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Placenta Previa
Updated: Jan 24, 2024
Author: Ronan Bakker, MD; Chief Editor: Carl V Smith, MD

Overview

Practice Essentials
Placenta previa is an obstetric complication that classically presents as painless vaginal bleeding in the third trimester
secondary to an abnormal placentation near or covering the internal cervical os. However, with the technologic advances in
ultrasonography, the diagnosis of placenta previa is commonly made earlier in pregnancy. Historically, there have been three
defined types of placenta previa: complete, partial, and marginal. More recently, these definitions have been consolidated
into two definitions: complete and marginal previa.

A complete previa is defined as complete coverage of the cervical os by the placenta. If the leading edge of the placenta is
less than 2 cm from the internal os, but not fully covering, it is considered a marginal previa (see the following image).
Because of the inherent risk of hemorrhage, placenta previa may cause serious morbidity and mortality to both the fetus and
the mother.

Placenta previa.

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Complete placenta previa noted on ultrasound.

Another ultrasound image clearly depicting complete placenta previa.

Pathophysiology
Placental implantation is initiated by the embryo (embryonic plate) adhering in the lower (caudad) uterus. With placental
attachment and growth, the developing placenta may cover the cervical os. However, it is thought that a defective decidual
vascularization occurs over the cervix, possibly secondary to inflammatory or atrophic changes. As such, sections of the
placenta having undergone atrophic changes could persist as a vasa previa.

A leading cause of third-trimester hemorrhage, placenta previa presents classically as painless bleeding. Bleeding is thought
to occur in association with the development of the lower uterine segment in the third trimester. Placental attachment is
disrupted as this area gradually thins in preparation for the onset of labor; this leads to bleeding at the implantation site,
because the uterus is unable to contract adequately and stop the flow of blood from the open vessels. Thrombin release
from the bleeding sites promotes uterine contractions and leads to a vicious cycle of bleeding–contractions–placental
separation–bleeding.

Etiology
The exact etiology of placenta previa is unknown. The condition may be multifactorial and is postulated to be related to the
following risk factors:

Advancing maternal age (>35 y)

Infertility treatment

Multiparity (5% in grand multiparous patients)

Multiple gestation

Short interpregnancy interval

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Previous uterine surgery, uterine insult or injury

Previous cesarean delivery,[1, 2] including first subsequent pregnancy following a cesarean delivery[1]

Previous or recurrent abortions

Previous placenta previa (4-8%)

Smoking

Cocaine use

Unlike first-trimester bleeding, second- and third-trimester bleeding is usually due to abnormal placental implantation.

Hemorrhaging, if associated with labor, would be secondary to cervical dilatation and disruption of the placental implantation
from the cervix and lower uterine segment. As noted previously, the lower uterine segment is inefficient in contracting and
thus cannot constrict vessels as in the uterine corpus, resulting in continued bleeding (see Pathophysiology).

Epidemiology
United States statistics

Placenta previa is frequently reported to occur in 0.5% of all US pregnancies. A large, US population-based, 1989-1997
study indicated an incidence of 2.8 per 1000 live births.[3] The risks increase 1.5- to 5-fold with a history of cesarean
delivery. A meta-analysis showed that the rate of placenta previa increases with increasing numbers of cesarean deliveries,
with a rate of 1% after 1 cesarean delivery, 2.8% after 3 cesarean deliveries, and as high as 3.7% after 5 cesarean
deliveries.[1]

Racial and age-related differences in incidence

The significance of race in having a role in placenta previa is somewhat controversial. Some studies suggest an increased
risk among Black and Asian women, whereas other studies cite no difference.[4, 5]

Advanced maternal age has also been strongly associated with an increasing incidence of placenta previa. The incidence of
placenta previa after age 35 years reported to be 2%. A further increase to 5% is seen after age 40 years, which is a 9-fold
increase when compared to females younger than 20 years.[6, 7]

