Placenta Previa and Accreta

11/24/21, 4:52 AM Placenta Previa and Accreta | GLOWM
This chapter should be cited as follows:

Saleh, H, Glob. libr. women's med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10121
This chapter was last updated:

January 2008
Placenta Previa and Accreta

AUTHORS
H. Jacob Saleh, MD
Vice Chairman, Department of Obstetrics and Gynecology, Northwestern University, Feinberg
School of Medicine, Evanston, Illinois, USA
INTRODUCTION
Although relatively rare, placenta previa and accreta account for a large percentage of
maternal morbidity and mortality in modern obstetrics. Hemorrhage is a major complication of
abnormal placentation, and early diagnosis and intervention in these conditions can more
readily enable the physician to minimize the risks to mother and fetus. The current widespread
use of ultrasound in obstetrics has greatly advanced our ability to diagnose and manage
abnormal obstetric bleeding.
CLASSIFICATION
Placenta previa is classified by the degree of encroachment upon the internal cervical os. In
total placenta previa, the cervical os is completely covered by the placenta. In partial placenta
previa, the cervical os is partly covered by the placenta. In marginal placenta previa, the edge
of the placenta is considered to be at the margin of the internal os.
The term low-lying placenta has been used when the placental edge does not reach the cervical
os, but is close enough to be palpated by an examiner's finger.1 The current distinction of low-
lying placenta, however, does not rely on digital cervical examination. Instead, it is described as
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a placental edge that approaches to within 2 cm of the cervix on ultrasound examination. The
most accurate measurement is obtained by endovaginal scanning.
Invasive placentas are classified according to the degree of myometrial invasion. In placenta
accreta, the abnormally adherent placental villi are attached directly into the myometrium, but
do not invade it. In a placenta increta, the villi invade the myometrium. When the placental villi
penetrate through the myometrium, reaching the serosal surface of the uterus, then a placenta
percreta is present (Fig. 1).
Fig. 1. Pathologic variants of placentation: (A) placenta accreta, (I) placenta increta, (P) placenta
percreta, (PR) placenta previa. (J.H. Pedigo, illustrator)
INCIDENCE
It is well established that the incidence of placenta previa increases with advancing age and
higher parity. Surgical history, especially if a previous cesarean section was performed for
placenta previa, is linked to recurrent development of placenta previa and, more importantly,
placenta accreta. Most studies report an overall incidence of placenta previa between 1 in 150
and 1 in 300 patients (3–6/1000).2, 3, 4, 5, 6, 7, 8, 9, 10, 11 Placenta previa has been reported to
result in maternal death in 3/1000 cases, and also has been noted to predispose patients to
abruptio placenta.6
Placenta accreta, increta, and percreta occur much less frequently, from 1 in 1600 to 1 in
12,000 patients.3, 4, 12, 13, 14, 15, 16, Placenta accreta occurs most commonly, followed in
decreasing frequency by placenta increta and placenta percreta.17, 18 For our purposes, we
refer to all three conditions under placenta accreta. Confirmation of placenta accreta requires
histopathologic methods, and so it is possible that incidence is underreported when the
condition is focal or not associated with performance of a hysterectomy. Likewise, in cases of
retained placenta where manual removal or sharp curettage is necessary, it is difficult to make
the diagnosis of placenta accreta as there is no uterine specimen for pathological diagnosis.
Placenta accreta often occurs in combination with placenta previa. In the presence of placenta
previa, accreta will also be noted in 24–67% of cases, increasing with the number of prior
uterine scars.4
These abnormalities of placentation are ominous conditions, contributing significantly to
maternal morbidity and mortality12 and accounting for 1.7% of all maternal deaths in the
United States.19 The association of both placenta previa and placenta accreta with extensive
maternal hemorrhage and transfusion is well documented. The unfortunate sequela of this
connection is that in order to achieve hemostasis, many women may require emergent
hysterectomy with its inherent surgical risks, additional blood loss, and subsequent loss of
reproductive capacity.
As preterm intervention and delivery is often required in cases of placenta previa or placenta
accreta, these conditions become significant contributors to perinatal morbidity and mortality
as well, accounting for as many as 24% of perinatal deaths.20 In one study, up to 11% of
previas were fatal to the fetus or neonate, with coexisting abruptio placenta in 41% of cases.8
Placenta accreta in the presence of placenta previa has been reported to account for a
mortality rate of 1 death in 2400 births.
ETIOLOGY/PATHOGENESIS
The etiologies of placenta previa and accreta are not well understood; however, several
hypotheses have been advanced. Placenta previa is noted more often in the second trimester,
and frequently resolves as the pregnancy progresses.21 For this reason, a widely accepted view
is that there normally exists an apparent placental migration, with one edge of the placenta
growing while the opposite edge atrophies. It has been noted that the placenta initially will
occupy from one half to one third of the uterine wall. By term, however, no more than one
fourth to one sixth of the uterine surface is covered.22 This change in ratio permits a degree of
apparent placental movement. In placenta previa, it is postulated that there is an impairment
of this normal placental progression away from the cervical os. It is believed that this migration
is impaired in women with surgically scarred uteri, which is why they are at greater risk for
placenta previa. The uterus itself is made up of several different areas, with differential growth
rates of each area. In the first 7 months of pregnancy, the relatively muscular upper portion of
