Ultrasound Obstet Gynecol 2001; 18: 103 – 108

Third-trimester transvaginal ultrasonography in placenta

BlackwellArticle
Original Science, Ltd

previa: does the shape of the lower placental edge predict

clinical outcome?
S. GHOURAB
Department of Obstetrics and Gynecology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

KEYWORDS: Placenta previa outcome, Transvaginal ultrasound, Placental edge shape

Cesarean hysterectomy was required in six patients with com-

ABSTRACT
Objective To evaluate the clinical significance of the shape
of the lower placental edge in women with transvaginal sono-
graphic diagnosis of placenta previa.
Design A prospective observational study at a tertiary teach-
ing hospital.
Population A total of 104 women with confirmed trans-
vaginal sonographic diagnosis of placenta previa before
32 weeks’ gestation.
plete placenta previa because of severe peripartum hemorrhage;
all of them had either central or thick-edge placenta accreta.
Conclusion Women with placenta previa are at a relatively
higher risk of developing complications if the lower placental
edge is thick. Integration of the shape of the lower placental
edge into transvaginal sonographic assessment of placenta
previa may improve the prediction of mode of delivery and
clinical outcome.

Methods Initial transvaginal sonography was performed at INTRODUCTION

between 28 and 32 weeks’ gestation in 138 patients with
The safety and accuracy of transvaginal sonographic dia-
either strong clinical suspicion or previous abdominal sono-
gnosis of placenta previa has been confirmed1–5 but the clinical
graphic diagnosis of placenta previa in the early third trimester.
outcomes of placenta previa are highly variable; antenatal
The lower placental edge was found to be positioned over the
events including the degree of placenta previa, cannot be used
internal cervical os in 33 women (complete previa) and within
to confidently predict outcome6.
3 cm from it in 71 women (low-lying placenta). Patients with
Although complete previa tends to be associated with
low-lying placenta were followed up by serial transvaginal
earlier and more severe bleeding, a lesser degree of placenta pre-
sonographic examinations until delivery; detailed information
via may cause life-threatening hemorrhage necessitating blood
including the placental location (anterior or posterior), the
transfusion and Cesarean section7. Thus, the degree of placenta
distance of its edge from the internal cervical os and its thick-
previa is only one factor in prognosis and management.
ness were recorded. The clinical outcomes of the 17 who had
Oppenheimer et al.8 predicted the likely clinical course and
a thick-edge low-lying placenta were compared with those
mode of delivery using the measurements of distance from the
who had a thin-edge one (54 women). In patients with complete
placental edge to the internal cervical os by transvaginal
placenta previa, demographic data, the shape of the lower
sonography (TVS). In their series of 127 women, no patient
placental edge whenever transvaginal sonography visualized
with a lower placental edge > 2 cm from the internal cervical
it, and the clinical outcomes were documented. The incidence
os required Cesarean delivery for placenta previa, whereas
of major complications in thick-edge or central placenta was
seven of eight patients with a distance of ≤ 2 cm underwent
compared to that in the thin-edge group.
Cesarean section because of bleeding characteristic of placenta
Results Women having a low-lying placenta with a thick previa. However, Timor-Tritsch et al.9 found that bleeding
edge had a significantly higher rate of antepartum hemor- tendency and need for Cesarean delivery increases when the
rhage (P = 0.0002), abdominal delivery (P = 0.02), abnor- placental edge is within 3 cm from the internal cervical os.
mally adherent placenta (P = 0.012) and low birth weight To date no study has addressed the clinical significance
(P = 0.006) than those in whom the placental edge was thin. of the shape of the lower placental edge in placenta previa.