Prognosis
Placenta previa complicates approximately 0.5% of all pregnancies.[4] Technologic advances in ultrasonography have
increased the early diagnosis of placenta previa, and several studies have shown that a significant portion of these early
diagnoses do not persist until delivery.[8, 9] In fact, 90% of all placentas designated as “low lying” on an early sonogram are
no longer present on repeat examination in the third trimester.[10]

However, maternal and fetal complications of placenta previa are well documented. Preterm birth is highly associated with
placenta previa, with 16.9% of women delivering at less than 34 weeks and 27.5% delivering between 34 and 37 weeks in a
population-based study from 1989 to 1997.[3] A meta-analysis by Jansen et al showed that pooled proportions for the risk of
preterm birth before 37, 34, 32 and 28 weeks of gestation in pregnant persons with placenta previa were 46%, 17%, 10%,
and 2%, respectively.[11] There is a significant increase in the risk of postpartum hemorrhage and need for emergency
hysterectomy in women with placenta previa.[12]

Maternal complications of placenta previa are summarized as follows:

Hemorrhage,[13] including rebleeding (Planning delivery and control of hemorrhage is critical in cases of placenta
previa as well as placenta accreta, increta, and percreta.)

Higher rates of blood transfusion[13, 14]

Placental abruption

Preterm delivery

Increased incidence of postpartum endometritis[14]

Mortality rate (2-3%); in the US, the maternal mortality rate is 0.03%, the great majority of which is related to uterine
bleeding and the complication of disseminated intravascular coagulopathy

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The Table, below, summarizes the relative risk of some morbidities in women with placenta previa.

Table. Relative Risk of Morbidities in Patients With Placenta Previa (Open Table in a new window)

Morbidities Relative Risk

Antepartum bleeding 10

Need for hysterectomy 33

Blood transfusion 10

Septicemia 5.5

Thrombophlebitis 5

Endometritis 6.6[14]

Complications of placenta previa in the neonate/infant are summarized as follows:

Congenital malformations

Fetal intrauterine growth retardation (IUGR)

Fetal anemia and Rh isoimmunization

Abnormal fetal presentation

Low birth weight (< 2500 g)[14]

Neonatal respiratory distress syndrome[14]

Jaundice[14]

Admission to the neonatal intensive care unit (NICU)[14]

Longer hospital stay[14]

Increased risk for infant neurodevelopmental delay and sudden infant death syndrome (SIDS)[15]

Neonatal mortality rate: As high as 1.2% in the United States[16]

Patient Education
Patients with placenta previa should decrease activity to avoid rebleeding. In addition, pelvic examinations and intercourse
should be avoided.

Counsel patients with placenta previa about the risk of recurrence. Instruct them to notify the obstetrician caring for their next
pregnancy about their history of placenta previa.

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Encourage patients with known placenta previa to maintain intake of iron and folate as a safety margin in the event of
bleeding.

Presentation

History
The classic presentation of placenta previa is painless, bright red vaginal bleeding that often stops spontaneously and then
recurs with labor.

Vaginal bleeding is most likely to occur in the third trimester. In a study of 179 patients, 33.7% of patients had their first
bleeding episode prior to 30 weeks, with 44.6% experiencing bleeding after 30 weeks. Of all the patients with confirmed
placenta previa, only 21.7% did not bleed at any time during their pregnancy.[17]

Placenta previa often leads to preterm delivery, with 44% of pregnancies with placenta previa delivered before 37 weeks.[16]

Physical Examination
Any pregnant woman beyond the first trimester who presents with vaginal bleeding requires a speculum examination
followed by diagnostic ultrasonography, unless previous documentation confirms no placenta previa.

Because of the risk of provoking life-threatening hemorrhage, a digital examination of the vagina is absolutely
contraindicated until placenta previa is excluded.