the uterus grows faster than the lower segment. Toward the end of pregnancy, the lower
segment begins to develop, and can grow quite rapidly. Failure of this differential growth may
occur when the lower uterine segment is scarred, also contributing to the occurrence of a
placenta previa.4
Smoking seems to increase the risk of previa via a hypoxemia-related mechanism. Nicotine has
a vasoconstricting effect on uteroplacental perfusion in smoking mothers. Placental studies
have demonstrated decreased vascularization and pronounced changes in the broad basement
membrane of mothers who smoked cigarettes.23 Tominaga and Page24 have postulated that
increasing the placental surface area would be an effective method of coping with the relative
hypoxia experienced by smokers. This hypothesis is supported by observations that in
comparison with nonsmokers, mothers who smoke have heavier, thinner placentas with larger
surface areas.25 Increased carbon monoxide combined with hypoxemia may result in
compensatory placental hypertrophy, which may also increase the likelihood of placental
encroachment on the cervical os.26 There is a strong similarity between the changes seen in
smoking mothers and those seen at high altitudes.27 This supports the theory that hypoxia is a
determinant of placenta previa in mothers who smoke.
Placenta accreta is associated with a thin, incompletely developed or absent decidua basalis. In
normal uteri, the decidua basalis and its protective membranous barrier (Nitabuch's layer) are
thinner and less developed in the lower uterine segment than in the fundal region. Damage to
the endometrium and uterine scarring are strongly implicated, as there is an increased
association of placenta accreta in surgically scarred uteri. It has been proposed that the
decidua basalis deficiency allows chorionic villi to implant directly into the myometrium.
Placenta accreta has been described to occur in up to 15% of cases of placenta previa and in
67% of cases where placenta previa occurs in a patient with previous cesarean section for
placenta previa. Decidua basalis absence or deficiency has been noted in the histopathologic
studies of accreta patients by several authors.4, 17, 28 Another study, confirming the absence of
decidua basalis, also noted that trophoblastic tissue was morphologically and
immunohistologically normal.29 This supports the concept that the development of accreta is
due primarily to a uterine deficiency or damage and not to any abnormalities of the
trophoblast itself.
RISK FACTORS
Most of the risk factors that predispose a patient to placenta previa will also predispose them
to placenta accreta/increta/percreta. Indeed, the presence of placenta previa is a well-
recognized risk factor for placenta accreta.4, 30, 31 The most important risk factors for placenta
previa and accreta are age, parity, and a history of uterine surgery. In their definitive 1985
paper, Clark and associates4 noted an 11-fold increase in the incidence of placenta previa
among mothers older than 40 years when compared to those younger than 20 years. A more
recent long-term epidemiologic study found that for all races there was a five-fold increase in
the occurrence of placenta previa for women more than 35 years compared to those less than
20 years of age.6 Other studies have also found an association between age and occurrence of
previa.2, 11, 30, 31 Some authors have proposed that age may be a more important determinant
than parity.32, 33 Clark and co-workers noted a seven-fold increase in previa among women
with a parity greater than five when compared to nulliparous patients, and nearly all papers
mention the rising risk of placenta previa with increasing parity.11, 30, 31, 32, 33, 34 One of the
most dramatic risk factors for placenta previa or accreta is clearly the presence of previous
cesarean section. Although mothers with one previous cesarean had a 2.5-fold increase in the
risk of previa, this number multiplied dramatically with increasing number of cesarean sections,
peaking at mothers with four or more uterine incisions, who experienced a 38-fold increase in
the incidence of placenta previa.4, 31 These results have been confirmed in numerous
subsequent studies.3, 6, 10, 11, 35, 36 Additionally, placenta previa has been noted to increase
with the number of elective or spontaneous abortions experienced.11, 20, 37, 38 This may be by
a similar mechanism to cesarean section. However, because the presence of either induced or
elective abortions increases the parity of the patient, the increase in parity may be the more
important factor.
Multiple gestations have been commonly mentioned as increasing the risk of previa, because
there is a greater amount of placental tissue present in these gestations. However, in one
study of 1.8 million Swedish births, the incidence of previa was found to be exactly equal in
singleton and twin gestations.39 Another study of 1253 twin mothers found no difference in
the frequency of placenta previa between twin and singleton pregnancies, although there was
a three-fold increased risk of abruptio placenta among the mothers of twins.40
Smoking has been convincingly linked as a significant risk factor for placenta previa, with a
dose-dependent increase of risk.5, 26, 39, 41, 42, 43, 44 Smokers had a relative risk of 2.6–4.4 for
placenta previa.26 Placenta previa babies were delivered sooner, at a lower birth weight and
with a greater mortality of 14.9/1000 deaths. Cocaine use has shown a mild association with
previa,5 and diethylstilbestrol (DES) exposure in utero has been connected with placenta previa
as well. Different studies have reported increased risks for previa or accreta among women of
Asian origin,9 Thai women, and women of Papua New Guinea.28
Overall, any circumstances that tend to cause uterine damage, myometrial scarring, or
deficient development of the decidua may predispose a patient to these placental
abnormalities. Other authors have noted conditions not previously mentioned that have been
associated with increased risk: myotonic dystrophy, adenomyosis, Asherman's syndrome,

