 20 weeks of gestation who presents with vaginal bleeding. Placenta previa should be described by distance (millimeters) that placenta covers internal cervical os. Ultrasonography A. Care should be taken to not make diagnosis of placenta previa when lower uterine segment is contracting. placenta is labeled as low-lying.complicated by placenta previa. 4. An over-distended bladder can compress anterior lower uterine segment against posterior lower uterine segment to give appearance of previa. antepartum bleeding should prompt sonographic determination of placental location before digital vaginal examination is performed because palpation of placenta can cause severe hemorrhage. If placental edge covers internal os. The sonographic diagnosis of placenta previa requires identification of echogenic homogeneous placental tissue covering or proximate to internal cervical os (distance > 2 cm from os excludes diagnosis of previa). such as placenta previa. 2. and transverse sonographic views should be obtained with patient's bladder partially full. Sagittal. If placental edge is < 2 cm from. if it shows placenta previa or findings are uncertain. placenta is labeled previa. cervix may be better visualized by placing patient in . Amniotic fluid embolism i. DIAGNOSIS 1. but not covering. 1. 3. which commonly occurs after woman empties her bladder. A low lying placenta should be described by distance (millimeters) between internal cervical os and inferior edge of placenta. The diagnosis of placenta previa should not be made without confirming placental position after patient has emptied bladder.

so diagnosis should be confirmed by TVU unless previa is clearly central.8. 5. and well-established safety and accuracy of TVU. Maternal A. TVU can be performed safely in patients with previa since optimal position of vaginal probe for visualization of internal os is 2 to 3 cm away from cervix and angle between cervix and vaginal probe is sufficient to prevent probe from inadvertently slipping into cervical canal.5.8). When placenta accreta is present. iii. Transvaginal i. iii. DIFFERENTIAL DIAGNOSIS 1. Placenta previa increases risk of APH (RR 9. ii. it is not used for diagnosis of placenta previa because of its high cost.6%. MORBIDITY AND MORTALITY 1. limited availability. Exclusion of placenta accreta A. On ultrasound. 98.3. The overall false positive rate of TAU for diagnosis of placenta previa is high (up to 25%). The sonographic diagnosis of complete central previa is readily made since the placenta is centered over cervix and placental tissue is imaged anterior and posterior to cervix. Magnetic resonance imaging (MRI) A. intraplacental sonolucent spaces (lacunar flow) may be observed adjacent to involved uterine wall. MRI is most useful for diagnosis of complicated placenta previa. IPH (RR 2. sensitivity. B. 4. 97. particularly when lateral. TVU generally provides a clearer image of relationship of edge of placenta to internal cervical os than TAU. However. this hypoechoic boundary is lost and placenta appears contiguous with bladder wall. TVU should be performed to better define placental position. the possibility of placenta previaaccreta/percreta should be considered. The normal interface between placenta and bladder is characterized by hypoechoic boundary that represents myometrium and normal retroplacental myometrial vasculature. specificity. Complete noncentral previas. and PPV and NPV of TVU for diagnosis of placenta previa were 87. are more difficult to confirm. The placental location may also be obscured by hematoma or lower uterine segment contraction. The use of 3D ultrasound may also improve accuracy.5). The diagnosis of placenta accreta is reviewed in detail separately. When placenta previa is diagnosed. such as previa-accreta and previa-percreta. Transverse views at and above internal cervical os should facilitate accurate diagnosis. 3. TAU is performed as initial examination.Trendelenburg position and/or gently pushing fetal head cephalad. Translabial (transperineal) ultrasound imaging is alternative technique that provides excellent images of cervix and placenta. MRI is well-suited to assessment of placental-cervical relationships because of differing magnetic resonance characteristics of two tissues. RCT and prospective comparative studies have established superior performance of TVU over TAU for diagnosis of placenta previa. 93. In one study of 100 suspected cases. if it shows placenta previa or findings are uncertain. and PPH .

5 vs. For women who have not had a second trimester ultrasound examination. 5.2.3). During this period. which is similar to the presentation of abruptio placenta. or embolization of pelvic vessels to control bleeding (2.5 per 1000 live births in non-previa pregnancies (RR 4. liberal use of cesarean delivery. In approximately one-third of affected pregnancies. An additional 10 to 20% of women present with both uterine contractions and bleeding. 2. decreased tissue perfusion. millimeters of extension over the cervical os. which occurs in 70 to 80% of cases. Neonatal morbidity and mortality rates in pregnancies complicated by placenta previa have fallen over the past few decades because of improvements in obstetrical management (antenatal corticosteroids. 4. The principal causes of neonatal morbidity and mortality are related to preterm delivery. significant loss of intravascular volume can lead to hemodynamic instability. Rapid. and outcome are insufficient to make precise predictions. organ damage. B.9). A retrospective cohort study of live births in the US (1989 to 1991 and 1995 to 1997) included over 61. (RR 1.000 singleton pregnancies complicated by placenta previa and delivered by cesarean birth after 24 weeks of gestation. hypoxia. The distance from the placental edge to the internal cervical os is the best predictor of placenta previa at delivery. The maternal mortality rate associated with placenta previa is < 1% in resource-rich countries. antepartum bleeding after 20 weeks of gestation should prompt sonographic determination of placental location before digital vaginal examination is performed because palpation of the placenta can cause severe hemorrhage. or growth restriction. 0. preterm labor or premature rupture of . and home births are common. malpresentation. The characteristic clinical presentation is painless vaginal bleeding. The risk is particularly high in those with previa-accreta. previous cesarean deliveries. and multiple gestations are major risk factors for placenta previa. but remains high in resource-poor countries where maternal anemia.7 per 1000 live births with placenta previa compared to 2. delayed delivery when possible). the neonatal mortality rate was 10. Placenta previa recurs in 4 to 8% of subsequent pregnancies.8% without previa) and undergo postpartum hysterectomy. 3. but available data correlating gestational age. B. women with placenta previa are more likely to receive blood transfusions (12 vs. SUMMARY AND RECOMMENDATIONS 1. lack of medical resources. Previous placenta previa. RECURRENCE 1. decreased oxygen delivery. Neonatal A. For this reason. Placenta previa should be suspected in any woman beyond 20 weeks of gestation who presents with painless vaginal bleeding. cellular hypoxia. and improved neonatal care. Some conditions that may be associated with placenta previa include placenta accreta. and death. uterine/iliac artery ligation. rather than anemia. the initial bleeding episode occurs prior to 30 weeks of gestation. 0% without previa).

6. the membranes. The diagnosis of placenta previa is based upon identification of placental tissue covering or proximate to internal cervical os on TVU. vasa previa and velamentous insertion of umbilical cord. .