Findings in a woman with placental previa may include the following:

Profuse hemorrhage

Hypotension

Tachycardia

Soft and nontender uterus

Normal fetal heart tones (usually)

DDx

Diagnostic Considerations
Instruments or fingers should not be placed near the cervix during a vaginal examination, because uncontrolled bleeding can
result. Do not perform vaginal or rectal examinations in an outpatient or emergency department setting unless
ultrasonography findings have ruled out placenta previa.

Rarely, ultrasonography is unavailable and a digital examination is necessary. If this is the case, the digital examination
should be performed in the operating room under double setup conditions (ie, one team ready for emergent cesarean
delivery and one team ready for uneventful vaginal delivery).

Other problems to consider in a woman with suspected placenta previa include the following:

Vasa previa

Cervical or vaginal laceration

Vaginal sidewall laceration

Miscarriage (spontaneous abortion)

Infection

Vaginal bleeding

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Lower genital tract lesions

Bloody show

Differential Diagnoses
Abruptio Placentae

Cervicitis

Disseminated Intravascular Coagulation (DIC)

Pregnancy, Delivery

Premature Rupture of Membranes

Preterm Labor

Uterine Rupture in Pregnancy

Vaginitis

Vulvovaginitis

Workup

Workup

Approach Considerations
In the workup of vaginal bleeding in pregnancy, ultrasonographic visualization of placentation is critical. A digital examination
is contraindicated under these circumstances until placental location is determined secondary to the risk of massive
hemorrhage.

Additionally, a thorough abdominal examination to identify uterine tenderness can be useful in differentiating other causative
factors for vaginal bleeding, including uterine rupture and placental abruption. Ideally, placental location should be identified
during an anatomy scan between 18 and 20 weeks' gestation. In women with either placenta previa or a low-lying placenta,
a repeat ultrasonographic evaluation at 32 weeks is indicated for coordination of mode of delivery.

Laboratory Studies
The following laboratory tests are indicated in women with suspected placenta previa:

Rh compatibility test

levels of fibrin split products (FSP) and fibrinogen

Prothrombin time (PT)/activated partial thromboplastin time (aPTT)

Blood type and cross; hold for at least 4 units

Complete blood cell (CBC) count

Amniocentesis and fetal lung maturity testing, if necessary

Other tests that may be obtained include Kleihauer-Betke test, if there is concern about fetal-maternal transfusion.

Ultrasonography
An ultrasonographic evaluation of the fetus is valuable in identifying current gestational age and weight, potential congenital
anomalies, malpresentation, and evidence for fetal growth restriction. Ultrasonographic evaluation is also recommended in
identifying umbilical cord insertion and excluding a velamentous insertion.

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A second- or third-trimester ultrasonography performed for any reason should discover placenta previa if it is present. This is
one of the many reasons obstetricians are discouraged from performing limited or target scans in the absence of at least one
thorough anatomic assessment.

Transvaginal ultrasonography

Transvaginal ultrasonography is considered the gold standard for the diagnosis of placenta previa. This imaging modality is
accurate, cost-effective, and well tolerated. Several studies have been published indicating the superiority of transvaginal
scans (TVS) as compared to the transabdominal (TAS) approach. In an early study, the false-positive and false-negative
rates of TVS were 1.0 % and 2.0%, respectively, with rates of 7% and 8%, respectively, for TAS.[18, 19]

The angle between the transvaginal probe and the cervical canal is such that the probe does not enter the cervical canal.
Some clinicians advocate insertion of the probe no more than 3 cm for visualization of the placenta to avoid inadvertent
insertion into the cervical os.

Transvaginal ultrasonographic techniques can also be used to evaluate the cervical length, when indicated. Shortened
cervical lengths have been shown to have an association with need for emergent cesarean delivery at less than 34 weeks'
gestation secondary to severe hemorrhage.[20]

The distance between the placental edge and internal cervical os on transvaginal ultrasonography after 35 weeks’ gestation
is also valuable in planning the route of delivery. When the placental edge is greater than 2 cm from the internal cervical os,
women can be offered a trial of labor with a high expectation of success. However, a distance of less than 2 cm from the os
is associated with a higher cesarean rate, although vaginal delivery is still possible depending on the clinical circumstances.

