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Australian and New Zealand Journal of Obstetrics and Gynaecology 2015; 55: 193–197

Letters to the Editor
Re: Kapoor S, Thomas JT, Petersen SG,
Gardener GJ. Is the third trimester repeat
ultrasound scan for placental localisation needed if
the placenta is low lying but clear of the os at the
mid-trimester morphology scan? Aust N Z J Obstet
Gynaecol 2014; 54(5): 428–32

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Dear Editor,
The study by Kapoor et al.1 confirms previous similar
studies, showing that mothers with a placenta identified on
transabdominal abdominal ultrasound in the second
trimester as within 20 mm of the internal cervical os are at
risk of placenta praevia requiring abdominal delivery at
term and thus require follow-up.
Unfortunately in their introduction, the authors
misquote national guidelines from the RCOG2 and
SOGC3 as suggesting that such women do not require
follow-up unless the placenta reaches or covers the
internal cervical os. What both guidelines actually advise is
that if the placenta is assessed on transvaginal ultrasound
between 18 and 24 weeks, only those found to reach or
cover the internal cervical os remain at risk of praevia at
term and require follow-up. This is based on studies by
Taiale et al.,4 Becker et al.,5 Smith et al.6 and Lauria
et al.7 amongst others involving over 10 000 women in
total.
Whilst this (transvaginal assessment at 18–14 weeks
gestation) is not currently routine practice in most
centres, it may become so as recent evidence about the
use of transvaginal cervical length measurement at 18–
22 weeks’ gestation, with progesterone treatment for those
with a short cervix to reduce the risk of preterm birth,8
begins to be incorporated into practice. Thus, an added
benefit of routine transvaginal ultrasound at the second
trimester morphology scan should be to dramatically
reduce the number of women requiring follow-up for a
low-lying placenta in the third trimester, along with the
restricted activities that many obstetricians continue to
advise.
FRANZCOG, FRCSC, FRCOG
David SOMERSET
Southern Alberta Centre for Maternal Fetal Medicine,
Calgary, AB, Canada
E-mail: david.somerset@efwrad.com
DOI: 10.1111/ajo.12310

References
1 Kapoor S, Thomas JT, Petersen SG, Gardener GJ. Is the third
trimester repeat ultrasound scan for placental localisation

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needed if the placenta is low lying but clear of the os at the
mid-trimester morphology scan? Aust N Z J Obstet Gynaecol
2014; 54(5): 428–432.
RCOG Green-top Guideline No. 27, 2011. Placenta praevia,
placenta praevia accreta and vasa praevia: diagnosis and
management. [Accessed 16 December 2014.] Available from
URL: https://www.rcog.org.uk/globalassets/documents/guidelines/
gtg27placentapraeviajanuary2011.pdf
SOGC Clinical Practice Guideline No. 189, 2007. Diagnosis
and Management of Placenta Previa. [Accessed 16 December
2014.] Available from URL: http://sogc.org/wp-content/uploads/
2013/01/189E-CPG-March2007.pdf
Taipale P, Hiilesmaa V, Ylostalo P. Transvaginal
ultrasonography at 18–23 weeks in predicting placenta previa at
delivery. Ultrasound Obstet Gynecol 1998; 12: 422–425.
Becker RH, Vonk R, Mende BC et al. The relevance of
placental location at 20–23 gestational weeks for prediction of
placenta previa at delivery: evaluation of 8650 cases. Ultrasound
Obstet Gynecol 2001; 17: 496–501.
Smith RS, Lauria MR, Comstock CH et al. Transvaginal
ultrasonography for all placentas that appear to be low-lying or
over the internal cervical os. Ultrasound Obstet Gynecol 1997; 9:
22–24.
Lauria MR, Smith RS, Treadwell MC et al. The use of
second-trimester transvaginal sonography to predict placenta
praevia. Ultrasound Obstet Gynecol 1996; 8: 337–340.
Hassan SS, Romero R, Vidyadhari D et al. Vaginal
progesterone reduces the rate of preterm birth in women with a
sonographic short cervix: a multicenter, randomized, doubleblind, placebo-controlled trial. Ultrasound Obstet Gynecol 2011;
38 (1): 18–31.

Re: Is the third trimester repeat ultrasound scan for
placental localisation needed if the placenta is low
lying but clear of the os at the mid-trimester
morphology scan?
The aim of our study was to determine the need for
repeat ultrasound scan for placental localisation in the
third trimester when the placenta was reported to be low
lying at the morphology scan. We did not differentiate
between the modality of scanning given the current
clinical practice in the community was mostly
transabdominal scanning (TAS) at the 18–20 week
morphology scan.
We regret the perceived lack of clarity in our paper with
regard to the national guidelines of the SOGC and
RCOG. We agree that the SOGC recommends follow-up
third trimester scan when the placental edge reaches or
overlaps the internal os clearly stating the modality as
transvaginal scan (TVS) between 18 and 24 weeks of
gestation.1 However, the RCOG guideline recommends

© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
The Australian and
New Zealand Journal
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sooner or later. 3 Becker RH. 189. but again does not specify the modality as TVS or TAS at the mid-trimester scan.org. as mandated by NSW Health under ‘Towards Normal Birth’. other recent reports. nor are they featured in the conclusions. I wonder though how that is going to be possible while maintaining valid informed consent. including ours. and only 160 actually underwent VBAC..12317 © 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists . let us try and talk more people into VBAC then. GARDENER2 1 Mater Mothers Hospital. and ‘Further targeted counselling towards women with previous malpresentation and/or East Asian descent may further improve VBAC attempt rates’. ‘Improving VBAC rates: the combined impact of two management strategies’. Rioux C. which have mixed TAS and TVS data. Craw SM. 4 Dashe JS. Yes. 54 (5): 428–432. McIntire DD. Gardener GJ. Mater Health Services. 5 Antenatal care.4 The NICE guideline on antenatal care provides similar recommendations. Allan R et al. Nepean Hospital. South Brisbane. to increase VBAC rates. Obstet Gynecol 2002. our interventions may be politically correct and they may well comply with NSW Health policy directives. Ramus RM et al. The stated goal of this clinic was.9 Shveta KAPOOR1. 7 Robinson AJ. Routine third trimester control ultrasound examination for low-lying or marginal placentas diagnosed at mid-pregnancy: is this indicated? J Obstet Gynaecol Can 2012. March 2007. Precise mid-trimester placenta localisation: does it predict adverse outcomes? Aust N Z J Obstet Gynaecol 2012. Of those 160.5%) and emergency caesarean delivery rate (35. 27.5 The introduction in our paper dealt with the differences between the current Australian practices and the international guidelines with regard to the need for a follow-up third trimester scan for placental localisation.thomas@mater. The authors convinced 57% of candidates to attempt VBAC.au DOI: 10. in particular in view of the findings of this study. 2 Department of Maternal Fetal Medicine. Quite on the contrary. Jan 2011. Are you going to disclose those deaths? Without informed consent. NICE guidelines [CG62] March 2008.com DOI: 10. but they do not mention those two deaths in the abstract. Muller PR.2 The evidence supporting the RCOG guideline includes papers. Barristers and judges are going to make us wake up. . The authors do point out that ‘we must be mindful that pursuing increased VBAC rates. 9 Copland JA.3. and both instrumental delivery rate (17. Petersen SG.1111/ajo. 34 (5): 425–428. New South Wales. Joseph T.1111/ajo. 8 Blouin D.1 The authors report on a series of 396 VBAC (Vaginal Birth after Caesarean) candidates who attended a dedicated clinic. Australia E-mail: joseph. Australia E-mail: hpdietz@bigpond. Penrith. RCOG Green Top Guideline No. Is the third trimester repeat ultrasound scan for placental localisation needed if the placenta is low lying but clear of the os at the midtrimester morphology scan? Aust N Z J Obstet Gynaecol 2014 Oct. 56: 158–162. indicate the need to continue follow-up scans for women with placenta < 2 cm from the os on TAS. Vonk R. The relevance of placental location at 20–23 gestational weeks for prediction of placenta previa at delivery: evaluation of 8650 cases. PETERSEN2 and Glenn J. 17: 496–501.7. Sydney Medical School Nepean. only 75 managed an spontaneous vaginal delivery. with predominantly TAS. What on earth are we doing this for? Why all this misguided effort? Why are well-trained and competent obstetricians risking the lives of their patients. Hans Peter DIETZ Obstetrics and Gynaecology. SOGC Clinical Practice Guideline No. And there were two deaths – one postdates stillbirth and one due to a ruptured uterus. 194 Regarding ‘Improving VBAC rates: The combined impact of two management strategies’ Please allow me to comment on a recent paper in ANZJOG. although about 10% of them changed their mind. Mende BC et al.8 However. THOMAS2. and ultimately their own careers? Do caesarean delivery rates (or rather. . 2 Placenta praevia. placenta accreta and vasa praevia: diagnosis and management. 6 Kapoor S. They conclude: ‘A dedicated NBAC clinic and more consistent approach to labour management can help improve VBAC rates’. without indicating the modality of scan although TVS is stated as the preferred modality. Herbison P. Queensland. Thomas JT.Letters to the Editor follow-up if the placenta covers or overlaps the cervical os at 20 weeks of gestation. Persistence of placenta previa according to gestational age at ultrasound detection. 52: 156–160.12352 References 1 Diagnosis and Management of Placenta Previa.6%) were high.6 Some recent observational studies. Scott G. compliance with ill-advised bureaucratic targets) matter more now than perinatal deaths? Of course we will all wake up from this bad dream. Ultrasound Obstet Gynecol 2001.6. Low-lying placenta: who should be recalled for a follow-up scan? J Med Imaging Radiat Oncol 2012. 99 (5 Pt 1): 692–697.might have significant costs such as increased uterine rupture rates’. suggest omitting a follow-up scan for asymptomatic women with placenta close to but not covering the os. but they will be illegal. I do not think it can be disputed that VBAC caused the death of those two babies and that it endangered the life of at least one mother rather seriously.