congenital uterine malformation, previous cornual pregnancy, histories of curettage,
endometritis, hysterotomy, peripartum infection, previous retained placenta, radiation therapy,
tubal reimplantation surgery, or presence of uterine fibroids.4, 17, 18, 28, 45, 46, 47, 48, 49, 50, 51 In
his exhaustive historical review of 612 accreta cases, Fox18 noted normal uteri and lack of all
risk factors in only 1.4% of women with placenta accreta.
CLINICAL PRESENTATION
The classic presentation of placenta previa is painless vaginal hemorrhage in a previously
normal pregnancy, which may be an isolated or recurrent event. The initial event usually does
not occur until the second trimester.52 Bleeding occurs due to disruption of the placental
attachment to the lower uterine segment. In the earliest weeks hemorrhage is usually
associated with vaginal examination or intercourse. The amount of bleeding is usually
proportional to the degree of placenta previa.52 Patients with a complete placenta previa bleed
earlier and heavier than do those with a partial or marginal previa. Clinical presentation of
placenta previa can differentiate it from abruptio placentae, another common cause of
bleeding in the second half of pregnancy. Bleeding episodes that often cease within 1 or 2
hours; an absence of abdominal discomfort; and a normal fetal heart tracing on electronic
monitoring usually characterize placenta previa. On the other hand, abruptio placentae is
associated with continuous bleeding; moderate to severe abdominal discomfort; fetal
tachycardia followed by bradycardia with loss of variability and decelerations; occasional
coagulation defects, including disseminated intravascular coagulation (DIC); and associated
history of hypertension or preeclampsia, cocaine use, abdominal trauma, or polyhydramnios.
On physical examination the uterus tends to be soft and fetal parts readily palpable. With
placenta previa, the presenting part is unengaged and malpresentation is common, seen in up
to 50% of cases.52
Most cases of placenta accreta are not discovered until the third stage of labor, when the
patient is noted to have an abnormally adherent placenta that requires manual removal or has
postpartum hemorrhage secondary to partial placental separation.18
DIAGNOSIS
Historically, the diagnostic confirmation of placenta previa had been through retrospective
findings at cesarean delivery53 or on palpation during double set-up examination. However,
because of difficulties in defining the exact location of the placental bed during an emergency
operation and the obvious implications of the double set-up exam, sonography has become
the most accurate and commonly used method for diagnosing placenta previa.53, 54 In fact,
most cases are diagnosed incidentally at mid-trimester ultrasound. Before Gottesfeld and co-
workers55 first reported on the usefulness of transabdominal sonography for localization of

