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Placenta Previa
Placenta Previa
Placenta previa.
Complete or total placenta previa. The
entire cervical os is covered.
Pathophysiology
Placental implantation is initiated by the embryo (embryonic plate) adhering
in the lower (caudad) uterus. With placental attachment and growth, the
developing placenta may cover the cervical os. However, it is thought that a
defective decidual vascularization occurs over the cervix, possibly
secondary to inflammatory or atrophic changes. As such, sections of the
placenta having undergone atrophic changes could persist as a vasa
previa.
A leading cause of third-trimester hemorrhage, placenta previa presents
classically as painless bleeding. Bleeding is thought to occur in association
with the development of the lower uterine segment in the third trimester.
Placental attachment is disrupted as this area gradually thins in preparation
for the onset of labor; this leads to bleeding at the implantation site,
because the uterus is unable to contract adequately and stop the flow of
blood from the open vessels. Thrombin release from the bleeding sites
promotes uterine contractions and leads to a vicious cycle of bleeding–
contractions–placental separation–bleeding.
Etiology
The exact etiology of placenta previa is unknown. The condition may be
multifactorial and is postulated to be related to the following risk factors:
Advancing maternal age (>35 y)
Infertility treatment
Multiparity (5% in grand multiparous patients)
Multiple gestation
Short interpregnancy interval
Previous uterine surgery, uterine insult or injury
Previous cesarean delivery, [1, 2] including first subsequent pregnancy
following a cesarean delivery [1]
Previous or recurrent abortions
Previous placenta previa (4-8%)
Nonwhite ethnicity
Low socioeconomic status
Smoking
Cocaine use
Unlike first-trimester bleeding, second- and third-trimester bleeding is
usually due to abnormal placental implantation.
Hemorrhaging, if associated with labor, would be secondary to cervical
dilatation and disruption of the placental implantation from the cervix and
lower uterine segment. As noted previously, the lower uterine segment is
inefficient in contracting and thus cannot constrict vessels as in the uterine
corpus, resulting in continued bleeding (see Pathophysiology).
Epidemiology
United States statistics
Placenta previa is frequently reported to occur in 0.3-0.5% of all US
pregnancies. A large, US population-based, 1989-1997 study indicated an
incidence of 2.8 per 1000 live births.[3] The risks increase 1.5- to 5-fold with
a history of cesarean delivery. A meta-analysis showed that the rate of
placenta previa increases with increasing numbers of cesarean deliveries,
with a rate of 1% after 1 cesarean delivery, 2.8% after 3 cesarean
deliveries, and as high as 3.7% after 5 cesarean deliveries.[1]
Racial and age-related differences in incidence
The significance of race in having a role in placenta previa is somewhat
controversial. Some studies suggest an increased risk among black and
Asian women, whereas other studies cite no difference.[4]
Advanced maternal age has also been strongly associated with an
increasing incidence of placenta previa. The incidence of placenta previa
after age 35 years reported to be 2%. A further increase to 5% is seen after
age 40 years, which is a 9-fold increase when compared to females
younger than 20 years.[5, 6]
Prognosis
Placenta previa complicates approximately 0.3-0.5% of all
pregnancies.[4]Technologic advances in ultrasonography have increased
the early diagnosis of placenta previa, and several studies have shown that
a significant portion of these early diagnoses do not persist until delivery.[7,
8]
In fact, 90% of all placentas designated as “low lying” on an early
sonogram are no longer present on repeat examination in the third
trimester.[9]
However, maternal and fetal complications of placenta previa are well
documented. Preterm birth is highly associated with placenta previa, with
16.9% of women delivering at less than 34 weeks and 27.5% delivering
between 34 and 37 weeks in a population-based study from 1989 to
1997.[3] There is a significant increase in the risk of postpartum hemorrhage
and need for emergency hysterectomy in women with placenta previa.[10]
Maternal complications of placenta previa are summarized as follows:
Hemorrhage, [11] including rebleeding (Planning delivery and control of
hemorrhage is critical in cases of placenta previa as well as placenta
accreta, increta, and percreta.)
Higher rates of blood transfusion [11, 12]
Placental abruption
Preterm delivery
Increased incidence of postpartum endometritis [12]
Mortality rate (2-3%); in the US, the maternal mortality rate is 0.03%, the
great majority of which is related to uterine bleeding and the complication
ofdisseminated intravascular coagulopathy
The Table, below, summarizes the relative risk of some morbidities in
women with placenta previa.
Table. Relative Risk of Morbidities in Patients With Placenta Previa (Open
Table in a new window)
Instruments or fingers should not be placed near the cervix during a vaginal
examination, because uncontrolled bleeding can result. Do not perform
vaginal or rectal examinations in an outpatient or emergency department
setting unless ultrasonography findings have ruled out placenta previa.
Rarely, ultrasonography is unavailable and a digital examination is
necessary. If this is the case, the digital examination should be performed
in the operating room under double setup conditions (ie, one team ready for
emergent cesarean delivery and one team ready for uneventful vaginal
delivery).
Other problems to consider in a woman with suspected placenta previa
include the following:
Vasa previa
Cervical or vaginal laceration
Vaginal sidewall laceration
Miscarriage (spontaneous abortion)
Infection
Vaginal bleeding
Lower genital tract lesions
Bloody show
Differential Diagnoses
Abruptio Placentae
Cervicitis
Disseminated Intravascular Coagulation
Pregnancy, Delivery
Premature Rupture of Membranes
Preterm Labor
Vaginitis
Vulvovaginitis