Placenta praevia 

is when the placenta attaches inside the uterus but near or over the cervical

opening.[1] Symptoms include vaginal bleeding in the second half of pregnancy.[1] The bleeding is
bright red and tends not to be associated with pain.[1] Complications may include placenta
accreta, dangerously low blood pressure, or bleeding after delivery.[2][4] Complications for the baby
may include fetal growth restriction.[1]
Risk factors include pregnancy at an older age and smoking as well as prior cesarean section, labor
induction, or termination of pregnancy.[3][4] Diagnosis is by ultrasound.[1] It is classified as
a complication of pregnancy.[1]
For those who are less than 36 weeks pregnant with only a small amount of bleeding
recommendations may include bed rest and avoiding sexual intercourse.[1] For those after 36 weeks
of pregnancy or with a significant amount of bleeding, cesarean section is generally recommended.
[1]
 In those less than 36 weeks pregnant, corticosteroids may be given to speed development of the
baby's lungs.[1] Cases that occur in early pregnancy may resolve on their own.[1]
It affects approximately 0.5% of pregnancies.[5] After four cesarean sections, however, it affects 10%
of pregnancies.[4] Rates of disease have increased over the late 20th century and early 21st century.
[3]
 The condition was first described in 1685 by Paul Portal.[6]
Signs and symptoms

Women with placenta previa often present with painless, bright red vaginal bleeding. This commonly
occurs around 32 weeks of gestation, but can be as early as late mid-trimester.[7] More than half of
women affected by placenta praevia (51.6)% have bleeding before delivery.[8] This bleeding often starts
mildly and may increase as the area of placental separation increases. Placenta praevia should be
suspected if there is bleeding after 24 weeks of gestation. Bleeding after delivery occurs in about 22% of
those affected.[2]

Women may also present as a case of failure of engagement of fetal head.[9]

Cause Risk factors with their odds ratio[11]

The exact cause of placenta previa is unknown. It Risk factor Odds ratio
is hypothesized to be related to abnormal Maternal age ≥ 40 (vs. < 20) 9.1
vascularisation of the endometrium caused by Illicit drugs 2.8
scarring or atrophy from previous trauma, surgery,
≥ 1 previous Cesarean section 2.7
or infection. These factors may reduce differential
growth of lower segment, resulting in less upward Parity ≥ 5 (vs. para 0) 2.3
shift in placental position as pregnancy advances. Parity 2–4 (vs. para 0) 1.9
[10] Prior abortion 1.9

Risk factors[edit] Smoking 1.6

Congenital anomalies 1.7
The following have been identified as risk factors
for placenta previa: Male fetus (vs. female) 1.1
Pregnancy-induced
0.4
hypertension
 Previous placenta previa (recurrence rate 4–8%),[12] caesarean delivery,[13] myomectomy[9] or
endometrium damage caused by D&C.[12]
 Women who are younger than 20 are at higher risk and women older than 35 are at
increasing risk as they get older.
 Alcohol use during pregnancy was previous listed as a risk factor, but is discredited by this
article.[14]
 Women who have had previous pregnancies (multiparity), especially a large number of
closely spaced pregnancies, are at higher risk due to uterine damage.[9]
 Smoking during pregnancy;[15] cocaine use during pregnancy[16][17]
 Women with a large placentae from twins or erythroblastosis are at higher risk.
 Race is a controversial risk factor, with some studies finding that people from Asia and Africa
are at higher risk and others finding no difference.
 Placental pathology (velamentous insertion, succenturiate lobes, bipartite i.e. bilobed
placenta etc.)[12]
 Baby is in an unusual position: breech (buttocks first) or transverse (lying horizontally across
the womb).
Classification

Traditionally, four grades of placenta previa were used,[15] but it is now more common to simply
differentiate between "major" and "minor cases.[18]

Type Description

Minor Placenta is in lower uterine segment, but the lower edge does not cover the internal os

Major Placenta is in lower uterine segment, and the lower edge covers the internal os

Other than that placenta previa can be also classified as:

Complete: When the placenta completely covers the cervix

Partial: When the placenta partially covers the cervix

Marginal: When the placenta ends near the edge of the cervix, about 2 cm from the internal cervical os

Classification

Traditionally, four grades of placenta previa were used,[15] but it is now more common to simply
differentiate between "major" and "minor cases.[18]

Type Description
Minor Placenta is in lower uterine segment, but the lower edge does not cover the internal os

Major Placenta is in lower uterine segment, and the lower edge covers the internal os

Other than that placenta previa can be also classified as:

Complete: When the placenta completely covers the cervix

Partial: When the placenta partially covers the cervix

Marginal: When the placenta ends near the edge of the cervix, about 2 cm from the internal cervical os

Complications

Maternal

Antepartum hemorrhage

Malpresentation

Abnormal placentation

Postpartum hemorrhage

Placenta previa increases the risk of puerperal sepsis and postpartum hemorrhage because the lower
segment to which the placenta was attached contracts less well post-delivery.