the placenta, angiography, radiography, radioisotope scanning, and digital examination of the
placenta were used for diagnosis of the placenta previa.56, 57, 58 Although far from perfect,
with false-positive rates of 3–7% and false-negative rates up to 2%, transabdominal sonography
is currently the standard in the diagnosis of placenta previa.55, 59, 60, 61 Explanations proposed
to account for the false-positive error rate, summarized by Langlois and colleagues,52 include
placental conversion, overdistention of the urinary bladder, low-lying myometrial contraction,
or leiomyomas and extraembryonic blood clots.
Placental conversion is the main source of the false-positive results of the first and second
trimester diagnosis of placenta previa. Various studies have indicated that the incidence of
placenta previa in mid-gestation is more frequent than at term.55, 62, 63, 64 The explanation of
placental conversion, supported by most authors, is based on the theory that the uterus grows
at a faster rate than the placenta as pregnancy progresses. This differential growth rate results
in a decrease in the proportion of the inner uterine surface that is covered by placenta. Thus,
with time, an initially diagnosed low-lying placenta appears to be carried away from the os
toward the fundus.
Overdistention of the maternal urinary bladder is sometimes cited as a cause of false-positive
diagnosis of placenta previa.38, 44, 45, 46, 65 Apposition of the anterior and posterior walls of
the lower uterine segment may decrease the length of this segment and falsely suggest a
placenta previa. Although some authors recommend the routine use of post-voiding scans,
other doubt their usefulness, citing the difficulties of visualizing the placenta and its
relationship to the os without a full bladder.38
Focal low-lying myometrial contractions may also distort the lower uterine segment and
contribute to a previa misdiagnosis. Myometrial contractions can either simulate placental
tissue or shorten the distance between the placental edge and the internal os. Townsend and
co-workers66 documented myometrial contractions in 16% of the false-positive diagnoses and
recommended repeat scanning after 30 minutes if the myometrial thickness exceeds 1.5 cm.31,
47
Morrison48 demonstrated that the lower uterine segment develops continuously throughout
pregnancy. Normal lower uterine segment varies from 0.5 cm from the internal os at 20 weeks'
gestation to 5 cm at 38 weeks. Therefore, the fixed limitation of the distance between the
lower uterine segment and the internal os to within 5 cm for diagnosis of placenta previa will
cause several false-positive results early in the third trimester.
Low-lying leiomyomas and extraembryonic blood clots can be easily confused with low-lying
placenta and cause false-positive results. Moreover, accurate localization of placenta via the
transabdominal route can be difficult in the presence of obesity and posterior or lateral
placentation. The acoustic shadow of the fetal head in a vertex presentation may prevent an
accurate localization of a low placenta.67
Transabdominal sonography becomes increasingly difficult as the third trimester progresses,