Correspondence: Dr S. Ghourab, Department of Obstetrics and Gynecology, King Khalid University Hospital, King Saud University, PO Box 2925,
Riyadh 11461, Saudi Arabia (e-mail: sghourab@ksu.edu.sa)
Received 12-6-00, Revised 3-11-00, Accepted 8-3-01

ORIGINAL PAPER 103

Third-trimester TVS in placenta previa
Therefore, the purpose of this study was to determine whether
the thickness of the lower placental edge might be used to
predict the clinical outcomes in patients with placenta previa.
MATERIAL AND METHODS
Between October 1995 and March 2000, a total of 138 con-
secutive women were referred for TVS examination because
of suspicion of placenta previa. Of these, 118 women had
placenta previa detected by early third-trimester abdominal
ultrasound scan and 20 women had antepartum hemorrhage
(APH) and abnormal fetal presenting part. All patients were
scanned by the same operator (S.G.) with either a Kretz
Combison 310 real-time transvaginal mechanical sector
scanner (Kretztechnik GmbH, Zipf, Austria), with variable
frequency of 5–10 MHz and a 240° sector angle or an Aloka
2000 (Aloka Co, Tokyo, Japan) phased array transvaginal
probe, with 5-MHz frequency and a 180° sector angle, also
equipped for pulsed Doppler and color Doppler imaging.
The transducer was inserted cautiously into the vagina, up
to a short distance from the cervix under continuous observa-
tion of the image. A sagittal scan of the whole length of the
cervix and lower part of the uterus was obtained first in each
patient. If the lower placental edge was not visualized in this
plane, the transducer was then rotated 90° in each direction
to visualize any presence of placental tissue in the four quad-
rants of the lower uterine cavity. During rotation, adjustment
of the transducer was necessary to keep the internal cervical
os continuously visualized. The internal cervical os and at
least 3 cm of lower uterine wall were clearly visualized in all
cases. Measurements were taken by tracing the distance
between the lower edge of the placental tissue and the margin
of the internal cervical os in the absence of uterine contrac-
tion. The shape of the lower placental edge was assessed by
measuring its maximum thickness within a cm of the meeting
point of the basal and chorionic plates and an estimation of
the angle between these plates. The shape of the placental edge
was defined as ‘thin’ when the thickness was ≤ 1 cm and/or
Figure 1 Anterior low-lying placenta with thin edge at 37 weeks’ gestation. The head is below the placental edge. The placenta is 3 cm away from
the internal os and was 1.5 cm away at 29 weeks with decreased vascularity of the subplacental zone. The fetus was delivered vaginally. PL, placenta;
H, head; CX, cervix; I.OS, internal os; B, bladder; P, ultrasound probe.
104
Ghourab
the angle was < 45° (Figure 1); otherwise it was referred to as
‘thick’ edge (Figure 2).
The diagnosis of complete placenta previa was made when
the internal cervical os was covered by placental tissue; it was
defined as central if the placental edge was not visualized by
TVS examination; it was defined as low-lying, when the
lower edge of the placenta was within 3 cm from the internal
cervical os. Transvaginal sonographic examination was ini-
tially performed at 28–32 weeks. Vascularity of the subpla-
cental zone and intraplacental blood flow of its lower edge
was observed with gray-scale sonography and color Doppler.
Abdominal ultrasound (TAS) and TVS were repeated every
2 weeks in patients with low-lying placenta, to assess fetal
condition, placental migration and the relationship of the
presenting part to both the internal cervical os and the
placental edge. Transvaginal sonographic examination was
repeated at 36 weeks’ gestation in undelivered patients with
complete placenta previa. In each case of Cesarean section,
the relationship between the lower placental edge and the
internal cervical os was digitally assessed and documented.
Demographic data and clinical outcomes were recorded in
all patients.
A chi-squared test and Fisher’s exact test were used to
assess the statistical significance when the incidences in
thin-edge and thick-edge placental groups were compared.
Student’s t-test was employed to calculate the significance of
differences in the means between the two groups. A P-value
of < 0.05 was considered to be significant.
RESULTS
During the study period there was a total of 18 670 deliver-
ies in the Department of Obstetrics. Of these, 104 (0.58%)
had placenta previa confirmed by TVS before 32 weeks’
gestation.
A total of 368 TVS examinations were performed on the
138 patients with either TAS diagnosis or clinical suspicion
of placenta previa. Transvaginal sonographic examination
Ultrasound in Obstetrics and Gynecology
Third-trimester TVS in placenta previa Ghourab