Transabdominal ultrasonography

Transabdominal ultrasonography is a simple, precise, and safe method to visualize the placenta that can often be used in
conjunction with TVS when available. This imaging modality can also be used as an alternative to TVS; however, it is less
accurate, with the false-positive and false-negative rates reported as 7% and 8%, respectively.[18] In one study, 26% of
placenta previas diagnosed by transabdominal ultrasonography were found to be misdiagnosed when rescanned using TVS.
[21]

Transperineal/translabial ultrasonography

Transperineal/translabial ultrasonography has been suggested as another alternative to transvaginal ultrasonography,

especially when instrumentation of the vaginal canal with a probe is a concern. However, it is often deferred to the accuracy,
safety and tolerability of transvaginal ultrasonography.

A study suggests that this modality may compliment transabdominal ultrasonography and help to eliminate false-positive
results using the transabdominal method alone.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) may be used for planning the delivery in that it may help identify placenta accreta
(adherence of the placenta to myometrium), placenta increta (invasion through myometrium), or placenta percreta (invasion
all the way through the myometrium into serosa, frequently into the bladder). These invasive placental abnormalities are
becoming more common (eg, placenta accreta occurs in up to 0.2% of pregnancies) due to the increase in cesarean
deliveries,[22] advancing maternal age, hypertensive disease, smoking, and placenta previa cases.

Although in most situations MRI is no more sensitive in diagnosing placenta accreta than ultrasonography, it may be superior
for the posterior placenta accreta or the more invasive increta and percreta. For women at high risk for placenta accreta, a 2-
step protocol that uses ultrasonography first and then MRI for cases with inconclusive ultrasonographic features may
optimize diagnostic accuracy.[23]

A large trial determining the efficacy and safety of the use of MRI during pregnancy has not been performed, and further
investigation is required.[24, 25]

Treatment

Approach Considerations
Always anticipate massive hemorrhage and preterm delivery in a woman with placenta previa. Document adequate
preparation, including transfer to a higher level of care, if necessary.

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Hemostasis may be established by one or more of the following:

Oversewing the placental implantation site

Bilateral uterine artery ligation (O'Leary stitch)

Internal iliac artery ligation

Circular interrupted ligation around the lower uterine segment both above and below the transverse incision

Packing with gauze or tamponade with the Bakri balloon catheter

B-lynch stitch

Cesarean hysterectomy

Diffuse bleeding often occurs at the implantation site within the lower uterine segment after delivery. [26] As such,
knowledge in the management of acute and heavy blood loss is imperative. Activation of the massive transfusion protocol
may be warranted depending on the situation. The use of uterotonics, including methylergonovine maleate (Methergine), 15
methyl prostaglandin F2 alpha (Hemabate), concentrated oxytocin, or misoprostol are excellent pharmacological agents to
help resolve uterine atony, the main cause of hemorrhage post-delivery.

Other options include surgical management, as listed above. Often a combination of medical and surgical interventions are
utilized.

In instances where significant bleeding ensues, rapid replacement of blood products is a priority. In such instances,
activation of the Massive Transfusion Protocol is warranted, allowing for stabilization of a patients hemodynamic status by
way of rapid supply and infusion of blood products.