predominantly because of attenuation of sound by the presenting part of the fetus.68, 69
Several techniques, including external fetal manipulation, overdistension of the maternal
urinary bladder,and Trendelenburg positioning, have been used to elevate the presenting part
of the fetus from the pelvis and facilitate visualization of the cervix.68, 69, 70, 71 However, such
maneuvers can be uncomfortable for the patient, distort the appearance of the cervix, and are
frequently unsuccessful late in the third trimester.69, 70, 71 Because of these limitations,
alternative techniques are needed to complement transabdominal sonography for the
diagnosis of placenta previa.69 Transvaginal and transperineal sonography are frequently used
with transabdominal studies.
There is little doubt that transabdominal sonography will remain as the first-line diagnostic
means for the localization of placenta previa.54 However, an emerging body of evidence
suggests the superiority of transvaginal sonography in this respect and supports its use as a
second-line investigation to avoid the complications of misdiagnosis of placenta previa due to
false-positive or false-negative results.
Brown and colleagues first described the use of transvaginal sonography to evaluate the lower
uterine segment and cervix during pregnancy in 1986.72 Transvaginal ultrasound not only
circumvents many problems faced by transabdominal sonography, but also possesses certain
inherent characteristics that improve diagnostic accuracy.54 The sound waves travel a shorter
distance from the tip of the vaginal probe to the pelvic organs than they do from the tip of the
abdominal probe.54, 67 This enables the use of a higher frequency ultrasound wave generator,
which in turn increases picture resolution.54, 67 Transvaginal ultrasonography avoids the
disturbances caused by body habitus, bladder overdistention, and acoustic shadowing of fetal
parts.54 Tan and co-workers54 demonstrated that transvaginal sonography ruled out placenta
previa in 12 cases out of 70 (17%) thought to be placenta previa by transabdominal ultrasound.
Leerentveld and colleagues73 reported a positive predictive value of 93.3% and a negative
predictive value of 97.6% of transvaginal sonography. Farine and co-workers74 reported a
positive predictive value of 71%, but a negative predictive value of 100%.
Despite the higher accuracy of transvaginal sonography, it remains underutilized in the
diagnosis of placenta previa.54 This is mainly because of safety concerns. Vaginal manipulation
in cases of suspected placenta previa runs against the grain of classic obstetric teaching.54
However, recent data in many studies suggest that sonography is a safe technique. None of
the authors encountered any evidence of vaginal bleeding, preterm labor, premature rupture
of membranes, or vaginitis.54, 61, 67, 73 Tan and co-workers54 attributed the safety of
transvaginal sonography to the fact that the vaginal probe is inserted under direct ultrasonic
visualization, and hence direct contact with the cervix is avoided. There is still a fair distance
between the tip of the vaginal probe and the cervix when the lower uterine segment comes
into focus because the focal range of the vaginal probe is 2–7 cm. Therefore, if the transducer
is closer to the target than its focal length, the image may be blurred and out of focus.61
Timor-Tritsch and Yunis61 evaluated the safety of transvaginal ultrasonography in the diagnosis
of placenta previa by determining whether the angle between the cervix and the vaginal probe
is sufficient for alignment of the probe with the cervix. They concluded that the anatomic
relationship between the vagina and cervix, as reflected in the measured angle between the
two (greater than 44°), makes inadvertent insertion of the probe into the internal cervical os
virtually impossible.
Transvaginal sonographic placental localization appears to be a simple, reliable, and safe
technique,73 and it is recommended as a second-line diagnosis in patients who are diagnosed
to have minor placenta previa by transabdominal sonography.54 Transperineal sonography is
another technique for imaging the cervix during the third trimester of pregnancy, allowing
cervical visualization in most patients in whom transabdominal sonography of this area is
unsuccessful.69 Although transvaginal ultrasound is more commonly used to complement
transabdominal studies, a transperineal approach provides a more convenient means of