Fetal

IUGR (15% incidence)[12]

Hypoxia

Premature delivery

Death

Placental abruption is when the placenta separates early from the uterus, in other words separates
before childbirth.[2] It occurs most commonly around 25 weeks of pregnancy.[2] Symptoms may include
vaginal bleeding, lower abdominal pain, and dangerously low blood pressure.[1] Complications for the
mother can include disseminated intravascular coagulopathy and kidney failure.[2] Complications for
the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.[2][3]
The cause of placental abruption is not entirely clear.[2] Risk factors include smoking, preeclampsia,
prior abruption, trauma during pregnancy, cocaine use, and previous cesarean section.[2][1] Diagnosis is
based on symptoms and supported by ultrasound.[1] It is classified as a complication of pregnancy.[1]

For small abruption bed rest may be recommended while for more significant abruptions or those that
occur near term, delivery may be recommended.[1][4] If everything is stable vaginal delivery may be
tried, otherwise cesarean section is recommended.[1] In those less than 36 weeks pregnant,
corticosteroids may be given to speed development of the baby's lungs.[1] Treatment may require blood
transfusion or emergency hysterectomy.[2]

Placental abruption occurs in about 1 in 200 pregnancies.[5] Along with placenta previa and uterine
rupture it is one of the most common causes of vaginal bleeding in the later part of pregnancy.[6]
Placental abruption is the reason for about 15% of infant deaths around the time of birth.[2] The
condition was described at least as early as 1664.[7]

Signs and symptoms

In the early stages of placental abruption, there may be no symptoms.[1] When symptoms develop, they
tend to develop suddenly. Common symptoms include sudden-onset abdominal pain, contractions that
seem continuous and do not stop, vaginal bleeding, enlarged uterus disproportionate to the gestational
age of the fetus, decreased fetal movement, and decreased fetal heart rate.[5]

Vaginal bleeding, if it occurs, may be bright red or dark.[1]

A placental abruption caused by arterial bleeding at the center of the placenta leads to sudden
development of severe symptoms and life-threatening conditions including fetal heart rate
abnormalities, severe maternal hemorrhage, and disseminated intravascular coagulation (DIC). Those
abruptions caused by venous bleeding at the periphery of the placenta develop more slowly and cause
small amounts of bleeding, intrauterine growth restriction, and oligohydramnios (low levels of amniotic
fluid).[8]

Risk factors

Pre-eclampsia[9]

Chronic hypertension.[10]

Short umbilical cord

Prolonged rupture of membranes (>24 hours).[10]

Thrombophilia[9]
Multiparity[9]

Multiple pregnancy[9]

Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk

Risk factors for placental abruption include disease, trauma, history, anatomy, and exposure to
substances. The risk of placental abruption increases sixfold after severe maternal trauma. Anatomical
risk factors include uncommon uterine anatomy (e.g. bicornuate uterus), uterine synechiae, and
leiomyoma. Substances that increase risk of placental abruption include cocaine and tobacco when
consumed during pregnancy, especially the third trimester. History of placental abruption or previous
Caesarian section increases the risk by a factor of 2.3.[10][11][12][13][8]

Pathophysiology

In the vast majority of cases, placental abruption is caused by the maternal vessels tearing away from
the decidua basalis, not the fetal vessels. The underlying cause is often unknown. A small number of
abruptions are caused by trauma that stretches the uterus. Because the placenta is less elastic than the
uterus, it tears away when the uterine tissue stretches suddenly. When anatomical risk factors are
present, the placenta does not attach in a place that provides adequate support, and it may not develop
appropriately or be separated as it grows. Cocaine use during the third trimester has a 10% chance of
causing abruption. Though the exact mechanism is not known, cocaine and tobacco cause systemic
vasoconstriction, which can severely restrict the placental blood supply (hypoperfusion and ischemia),
or otherwise disrupt the vasculature of the placenta, causing tissue necrosis, bleeding, and therefore
abruption.[8]