A study by Soyama et al that included 266 women with placenta previa evaluated the effectiveness of routine rapid insertion
of a Bakri balloon for placenta previa during cesarean section. The study reported smaller bleeding amounts in the Bakri
balloon group than in the non-balloon group: intraoperative bleeding (991 vs. 1250 g, p < 0.01), postoperative bleeding (62
vs. 150 g, p < 0.01), and total bleeding (1066 vs. 1451 g, p < 0.01). The study also found that surgical duration was shorter
in the balloon group than the non-balloon group (30 vs. 50 min, p < 0.01).[27]

Management of Vaginal Bleeding

Stepwise approach to managing 3rd trimester vaginal bleeding

Patient should be assessed in the labor and delivery unit and the focus should be on maternal hemodynamic stability and
fetal well-being. Evaluation should be initiated through close observation of maternal vital signs and initiation of electronic
fetal monitoring. Intravenous access is imperative and should be initiated the moment the patient is brought to the labor floor.
CBC and T&S should be sent to determine Hg level and possible need for administration of Rh immunoglobulin pending
maternal Rh status. If significant vaginal bleeding is noted during evaluation, blood should be cross matched in preparation
for rapid replacement of blood volume. Two to four units of blood may be required rather quickly, if hemorrhage ensues.
Initiation of massive transfusion protocol may be appropriate if rapid access to blood products is necessary.[15]

Once the patient is deemed stable and fetal well-being has been noted, etiology of the vaginal bleeding can be assessed.
Assessment of the placenta should be undertaken through ultrasound by either a transabdominal or transperineal approach.
Sterile speculum exam should follow to further assess the quantity and source of the bleeding. It is imperative that a digital
cervical exam is never performed in a patient with concern or ultrasound confirmed placenta previa as this may lead to
torrential hemorrhage due to disruption of the placenta and its vessels.[15]

Expectant management with close observation is indicated in situations where the fetal gestational age is less than 36weeks
of gestation as long as reassuring fetal monitoring is present and vaginal bleeding has resolved or significantly decreased.
Administration of betamethasone should be provided if gestational age is less than 34weeks. If bleeding is severe or non-
reassuring fetal monitoring is present then emergency cesarean delivery is indicated.[26]

Indications for hospitalization

For an otherwise uncomplicated pregnancy, continue expectant management in a woman with placenta previa until an
episode of bleeding occurs. Studies have not shown any difference regarding maternal or fetal morbidity with home
management versus hospitalization prior to the first bleed in these women. Any patient with suspected or known placenta
previa and new onset vaginal bleeding should be admitted to the hospital for close monitoring. It is challenging to
standardize the duration of a patients hospitalization given the episodic nature of the bleeding. Patients should be closely
monitored for a minimum of 48hours during a sentinel bleeding episode. [15] With certain patients, after the initial episode of
bleeding has resolved and fetal evaluation has noted to be reassuring, it is appropriate to undergo expectant mgmt. at
home. [26] Several studies have shown this to be a safe approach as long as certain criteria are met. [15] However, it is

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advisable to continue hospitalization in any patient with multiple episodes of bleeding or with those pts with limited access to
appropriate medical care if they were to be discharged. [26] At times this may result in hospitalization until delivery.

If bleeding persists and is heavy, preparation for immediate surgery is indicated. In cases where placental location remains
uncertain, a double setup examination—in which one management team is prepared for an uneventful vaginal delivery, and
a second team is prepared for an immediate cesarean delivery, as needed—may be considered.

Order clotting studies (ie, prothrombin time/activated partial thromboplastin time [PT/aPTT], fibrinogen) if concern arises for
disseminated intravascular coagulation (DIC).

Tocolysis

Tocolytics may be considered in cases of minimal bleeding and extreme prematurity in order to administer antenatal
corticosteroids. One study appeared to suggest that the use of tocolytics increases the duration of pregnancy and increases
the baby's birth weight without causing adverse effects on the mother and the fetus.[28] However, a review article by Bose et
al concluded that there is no improvement in perinatal outcome with prolonged tocolytics, and tocolysis beyond 48 hours is
not clinically indicated.[16]

If more than one episode of bleeding occurs during gestation (at viability or >24 wk), the clinician should consider
hospitalization until delivery, given the increased potential for placental abruption and fetal demise.