imaging the cervix and lower uterus without requiring specialized equipment, vaginal
penetration, or external fetal manipulation.75 Hertzberg and colleagues75 demonstrated that
the greatest value of transperineal sonography was in helping to exclude placenta previa in
patients in whom the cervix was not seen on transabdominal sonography. In such cases,
transperineal sonography will usually show the internal surface of the cervix without overlying
placental tissue, allowing confident exclusion of placenta previa. In a significant minority of
patients with placenta previa, however, transperineal sonography will show a placenta previa
that was not seen with transabdominal sonography.
The cervix is almost always seen on transperineal sonograms, but the lower edge of the
placenta may be beyond the field of view.75 Therefore, transperineal sonography is a valuable
procedure to complement transabdominal studies, but not to replace them.
Accurate interpretation of transperineal sonograms requires the same precautions as in the
evaluation of transabdominal sonograms,75 and inherent in the procedure are the same
sources of false-positive results. The potential value of magnetic resonance imaging (MRI) for
placental localization has been investigated in several centers.76, 77 MRI offers two major
advantages over ultrasound that may make it particularly suitable for evaluating third trimester
bleeding and diagnosis of placenta previa. These advantages are potentially better tissue
differentiation and an ability to highlight blood.78 Excellent maternal soft tissue definition can
be obtained; both placenta and cervix have a characteristic appearance. Therefore, the
relationship of the lower edge of the placenta to the internal cervical os can be accurately
determined.
Despite the encouraging research results, MRI diagnosis of placenta previa is still an
experimental technique and is not widely used in a clinical setting. Disadvantages associated
with MRI for diagnosis of placenta previa include: (1) safety concerns regarding moving a
patient from labor and delivery to a radiology suite; (2) the relatively lengthy examination
(typically 30–60 minutes); (3) long-term safety in pregnancy has yet to be established; and (4)
MRI scans are more costly than ultrasound examination.78 Although there is some evidence for
using MRI as a complementary technique to ultrasound, these barriers effectively preclude its
use in most patients.
The diagnosis of placenta accreta usually is made at delivery, when it becomes apparent the
placenta is abnormally adherent. The diagnosis can be confirmed after surgery with
histopathologic examination of the uterus or by biopsy of the placental bed. The characteristic
histopathologic feature of this condition is absence or poor development of decidua basalis.79
Diagnosis before delivery would allow adequate surgical preparation to decrease maternal
morbidity and mortality. Although it is possible to do so, placenta accreta is rarely diagnosed
antenatally.80
The sonographic characteristics of a placenta accreta are the absence of the normal
retroplacental clear space, placental tissue contiguous with myometrium, and prominent
placental venous lakes and uterine vascularity.79, 80 Absence of the hypoechoic zone is thought
to represent a defect in decidua basalis and adjacent myometrium, whereas the vascular
changes may be a result of alternative vascular patterns associated with an abnormal basal
plate.79, 81
Rosemond and Kepple80 described a case in which abnormal sonographic findings were
appreciated only with transvaginal color Doppler sonography. When Doppler flow studies of
the normal retroplacental clear space are performed, multiple venous flow signals are seen in
this area.80, 82 Absence of this space represents abnormal placentation. In a case of placenta
percreta diagnosed at our institution (Fig. 2), the interface between the placenta and the
maternal urinary bladder is essentially absent. Transabdominal color Doppler studies were
diagnostic in this patient, and placenta percreta was subsequently confirmed at cesarean
delivery.
Fig. 2. Placenta percreta diagnosed antenatally by transabdominal color Doppler ultrasound. Note the
loss of interface between the placenta and the maternal urinary bladder.(J.S. Sholl, MD;
ultrasonographer)
Color flow Doppler sonography is also particularly useful in identifying hypervascularity