In most cases, placental disease and abnormalities of the spiral arteries develop throughout the
pregnancy and lead to necrosis, inflammation, vascular problems, and ultimately, abruption. Because of
this, most abruptions are caused by bleeding from the arterial supply, not the venous supply. Production
of thrombin via massive bleeding causes the uterus to contract and leads to DIC.[8]

The accumulating blood pushes between the layers of the decidua, pushing the uterine wall and
placenta apart. When the placenta is separated, it is unable to exchange waste, nutrients, and oxygen, a
necessary function for the fetus's survival. The fetus dies when it no longer receives enough oxygen and
nutrients to survive.[8]

Classification

Based on severity:
Class 0: Asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a
depressed area on a delivered placenta.

Class 1: Mild and represents approximately 48% of all cases. Characteristics include the following:

No vaginal bleeding to mild vaginal bleeding

Slightly tender uterus

Normal maternal blood pressure and heart rate

No coagulopathy

No fetal distress

Class 2: Moderate and represents approximately 27% of all cases. Characteristics include the following:

No vaginal bleeding to moderate vaginal bleeding

Moderate-to-severe uterine tenderness with possible tetanic contractions

Maternal tachycardia with orthostatic changes in blood pressure and heart rate

Fetal distress

Hypofibrinogenemia (i.e., 50–250 mg/dL)

Class 3: Severe and represents approximately 24% of all cases. Characteristics include the following:

No vaginal bleeding to heavy vaginal bleeding

Very painful tetanic uterus

Maternal shock

Hypofibrinogenemia (i.e., <150 mg/dL)

Coagulopathy

Fetal death

Prevention

Although the risk of placental abruption cannot be eliminated, it can be reduced. Avoiding tobacco,
alcohol and cocaine during pregnancy decreases the risk. Staying away from activities which have a high
risk of physical trauma is also important. Women who have high blood pressure or who have had a
previous placental abruption and want to conceive must be closely supervised by a doctor.[15]

The risk of placental abruption can be reduced by maintaining a good diet including taking folate, regular
sleep patterns and correction of pregnancy-induced hypertension.
Use of aspirin before 16 weeks of pregnancy to prevent pre-eclampsia also appears effective at
preventing placental abruption.[16]

Management

Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36
weeks and neither mother or fetus are in any distress, then they may simply be monitored in hospital
until a change in condition or fetal maturity whichever comes first.

Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother is in
distress. Blood volume replacement to maintain blood pressure and blood plasma replacement to
maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over Caesarean section
unless there is fetal distress. Caesarean section carries an increased risk in cases of disseminated
intravascular coagulation. People should be monitored for 7 days for postpartum hemorrhage. Excessive
bleeding from uterus may necessitate hysterectomy. The mother may be given Rhogam if she is Rh
negative.

Prognosis

The prognosis of this complication depends on whether treatment is received by the patient, on the
quality of treatment, and on the severity of the abruption. Outcomes for the baby also depend on the
gestational age.[5]

In the Western world, maternal deaths due to placental abruption are rare. The fetal prognosis is worse
than the maternal prognosis; approximately 12% of fetuses affected by placental abruption die. 77% of
fetuses that die from placental abruption die before birth; the remainder die due to complications of
preterm birth.[8]

Without any form of medical intervention, as often happens in many parts of the world, placental
abruption has a high maternal mortality rate.

Mother

A large loss of blood may require a blood transfusion.[2]

If the mother's blood loss cannot be controlled, an emergency hysterectomy may become necessary.[2]

The uterus may not contract properly after delivery so the mother may need medication to help her
uterus contract.
The mother may develop a blood clotting disorder, disseminated intravascular coagulation.[2]

A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland. Diffuse
cortical necrosis in the kidney is a serious and often fatal complication.[2]

Placental abruption may cause bleeding through the uterine muscle and into the mother's abdominal
cavity, a condition called Couvelaire uterus.[17]

Maternal death.[2]

Baby

The baby may be born at a low birthweight.[2]

Preterm delivery (prior to 37 weeks gestation).[2]

The baby may be deprived of oxygen and thus develop asphyxia.[2]

Placental abruption may also result in death of the baby, or stillbirth.[2]

The newborn infant may have learning issues at later development stages, often requiring professional
pedagogical aid.