Mode of delivery

In general, mode of delivery is directed by the proximity of the leading edge of the placenta in relation to the internal os of
the cervix. Several professional organizations and previous studies have recommended elective cesarean delivery when the
placenta is les than 2 cm from the internal os. In a retrospective study of 121 pregnancies complicated by placenta previa,
90% of pregnancies with placental edge-to-cervical os distance of 1-2 cm resulted in cesarean deliveries.

Another consideration is the distance to the internal cervical os and the mode of delivery. In general, women with a placental
edge–to–cervical os distance that is greater than 2 cm from the internal cervical os can be offered a trial of labor.[29]
However, a more recent study by Vergani et al reported that more than two thirds of women with placenta previa who have a
placental edge–to–cervical os distance greater than 1 cm deliver vaginally without an increased risk of hemorrhage.[30] The
decision to proceed with a trial of labor should be made on an individualized basis at a center that provides 24-hour
anesthesia, in-house obstetricians, and trauma blood transfusion protocols.

Surgical Intervention
There is limited data to guide management and as such optimal timing of delivery is controversial. However, in patients with
uncomplicated placenta previa, delivery is recommended in the late preterm period between 36weeks 0days to 37weeks
0days of gestation. [31] This provides for the lowest possible risk of bleeding due to labor while also decreasing the risks of
prematurity for the fetus.

Earlier delivery may be warranted, however, based on bleeding profile, previous bleeding history, or preterm labor. [26] Each
patient and their situation must be taken into individual account.

As noted earlier, the distance between the placental edge and internal cervical os on transvaginal ultrasonography after 35
weeks’ gestation is valuable in planning route of delivery. In general, there is a higher cesarean rate associated with
placental edge–to–cervical os distances of less than 2 cm.

In performing cesarean delivery for placenta previa, a low transverse uterine incision is most often used. However, a vertical
uterine incision may be considered secondary to an anterior placenta and risk of fetal bleeding.

Invasive placentations

If the patient is at increased risk for invasive placentation (accreta, increta, or percreta), then the patient and surgical team
must be prepared prior to delivery. These invasive placentations carry a high mortality rate (7% with placenta accreta) as
well as a high morbidity rate (blood transfusion, infection, adjacent organ damage).

Traditionally, uterine atony was the most common cause of cesarean hysterectomy; however, a meta-analysis by Machado
showed that abnormal placentation is the most common cause, occurring in up to 45% of cesarean hysterectomies.[32] Risk
for cesarean hysterectomy is increased by the presence of complete placenta previa and a history of cesarean delivery or
prior abortion.[33]

Controlling blood loss

These complicated pregnancies must have delivery plans that include patient-matched blood and informed consent for
possible cesarean hysterectomy. Predelivery placement of balloon catheters for angiographic embolization of pelvic vessels

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is a technique described in reducing blood loss associated with cesarean hysterectomy and provides the opportunity to
manage potential postoperative bleeding with embolization rather than operative re-exploration.[15]

Aortic balloon occlusion prior to cesarean hysterectomy has also been demonstrated to reduce blood loss.[34] Other means
to control hemorrhage include the following:

B-Lynch or parallel vertical compression sutures

Uterine artery ligation (O'Leary stitch)

Hypogastric artery ligation

Hysterectomy

In the case of a small and focal placenta accreta, resection of the implantation site and primary repair may allow for uterine
preservation.