beneath the placental attachment site. This technique highlights the areas of increased
vascularity and reveals a continuum of lacunar flow from the placenta through the myometrial
layer without an intervening clear space. However, sonographic findings are not
pathognomonic for placenta accreta.80 Callen and Filly33 documented absence of a

retroplacental clear space in 27 of 100 cases examined prospectively; but none of these
patients had placenta accreta.
Antepartum diagnosis of these invasive placental conditions may allow for the placement of
arterial catheters preoperatively in case it is necessary to perform uterine artery embolization
by interventional radiology, which is designed to lessen the risk of catastrophic hemorrhage.
Foreknowledge of placental invasion can also provide the opportunity for additional patient
counseling, blood product availability, and an appropriate surgical team to be assembled for
the delivery.
TREATMENT
Historically, placenta previa and accreta have been one of the major causes of mortality and
morbidity. Often the bleeding may necessitate early delivery, along with its concurrent risks for
the premature neonate.83 Prenatal management of placenta previa remains controversial.
Although there is a consensus that patients should be confined to bedrest, and that pelvic rest
should also be observed, there is no agreement on whether hospitalized bedrest is safer or
more effective.84, 85, 86 Most authors agree that patients can be expectantly managed as
outpatients until the first bleeding episode. Subsequent management should be individualized
to the circumstances, including gestational age, severity of hemorrhage, patient's ability to
comply with bedrest, and patient's proximity to the hospital. Various strategies have been tried
to prolong pregnancy in the face of nonacute bleeding. Cervical cerclage has been found
ineffective in prolonging gestation or decreasing eventual need for blood usage.87 Originally
the most common treatment for placenta previa with associated bleeding was the delivery of
the infant. With the advent of tocolytic use, it became more common to adopt a conservative
management strategy. Tocolytic treatment decreases the amount of uterine contractions, which
can also decrease any bleeding. A study by Towers and colleagues found that the use of
tocolytics in the management of third trimester bleeding did not increase morbidity or
mortality when used in a controlled tertiary setting.88 Similar findings had been reported
earlier by other authors.89
In cases of complete placenta previa, if patients remain otherwise stable, documentation of
fetal lung maturity and elective cesarean delivery are usually advocated at 35–36 weeks'
gestation.60, 89 D'Angelo and Irwin found that most of the severe bleeding episodes they
reported in their study occurred after 36 weeks.84 Elective cesarean also allows for use of a
regional anesthetic in an otherwise stable patient. In fact, in a retrospective analysis of a 22-
year experience, Frederickson noted a significant increase in intraoperative blood loss and the
subsequent need for hysterectomy when a general anesthetic was used in cases of placenta
previa.90
Management of partial placenta previa is varied. Although double set-up examinations are
often mentioned both in reference texts and in the literature, in reality, this is rarely
performed in the modern clinical practice. Most practitioners use ultrasound to assess the
degree of previa when delivery decisions are being made. There is agreement that when the
placental edge is at least 2 cm from the cervical edge, and the fetus is in vertex presentation, it
is usually safe to allow the patient a trial of vaginal labor.91 One reason that bleeding is within
an acceptable range in these conditions is that the fetal head will act as a tamponade to stop
or diminish the bleeding at the placental edge. In most cases, when the placental edge is less
than 2 cm from the cervical os, it is considered preferable to proceed with elective cesarean to
prevent massive hemorrhage and its complications.
Placenta accreta, increta, and percreta remain among the greatest treatment challenges in
modern obstetrics. Massive hemorrhage can easily accompany these conditions. Often patients
may exit the operating room in an extremely critical condition, and it is common for
disseminated intravascular coagulation (DIC)92 and acute respiratory distress syndrome
(ARDS)93 to develop, with a subsequent prolonged intensive care episode.
The most important component of successful management of invasive placental conditions
remains preparation. The optimal management will involve the cooperation of members of a
multidisciplinary team headed by the obstetrician and including neonatology, anesthesia, blood
bank, urology (if bladder involvement is suspected), general surgery, and possibly interventional
radiology. It is desirable, if possible, to have uterine artery catheters placed before surgery,
because this has been shown in many series to decrease the risk of massive hemorrhage.94 In
his 5-year series, Hansch and co-workers had extensive hemorrhage in only of one of six
patients. In four patients, bleeding was controlled by uterine artery embolization (UAE), and
one patient had prophylactic catheters placed but did not require embolization. In the authors'
experience at Evanston Northwestern Healthcare, this approach has been taken in four
patients with known placenta percreta, with satisfactory results in three and one patient who
did not require use of embolization after preoperative placement of catheters. There are also
reports of successful use of argon laser for hemostasis management.93, 95 Paradoxically, after
surgery, it is crucial that these women receive thromboprophylaxis, because they are at
increased risk of thrombosis due to longer surgical times and the extensive pelvic dissection