excluded the presence of placenta previa in 34 (24.6%) patients;
none of these patients had a Cesarean delivery because of
bleeding. Gestational weeks at diagnosis of placenta previa
ranged between 28 and 32 (mean 30.3 weeks). Aggravation
or induction of vaginal bleeding did not occur either during
or within 24 h of the examinations. The thickness of the
lower placental edge ranged between 0.4 cm and 1 cm in the
thin-edge group (mean, 0.73 ± 0.18 cm) and between 1.1 cm
and 3.2 cm in the thick-edge group (mean, 1.9 ± 0.64 cm).
Of the 71 patients who were initially diagnosed with a
low-lying placenta, 17 patients had a thick-edge placenta and
the remaining 54 had a thin-edge placenta. No statistical
differences between these two groups were detected for
most of the known confounding factors that might affect the
clinical outcome (Table 1). However, the gestational age at
diagnosis was significantly earlier in the thick-edge group
(P = 0.0001). When the two groups were compared for clinical
outcome, the thin-edge group had a significantly higher
vaginal delivery ratio and birth weight, while the thick-
edge group had a significantly higher risk for emergency
delivery, peripartum hemorrhage, placenta accreta, and
low birth weight (Table 2).
Thirty-three patients had complete placenta previa at initial
examination, 15 of them had a thin-edge, and the remaining
18 had either a thick-edge or a central placenta. Transvaginal
sonographic examination showed no change in placental
location at 36 weeks’ gestation. All of these patients delivered
by Cesarean section; at the time of surgery digital exami-
nation confirmed the presence of placental tissues over the
internal cervical os in all of them. Table 3 summarizes patients
and their placental characteristics and clinical outcomes of
complete placenta previa. All six patients who required
Cesarean hysterectomy for severe peripartum hemorrhage
had had a previous Cesarean section, anterior accreta and
a central or a thick-edge placenta (Figure 3). The mean
number of APH episodes was 1.6 ± 0.7 in the thin-edge
placenta group (Figure 4) compared to 3.8 ± 1.6 in the thick-
edge or central placenta group (P < 0.001). Also, there was
a significant difference in the mean number of blood units
transfused; 1.8 ± 0.9 in the thin-edge and 3.4 ± 1.3 in the
thick-edge or the central placenta groups (P = 0.0003). Birth
weight in the thin-edge group was 2.53 ± 0.58 compared to
1.91 ± 19 in the thick-edge and the central placenta groups
(P = 0.0002).

Figure 2 Anterior low-lying placenta with very thick edge (2.8 cm). There was no placental migration and there were several episodes of antepartum
hemorrhage. An emergency Cesarean section was carried out at 34 weeks’ gestation. PL, placenta; CX, cervix; I.OS, internal os; B, bladder;
P, ultrasound probe.

Table 1 Patient and placental characteristics for 71 women with a low-lying placenta

Thin-edge Thick-edge P
placenta (n = 54) placenta (n = 17) (two-tailed test)

Maternal age (years), mean ± SD 29.3 ± 4.1 30.1 ± 2.3 NS

Parity, mean ± SD 4.2 ± 0.8 3.8 ± 1.1 NS
Gestational age at diagnosis (weeks), mean ± SD 30.2 ± 1.4 28.3 ± 2.4 0.0001
Number of patients with previous Cesarean sections, n (%) 12 (22.2) 4 (23.5) NS*
Number of previous Cesarean sections per patient, mean ± SD 2.3 ± 1.2 3.7 ± 1.2 0.0001
Previous placenta previa, n (%) 7 (13) 4 (23.5) NS
Incidence of posterior previa, n (%) 24 (42) 7 (41.2) NS*
Distance of placental edge from cervical os at diagnosis (cm), mean ± SD 1.45 ± 0.79 1.52 ± 0.84 NS
Placental edge 2–3 cm from cervical os at diagnosis, n (%) 10 (18.5) 4 (23.5) NS*

*one-tail P-value; SD, standard deviation; NS, not significant.