Consultations
Women with placental previa are considered to have high-risk pregnancies, and a multidisciplinary team is involved in their
management, including specialists in the following areas:

Obstetrics

Obstetric anesthesiology

Interventional radiology

Surgical oncology or general surgery, if extensive surgical dissection is anticipated

Gynecologic oncology

Urology, if significant involvement of the bladder is anticipated

Guidelines

Guidelines Summary
The Society of Obstetricians and Gynaecologists of Canada have published the following recommendations[35] :

History of antepartum hemorrhage (first episode < 29 wk or recurrent episodes [≥3]), a thick placental edge covering
(or close to) the cervical os, short cervical length (< 3 cm with placenta previa, < 2 cm with low-lying placenta), and a
previous cesarean delivery are risk factors with an associated increased risk of urgent/preterm cesarean delivery.
Preoperative bedside ultrasound assessment of placental location can be useful for planning of surgical technique
and may reduce risk of intraoperative transection of placenta.
When deciding the location of delivery, consider ultrasound assessment of placental location, any risk factors, the
patient's history, and logistical factors, including available resources at the delivery unit.
Diagnosis of placenta previa or low-lying placenta should not be made < 18 to 20 wk gestation, and the provisional
diagnosis must be confirmed after >32 wk gestation, or earlier if the clinical situation warrants. In women with a low-
lying placenta, a recent ultrasound scan (within 7-14 days) should be used to confirm placental location before a
cesarean delivery.
Assessment by transvaginal ultrasound is recommended in all cases where placenta previa or a low-lying placenta is
present or suspected by transabdominal ultrasonography, with attempt to clearly define placental location (including
laterality), characteristics of placental edge (including thickness, presence of a marginal sinus), and associated
findings (succenturiate lobe, cord insertion close to the cervix).
Cervical cerclage is not recommended as a preventive measure for all women with placenta previa; however, it can
be considered for women who have a short cervix, particularly those with antepartum hemorrhage.
Reserve the use of antenatal corticosteroids for women in whom the risk of preterm delivery within 7 days is very
high.
Tocolysis is an option to permit corticosteroid administration or transfer of care in women with antepartum
hemorrhage associated with uterine contractions, but tocolytics should not be used to prolong pregnancy.
Cesarean delivery is recommended for women with placenta previa who have risk factors at 36 weeks of gestation
and for those who do not have risk factors at 37 weeks of gestation.
Cesarean delivery is also recommended for women who have a low-lying placenta and a placental edge ≤10 mm
from the cervical os at 37 weeks of gestation if risk factors are present and at 38 weeks of gestation if no risk factors

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are present.
For women who have a low-lying placenta and a placental edge that is 11-20 mm from the cervical os, a trial of labor
is recommended.

Medication

Medication Summary
No medication is of specific benefit to a patient with placenta previa. Tocolysis may be cautiously considered in some
circumstances in order to administer antenatal corticosteroids. A review article concluded that there is no improvement in
perinatal outcome with prolonged tocolytics, and tocolysis beyond 48 hours is not clinically indicated.[16]

Encourage patients with known placenta previa to maintain intake of iron and folate as a safety margin in the event of
bleeding.

There have been studies that report using prothrombin complex and recombinant factor VII to control hemorrhage
associated with obstetric complications and placenta previa.

Tocolytics

Class Summary
Tocolytic agents prevent preterm labor or contractions. Some specialists advocate tocolytics to promote the time for
expectant management of symptomatic placenta previa. They should only be used after consultation with an obstetrician.

Magnesium sulfate
Magnesium sulfate is a nutritional supplement in hyperalimentation. It is a cofactor in enzyme systems involved in
neurochemical transmission and muscular excitability. In adults, 60-180 mEq of potassium, 10-30 mEq of magnesium, and
10-40 mEq of phosphate per day may be necessary for optimum metabolic response.

Administer magnesium sulfate intravenously (IV) or intramuscularly (IM) for seizure prophylaxis in preeclampsia. Use the IV
route for a quicker onset of action in true eclampsia. Discontinue treatment as soon as the desired effect is obtained. Repeat
the doses, depending on the continuing presence of a patellar reflex and adequate respiratory function.

Corticosteroids

Class Summary
Steroids may be administered after consultation with a gynecologist, if vaginal bleeding is mild and intermittent, if the patient
is not in labor, and if gestation is less than 37 weeks.

