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Placenta Previa
By Antonette T. Dulay , MD, Main Line Health System

Last full review/revision Jun 2019| Content last modified Jun 2019

Placenta previa is implantation of the placenta over or near the internal os of the cervix. Typically,
painless vaginal bleeding with bright red blood occurs after 20 weeks gestation. Diagnosis is by
transvaginal or abdominal ultrasonography. Treatment is modified activity for minor vaginal bleeding
before 36 weeks gestation, with cesarean delivery at 36 to 37 weeks/6 days. If bleeding is severe or
refractory or if fetal status is nonreassuring, immediate delivery, usually cesarean, is indicated.

Placenta previa refers to placental tissue that covers any portion of the internal cervical os. A placenta is termed low
lying when the placental edge does not cover the internal os but is within 2 cm of it.
Incidence of placenta previa is 1/250 deliveries. If placenta previa occurs during early pregnancy, it usually resolves by
28 weeks as the uterus enlarges.

Overview of Placenta Previa

VIDEO

Risk factors
Risk factors for placenta previa include the following:
Multiparity

Prior cesarean delivery

Uterine abnormalities that inhibit normal implantation (eg, fibroids, prior curettage)

Prior uterine surgery (eg, myomectomy) or procedure (eg, multiple dilation and curettage [D and C] procedures)

Smoking

Multifetal pregnancy

Older maternal age

Complications
For patients with placenta previa or a low-lying placenta, risks include fetal malpresentation, preterm premature
rupture of the membranes, fetal growth restriction, vasa previa, and velamentous insertion of the umbilical cord (in
which the placental end of the cord consists of divergent umbilical vessels surrounded only by fetal membranes).
In women who have had a prior cesarean delivery, placenta previa increases the risk of placenta accreta; risk increases
significantly as the number of prior cesarean deliveries increases (from about 10% if they have had one cesarean
delivery to > 60% if they have had > 4).

Symptoms and Signs

Symptoms usually begin during late pregnancy. Then, sudden, painless vaginal bleeding often begins; the blood may
be bright red, and bleeding may be heavy, sometimes resulting in hemorrhagic shock. In some patients, uterine
contractions accompany bleeding.

Diagnosis
Transvaginal ultrasonography

Placenta previa is considered in all women with vaginal bleeding after 20 weeks. If placenta previa is present, digital
pelvic examination may increase bleeding, sometimes causing sudden, massive bleeding; thus, if vaginal bleeding
occurs after 20 weeks, digital pelvic examination is contraindicated unless placenta previa is first ruled out by
ultrasonography.
Although placenta previa is more likely to cause heavy, painless bleeding with bright red blood than abruptio
placentae, clinical differentiation is still not possible. Thus, ultrasonography is frequently needed to distinguish the two.
Transvaginal ultrasonography is an accurate, safe way to diagnose placenta previa.

Pearls & Pitfalls

If vaginal bleeding occurs after 20 weeks
gestation, exclude placenta previa by

ultrasonography before doing a digital

examination.

In all women with suspected symptomatic placenta previa, fetal heart rate monitoring is indicated.

Treatment
Hospitalization and modified activity for a first episode of bleeding before 36 weeks

Delivery if mother or fetus is unstable

If the woman is stable, delivery at 36 weeks/0 days to 37 weeks/6 days

For a first (sentinel) episode of vaginal bleeding before 36 weeks, management consists of hospitalization, modified
activity (modified rest), and avoidance of sexual intercourse, which can cause bleeding by initiating contractions or
causing direct trauma. (Modified activity involves refraining from any activity that increases intra-abdominal pressure
for a long period of time—eg, women should stay off their feet most of the day.) If bleeding stops, ambulation and
usually hospital discharge are allowed.
Typically for a 2nd bleeding episode, patients are readmitted and may be kept for observation until delivery.
Some experts recommend giving corticosteroids to accelerate fetal lung maturity when early delivery may become
necessary and gestational age is < 34 weeks. Corticosteroids may be used if bleeding occurs after 34 weeks and before
36 weeks (late preterm period) in patients who have not required corticosteroids before 34 weeks (1).
Timing of delivery depends on the maternal and/or fetal condition. If the patient is stable, delivery can be done at 36
weeks/0 days to 37 weeks/6 days. Documentation of lung maturity is no longer necessary (2).
Delivery is indicated for any of the following:
Heavy or uncontrolled bleeding

Nonreassuring results of fetal heart monitoring

Maternal hemodynamic instability

Delivery is cesarean for placenta previa. Vaginal delivery may be possible for women with a low-lying placenta if the
placental edge is within 1.5 to 2.0 cm of the cervical os and the clinician is comfortable with this method.
Hemorrhagic shock is treated. Prophylactic Rho(D) immune globulin should be given if the mother has Rh-negative
blood.

Treatment references
1. Gyamfi-Bannerman C, Thom EA, Blackwell SC, et al: Antenatal betamethasone for women at risk for late preterm
delivery. N Engl J Med 374 (14):1311–1320, 2016. doi: 10.1056/NEJMoa1516783.

2. Spong CY, Mercer BM, D'alton M, et al: Timing of indicated late-preterm and early-term birth. Obstet Gynecol 118 (2
Pt 1):323–333, 2011. doi: 10.1097/AOG.0b013e3182255999.

Key Points

Placenta previa is more likely to result in heavy, painless bleeding with bright red blood than abruptio
placentae, but clinical differentiation is still not possible.

Consider placenta previa in all women who have vaginal bleeding after 20 weeks.

For most first bleeding episodes before 36 weeks, recommend hospitalization, modified activity, and
abstinence from sexual intercourse.

Consider corticosteroids to accelerate fetal lung maturity if delivery may be needed before about 34
weeks or if bleeding occurs between 34 and 36 weeks in patients who have not required corticosteroids
before 34 weeks.

Delivery is indicated when bleeding is severe or when the mother or fetus is unstable.

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