Ultrasound in Obstetrics and Gynecology 105

Third-trimester TVS in placenta previa Ghourab

Table 2 Comparison of clinical outcomes between women with a thin-edge vs. a thick-edge low-lying placenta

Thin-edge placenta Thick-edge placenta

(n = 54) (n = 17) P (two-tailed test)

Gestational age at delivery (weeks), mean ± SD 35.8 ± 4.3 33.2 ± 3.7 0.0281
Migration of placental edge to distance of > 3 cm 0.039
at 36 weeks’ gestation, n (%) 16 (29.6) 1 (5.8)
Fetal head at or below placental edge 0.0077
at 36 weeks’ gestation, n (%) 21 (38.8) 1 (5.8)
Number of patients with APH, n (%) 22 (40.7) 15 (88.2) 0.016
Number of APH episodes per patient, mean ± SD 1.1 ± 0.9 2.4 ± 1.8 0.0002
Vaginal delivery, n (%) 19 (35.2) 1 (5.8) 0.0152
Emergency CS before 36 weeks, n (%) 16 (29.6) 11 (64.7) 0.0208
Placenta accreta, n (%) 0 3 (17.6) 0.0119
Cesarean hysterectomy, n (%) 0 1 (5.8) NS
Peripartum blood transfusion (units), mean ± SD 1.03 ± 1.3 2.4 ± 2.6 0.0049
Mean birth weight (kg), mean ± SD 2.72 ± 0.86 1.93 ± 0.47 0.006

APH, antepartum hemorrhage; CS, Cesarean section; SD, standard deviation.

Figure 3 Posterior total placenta previa with very thick edge (2.2 cm). Cervical length was 3.6 cm and there was increased vascularity of the
subplacental zone. An emergency Cesarean section was carried out at 33 weeks’ gestation for severe antepartum hemorrhage. PL, placenta;
H, head; CX, cervix; I.OS, internal os; C.C, cervical canal; B, bladder; P, ultrasound probe.

Table 3 Demographic data and clinical outcomes in 33 women with In ten out of the 11 patients with placenta accreta /increta
complete placenta previa the diagnosis was suspected antenatally utilizing both TVS
and TAS with color Doppler. Previously reported criteria
Maternal age (years), mean ± SD 31.8 ± 3.7
were used to help in the diagnosis of placenta accreta10; all
Patients with previous Cesarean section, n (%) 12 (36.4)
Number of previous Cesarean sections, 1.8 ± 1.3 of these patients had previous Cesarean scars, an anterior
mean ± SD placenta and a thick-edge or central placenta.
Parity, mean ± SD 3.9 ± 2.2
Anterior placenta, n (%) 16 (48.5)
Thin-edge placenta, n (%) 15 (45.5) D ISCU SSIO N
Thick-edge or central placenta, n (%) 18 (54.5)
Accreta and previous section, n (%) 8 (24) Transvaginal sonography is the gold standard in the diagnosis
Number of patients with APH, n (%) 27 (81.8) of placenta previa as it can provide detailed and accurate informa-
Number of APH episodes per patient, mean ± SD 2.6 ± 0.9 tion about the lower placental edge, placental migration, and
Duration of admission (days), mean ± SD 29.5 ± 8.7 implantation site, and may help predict delivery outcome8,11–13.
Gestational age at delivery (weeks), mean ± SD 33.7 ± 2.3
Prediction of mode of delivery and the likelihood of APH is
Peripartum blood transfusion (units), mean ± SD 82.7 ± 1.2
Emergency Cesarean section before 36 weeks, n (%) 22 (66.7) important in planning the management of placenta previa,
Cesarean hysterectomy, n (%) 6 (18) including the method and time of intervention and the contro-
Birth weight (kg), mean ± SD 2.1 ± 0.91 versial area of outpatient management. Most cases of placenta
previa would have been diagnosed by 32 weeks’ gestation
APH, antepartum hemorrhage; SD, standard deviation.
because of widespread use of ultrasound in obstetrics. Whilst