Dexamethasone acetate (Baycadron)

Dexamethasone may be given to promote the development of the lungs in the fetus.

Betamethasone (Celestone)
Betamethasone helps to promote fetal lung maturity.

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Adrenergic Agonists

Class Summary
These agents have sympathomimetic vasopressor activity.

Terbutaline (Brethine)
Terbutaline acts directly on beta2-receptors to relax uterine contractions.

Contributor Information and Disclosures

Author

Ronan Bakker, MD Maternal-Fetal Medicine Specialist, The Perinatal Center

Ronan Bakker, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists,
American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia
Commonwealth University School of Medicine

Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists,
American Institute of Ultrasound in Medicine, Medical Society of Virginia, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

John G Pierce, Jr, MD Chairman of Women’s Health and Medical Specialties, Liberty University College of Osteopathic
Medicine; Obstetrician/Gynecologist, Women’s Health of Central Virginia

John G Pierce, Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists,
Association of Professors of Gynecology and Obstetrics, Christian Medical and Dental Associations, Medical Society of
Virginia, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department
of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center

Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists,
American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of
Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Council of University Chairs of Obstetrics and
Gynecology, Nebraska Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Saju Joy, MD, MS Associate Director, Division Chief of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,
Carolinas Medical Center

Saju Joy, MD, MS is a member of the following medical societies: American College of Obstetricians and Gynecologists,
American Institute of Ultrasound in Medicine, Society for Maternal-Fetal Medicine, American Medical Association

Disclosure: Nothing to disclose.

Matthew M Finneran, MD Resident Physician, Department of Obstetrics and Gynecology, Carolinas Healthcare System

https://emedicine.medscape.com/article/262063-print 12/15
2/5/24, 5:58 PM emedicine.medscape.com/article/262063-print
Disclosure: Nothing to disclose.

Acknowledgements

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen
School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American
College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Patrick Ko, MD Clinical Assistant Professor, Department of Emergency Medicine, New York University Medical School;
Assistant Program Director, Department of Emergency Medicine, North Shore University Hospital

Patrick Ko, MD is a member of the following medical societies: American College of Emergency Physicians and Society for
Academic Emergency Medicine

Disclosure: Nothing to disclose.

Deborah Lyon, MD Director, Division of Gynecology, Associate Professor, Department of Obstetrics and Gynecology,
University of Florida Health Science Center at Jacksonville

Deborah Lyon, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists,
Association of American Medical Colleges, Association of Professors of Gynecology and Obstetrics, and Florida Medical
Association

Disclosure: Nothing to disclose.

John G Pierce Jr, MD Associate Professor, Departments of Obstetrics/Gynecology and Internal Medicine, Medical College of
Virginia at Virginia Commonwealth University

John G Pierce Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists,
Association of Professors of Gynecology and Obstetrics, Christian Medical & Dental Society, Medical Society of Virginia, and
Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Joseph J Sachter, MD, FACEP Consulting Staff, Department of Emergency Medicine, Muhlenberg Regional Medical Center

Joseph J Sachter, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine,
American College of Emergency Physicians, American College of Physician Executives, American Medical Association, and
Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ryan A Stone, MD Fellow, Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Section, Wake Forest
University Health Sciences

Ryan A Stone, MD is a member of the following medical societies: Academic Pediatric Association, American College of
Obstetricians and Gynecologists, American Medical Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy;
Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Lorene Temming, MD Resident Physician, Department of Obstetrics and Gynecology, Carolinas Medical Center

Lorene Temming, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists
and North Carolina Medical Society

Disclosure: Nothing to disclose.

Young Yoon, MD Associate Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai Medical Center

Young Yoon, MD is a member of the following medical societies: Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas
Jefferson University
https://emedicine.medscape.com/article/262063-print 13/15
2/5/24, 5:58 PM emedicine.medscape.com/article/262063-print
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine,
American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

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