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Placenta previa

Last reviewed: September 12, 2009.

Placenta previa is a complication of pregnancy in which the placenta grows in the lowest part of the womb (uterus) and covers all or part of the opening to the cervix. The placenta is the organ that nourishes the developing baby in the womb.

Causes, incidence, and risk factors


During pregnancy, the placenta moves as the uterus stretches and grows. In early pregnancy, a low-lying placenta is very common. But as the pregnancy progresses, the growing uterus should "pull" the placenta toward the top of the womb. By the third trimester, the placenta should be near the top of the uterus, leaving the opening of the cervix clear for the delivery. Sometimes, though, the placenta remains in the lower portion of the uterus, partly or completely covering this opening. This is called a previa. There are different forms of placenta previa: Marginal: The placenta is against the cervix but does not cover the opening. Partial: The placenta covers part of the cervical opening. Complete: The placenta completely covers the cervical opening.

Placenta previa occurs in 1 out of 200 pregnancies. It is more common in women who have: Abnormally developed uterus Many previous pregnancies Multiple pregnancy (twins, triplets, etc.)

Scarring of the uterine wall caused by previous pregnancies, cesareans, uterine surgery, or abortions Women who smoke or have their children at an older age may also have an increased risk. Possible causes of placenta previa include: Abnormal formation of the placenta Abnormal uterus Large placenta Scarred lining of the uterus (endometrium)

Symptoms
The main symptom of placenta previa is sudden, painless vaginal bleeding that often occurs near the end of the second trimester or beginning of the third trimester. In some cases, there is severe bleeding, or hemorrhage. The bleeding may stop on its own but can start again days or weeks later.

There may be uterine cramping with the bleeding. Labor sometimes starts within several days after heavy vaginal bleeding. However, in some cases, bleeding may not occur until after labor starts. See: Vaginal bleeding in pregnancy

Signs and tests


Your health care provider can diagnose placenta previa with an ultrasound exam. Most cases of placenta previa are identified by routine ultrasound during pregnancy.

Treatment
Treatment depends on various factors: How much bleeding you had Whether the baby is developed enough to survive outside the uterus How much of the placenta is covering the cervix The position of the baby The number of previous births you have had Whether you are in labor

Many times the placenta moves away from the cervical opening before delivery. If the placenta is near the cervix or is covering a portion of it, you may need to reduce activities and stay on bed rest. Your doctor will order pelvic rest, which means no intercourse, no tampons, and no douching. Nothing should be placed in the vagina. If there is bleeding, however, you will most likely be admitted to a hospital for careful monitoring. If you have lost a lot of blood, blood transfusions may be given. You may receive medicines to prevent premature labor and help the pregnancy continue to at least 36 weeks. Beyond 36 weeks, delivery of the baby may be the best treatment. If your blood type is Rh-negative, you will be given anti-D immunoglobulin injections. Your health care providers will carefully weigh your risk of ongoing bleeding against the risk of an early delivery for your baby. Women with placenta previa most likely need to deliver the baby by cesarean section. This helps prevent death to the mother and baby. An emergency c-section may be done if the placenta actually covers the cervix and the bleeding is heavy or very life threatening.

Expectations (prognosis)
Placenta previa is most often diagnosed before bleeding occurs. Careful monitoring of the mother and unborn baby can prevent many of the significant dangers. The biggest risk is that severe bleeding will require your baby to be delivered early, before major organs, such as the lungs, have developed.

Most complications can be avoided by hospitalizing a mother who is having symptoms, and delivering by C-section.

Complications
Risks to the mother include: Death Major bleeding (hemorrhage) Shock

There is also an increased risk for infection, blood clots, and necessary blood transfusions. Prematurity (infant is less than 36 weeks gestation) causes most infant deaths in cases of placenta previa. The baby may lose blood if the placenta separates from the wall of the uterus during labor. The baby also can lose blood when the uterus is opened during a Csection delivery.

Calling your health care provider


Call your health care provider if you have bleeding from the vagina at any point in your pregnancy. Placenta previa can be dangerous to both you and your baby.

Prevention
This condition is not preventable.

Background: Placenta previa is an obstetric complication that occurs in the second and third trimesters of pregnancy. It may cause serious morbidity and mortality to both the fetus and the mother. It is one of the leading causes of vaginal bleeding in the second and third trimesters.

Placenta previa.

Placenta previa is generally defined as the implantation of the placenta over or near the internal os of the cervix. Total placenta previa occurs when the internal cervical os is completely covered by the placenta. Partial placenta previa occurs when the internal os is partially covered by the placenta. Marginal placenta previa occurs when the placenta is at the margin of the internal os. Low-lying placenta previa occurs when the placenta is implanted in the lower uterine segment. In this variation, the edge of the placenta is near the internal os but does not reach it.

A recent study concluded that more than two thirds of women with a distance of more than 10 mm from the placental edge to cervical os have vaginal delivery without an increased risk of hemorrhage.[1]

Pathophysiology
The exact etiology of placenta previa is unknown. The condition may be multifactorial and is postulated to be related to multiparity, multiple gestations, advanced maternal age, previous cesarean delivery, [2] previous abortion, and possibly, smoking. Unlike first trimester bleeding, second and third trimester bleeding is usually secondary to abnormal placental implantation.

Epidemiology
Frequency
United States Placenta previa complicates approximately 5 of 1,000 deliveries and has a mortality rate of 0.03%. Data recorded from 1989-1997 indicated placenta previa occurs in 2.8 per 1000 live births in the United States.

Mortality/Morbidity
The maternal mortality rate secondary to placenta previa is approximately 0.03%. Babies born to women with placenta previa tend to weigh less than babies born to women without placenta previa. The risk of neonatal mortality is higher for placenta previa babies compared with pregnancies without placenta previa. The great majority of deaths are related to uterine bleeding and the complication of disseminated intravascular coagulopathy. In early pregnancy, a partial previa can often self-correct as the uterus enlarges and the placental site moves cephalad.

Race
Significance of race is somewhat controversial. Some studies suggest an increased risk of placenta previa among blacks and Asians, whereas other studies cite no difference.

Age
Women older than 30 years are 3 times more likely to have placenta previa than women younger than 20 years.