106 Ultrasound in Obstetrics and Gynecology

Third-trimester TVS in placenta previa Ghourab

some studies have claimed that location (anterior or posterior)
and degree of placenta previa may indicate the delivery and
clinical outcome8,10,13, other studies have shown that the degree
of placenta previa is not predictive of clinical outcome6,14–15.
However, none of these studies have considered the shape of
the lower placental edge. This prospective study shows that
a combination of TVS assessment of the shape of the lower
placental edge and other sonographic findings would improve
the prediction accuracy of clinical outcome in placenta previa.
Women with a thick-edge low-lying placenta were a par-
ticularly high-risk group irrespective of degree and location
of placenta because, with one exception, there was no signifi-
cant evidence of placental migration on subsequent sonographic
examination. The presenting parts were always above the lower
placental edge. Eleven (64.7%) patients had severe enough
APH to warrant emergency Cesarean section before 36 weeks;
the remaining five were electively sectioned and they also had
significantly poorer maternal and neonatal outcomes and more
serious complications (hysterectomy and sever hemorrhage)
than those with a thin-edge placenta (Table 2). It could be
speculated that the high rate of emergency abdominal delivery
and the increased incidence and severity of APH in patients
with a thick-edge low-lying placenta might be explained by the
abundant vasculature of the lower placental edge and the
subplacental zone and the interference of a thick-edge placenta
with descent of the fetal head (Figure 5). To the best of our know-
ledge, these findings have not been reported previously and may
be important in predicting the clinical course of placenta previa.
None of the women with an anterior thin-edge low-lying
placenta had a Cesarean section for placenta previa if the lower
placental edge was > 3 cm from the internal cervical os at the
last TVS examination. On the other hand, vaginal delivery was
achieved in three out of four patients when the distance was
2–3 cm, and in one out of six when the distance was < 2 cm.
In the case of a posterior thin-edge low-lying placenta, vaginal
delivery was achieved in two out of eight patients. In both of

Figure 4 Posterior total placenta previa with thin edge and decreased vascularity of the subplacental zone. An elective Cesarean section was carried
out at 37 weeks’ gestation. PL, placenta; H, head; CX, cervix; I.OS, internal os; EX.OS, external os; B, bladder; P, ultrasound probe.

Figure 5 Anterior low-lying placenta with thick edge at 28 weeks’ gestation. The placenta is 1.6 cm away from the internal os. There was no placental
migration, the presenting part was always high, and there was increased vascularity of the subplacental zone. An emergency Cesarean section was
carried out at 35 weeks’ gestation for severe antepartum hemorrhage. PL, placenta; CX, cervix; I.OS, internal os.

Ultrasound in Obstetrics and Gynecology 107

Third-trimester TVS in placenta previa
them the distance between the lower placental edge and the
internal cervical os was > 2.5 cm at the last TVS examination.
The diagnosis of complete placenta previa, in 33 women,
was confirmed at Cesarean section and there was no evidence
of change in grade of placenta. These findings support the
suggestions of Townsend et al.1 and Ancona et al.16 that
dynamic placentation does not occur, and that once the
placenta is implanted over the os, it remains fixed in that
position. Twenty-two (66.7%) of the cases of complete
placenta previa had severe APH and required immediate
Cesarean delivery before 36 weeks’ gestation; in 18 (82%)
of them, the placenta was either central or thick-edge.
Cesarean hysterectomy was required in seven cases
(6.7%); all of them developed severe intrapartum hemor-
rhage, had a previous Cesarean section scar and anterior
placenta previa accreta. Six of them developed coagulopathy
and surgically uncontrollable hemorrhage and were treated with
abdomino-pelvic packing17. Antenatal diagnosis of accreta
was made in 10 patients, none of whom had a thin-edge placenta.
Nielson et al.18 showed that the Cesarean hysterectomy rate
was as high as 16% due to placenta accreta.
In addition to the placental degree and location (anterior,
posterior), the shape of the lower placental edge is an import-
ant sonographic finding in predicting clinical outcome in
women with placenta previa. Although a relatively small
number of patients were investigated, it was shown that
women with a thick-edge placenta are at a higher risk of
having surgical delivery and serious complications. However,
vaginal delivery and more favorable maternal and neonatal
outcomes could be anticipated in the case of a thin-edge pla-
centa, especially if it had an anterior location and its lower
edge were > 2 cm away from the internal cervical os in the
early third trimester. To consolidate this conclusion a larger
prospective controlled study comparing the clinical out-
comes of thin-edge vs. thick-edge placentae is needed.
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