and manipulation often required.96
COMPLICATIONS
Advances in antenatal surveillance and early diagnosis have led to significant improvements in
outcomes associated with placenta previa. Current surgical, anesthetic, and blood component
therapeutics have also greatly improved maternal and fetal morbidity and mortality.
Nonetheless, placenta previa and placenta accreta continue to present clinical challenges with
many associated complications. Hemorrhage remains the major complication of abnormal
placentation, often necessitating premature delivery with its own perinatal impact.31 Emergent
surgical intervention due to hemorrhage is associated with multiple risks and may require
hysterectomy to control blood loss. Although most patients with placenta previa will not
require blood transfusion, those who do may have significant blood product requirements.
One study of blood bank utilization in placenta previa patients found that 14.6% of patients
required transfusion, and 6.3% went on to require hysterectomy.97 Most transfusions were for
1–3 units of packed red cells; however, one patient required 25 units, and another who
developed a coagulopathy eventually received 58 units of blood products. In the experience of
this institution, we have had similar utilization patterns, where patients require either modest
or massive amounts of blood products.
Neonatal complications of placenta previa and accreta are varied. In one study of neonatal
outcomes in nearly 93,000 pregnancies, there was a 0.3% rate of placenta previa.83 Among
these pregnancies neonatal complications significantly associated with placenta previa were
major congenital anomalies, respiratory distress syndrome (secondary to premature delivery),
and anemia. The perinatal mortality rate associated with placenta previa was 2.30% versus
0.78% for controls. In addition, the chronic bleeding associated with a placenta previa may be
associated with fetal growth restriction, perhaps due to chronic mild hypoxia.
Another complication may be vasa previa, where the placental blood vessels cross the cervical
os in advance of the presenting fetal part.98 The major concern is the propensity of these
vessels, which lack the protection of either the placental bed or the Wharton's jelly, to become
lacerated when the membrane ruptures, with catastrophic results.99 Both of the authors
referenced have advocated using Doppler ultrasonography to diagnose vasa previa before
delivery, avoiding the potential for laceration or vessel compression and bradycardia.
Undiagnosed vasa previa has had a reported mortality of between 33% and 100%.100
Optimal outcomes with vasa previa depend on accurate antenatal diagnosis and cesarean
delivery prior to membrane rupture. The impact of antenatal diagnosis of vasa previa
was reviewed in a multicenter retrospective study.101 It was determined that, in the absense of
prenatal diagnosis, the perinatal mortality was 56%, whereas 97% of babies survived when
vasa previa was diagnosed prior to labor. In asymptomatic patients with vasa previa cesarean
delivery should be planned for 36–37 weeks. Although amniocentesis is generally
recommended for planned delivery prior to 39 completed weeks, the risk of rupture of
membranes, fetal exsanguination and death outweighs the relative risks of lung
immaturity and respiratory distress syndrome. Therefore, amniocentesis for fetal lung maturity
is not generally required prior to delivery in patients with vasa previa. Delivery should take
place in an institution where adequate facilities for neonatal resuscitation and blood
transfusions are readily available. Finally, the surgical approach should be planned with review
of the location of the vessels on ultrasound and avoiding injury to them during cesarean
delivery. Figure 3 demonstrates intact membranes at cesarean section with vessels traversing
the lower segment and precariously coursing across the interval cervical os. Even under such
controlled conditions, careful dissection is necessary to avoid injury to these vessels prior to
delivery of the baby.
Fig. 3. Intact membranes at cesarean section with vessels traversing the lower segment and
precariously coursing across the interval cervical os. (Courtesy of H. Jacob Saleh.)
CONCLUSION
Placenta previa, placenta accreta, and vasa previal are significant and sometimes catastrophic
causes of third trimester bleeding and are today more prevalant causes of maternal and
perinatal morbidity and mortality. Leading the list for this increased incidence is the rising rate
of cesarean section. Advances in ultrasonography and Doppler imaging have allowed the
obstetrician to accurately diagnose these conditions in the antenatal period and better develop
treatment strategies with planned delivery in well-equipped facilities.
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11/24/21, 4:52 AM Placenta Previa and Accreta | GLOWM

This chapter should be cited as follows:

This chapter was last updated:

percreta, (PR) placenta previa. (J.H. Pedigo, illustrator)

associated with increased risk: myotonic dystrophy, adenomyosis, Asherman's syndrome,

workers55 first reported on the usefulness of transabdominal sonography for localization of

Transabdominal sonography becomes increasingly difficult as the third trimester progresses,

Color flow Doppler sonography is also particularly useful in identifying hypervascularity

pathognomonic for placenta accreta.80 Callen and Filly33 documented absence of a

8 Naeye RL: Placenta

16 Sfar E, Zine S, Chaar N

26 Williams MA, Mittendorf

33 Callen PW, Filly RA: The

40 Spellacy WN, Handler A,

48 Woolcott RJ, Nicholl M,

64 Laing FC: Ultrasound

70 Lee TG, Knochel JQ,

77 Johnson IR, Symonds

85 Baron F, Hill WC:

93 Hudon L, Belfort MA,

101 Oyelese Y, Cantanzarite,

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