Ultrasound Obstet Gynecol 2024; 63: 128–130

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.27505

Picture of the Month

Evolution from placenta previa to Type-3 vasa previa

Y. OYELESE1,2
1
Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical
School, Boston, MA, USA; 2 Maternal Fetal Care Center (MFCC), Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA

A number of recent publications have described Type-3

vasa previa, a variant of vasa previa in which fetal vessels
run unprotected over the cervix from one placental edge
to another in a placenta that does not have a velamentous
cord insertion or accessory lobes1–3 . Because most cases
of Type-3 vasa previa have a normal cord insertion,
relying merely on the identification of a velamentous
cord insertion or the presence of accessory lobes as risk
factors for vasa previa will inevitably miss some cases,
potentially leading to avoidable perinatal death. Thus,
all professionals involved in imaging in pregnancy should
be aware of this variant. Herein is presented a case of
Type-3 vasa previa, illustrated by two-dimensional and
three-dimensional (3D) ultrasound images that informed
the diagnosis.
A 32-year-old patient, gravida 2 para 1, presented for a Figure 1 Transabdominal ultrasound image with color Doppler in
fetal anatomy ultrasound survey at 20 weeks of gestation. sagittal plane, showing central cord insertion into anterior placenta.
Fetal biometry and anatomy were normal. The placental
cord insertion was noted to be normal and central in the
anterior placenta (Figure 1). On transabdominal Doppler
imaging in the sagittal plane, there appeared initially to be
a bilobed placenta previa with an anterior and a posterior
lobe joined by a fetal vessel that ran over the internal
os (Figure 2). However, closer examination with both a
transabdominal sweep of the lower uterine segment and
transvaginal sonography revealed that there was a left
lateral placenta previa with a single placental mass, and
that a fetal vessel ran on the medial edge of the placenta
which covered the internal os. Transvaginal ultrasound
imaging showed that this vessel was not unprotected, but
rather ran on the surface of the thin rim of the placenta
overlying the cervix (Figure 3). As such, the condition was
not vasa previa, but rather placenta previa. Transvaginal
ultrasound imaging with color, power and pulsed-wave
Doppler showed a fetal arterial waveform in this vessel.
At 32 weeks of gestation, the patient underwent a repeat
ultrasound examination. On transvaginal 3D ultrasound Figure 2 Transabdominal ultrasound image with color Doppler in
imaging with color Doppler angiography in the sagittal sagittal plane, demonstrating what appears to be an anterior
plane, three fetal vessels were noted to run under the placental lobe (A) and posterior placental lobe (P) with fetal vessel
fetal head and over the cervix (Figures 4 and 5). These running over cervix (C). B, bladder.

Correspondence to: Dr Y. Oyelese, Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess
Medical Center, 330 Brookline Avenue, KS3, Boston, MA 02215, USA (e-mail: koyelese@bidmc.harvard.edu)

© 2023 International Society of Ultrasound in Obstetrics and Gynecology. PICTURE OF THE MONTH
Picture of the Month
Figure 3 Grayscale transvaginal ultrasound image of cervix
(calipers), showing placental tissue overlying cervix, with fetal
vessel (hypoechogenic linear structure) on placental surface.
Figure 4 Transvaginal ultrasound image with color Doppler in
sagittal plane, showing fetal vessel running over cervix (C).
fetal vessels over the cervix were found to no longer have
underlying placental tissue and a diagnosis of Type-3
vasa previa was made. This diagnosis was made rather
than Type-2 vasa previa because it had been established
previously that there were no accessory lobes. Pulsed-wave
Doppler revealed that one of the vessels was a fetal vein
while two were fetal arteries. Again, the cord insertion
was noted to be central into the main lobe of the placenta,
which was anterior.
The patient was admitted to hospital at 33 weeks of
gestation and underwent a scheduled Cesarean delivery
at 36 weeks. The neonate had a birth weight of 2490 g
and Apgar scores of 9 and 9 at 1 and 5 min, respectively.
Examination of the placenta confirmed Type-3 vasa previa
(Figure 6). The cord insertion was central; however, from
one edge of the placenta, three unprotected fetal vessels
ran into the fetal membranes and returned into another
edge of the placenta.
Vasa previa, defined as unprotected fetal vessels
traversing the membranes over the cervix, is a condition
that is associated with high perinatal mortality when
undiagnosed prenatally4 . Delivery by Cesarean section
© 2023 International Society of Ultrasound in Obstetrics and Gynecology.
129
Figure 5 Transvaginal three-dimensional ultrasound image with
color Doppler angiography in sagittal plane, demonstrating three
fetal vessels running below fetal head.
Figure 6 Photograph of placenta after delivery, showing central
cord insertion and three vessels running through membranes from
one edge of placenta to another (right side of image), confirming
diagnosis of Type-3 vasa previa.
prior to rupture of the membranes largely prevents
perinatal death4–6 . Several studies have documented the
feasibility of screening routinely for vasa previa and the
impact of screening in preventing death4,7,8 . Consensus
guidelines recommend sonographic examination of the
placental cord insertion when feasible4 . While most
early reports indicated that vasa previa results from
velamentous cord insertion, Catanzarite and colleagues
first described in 2001 Type-2 vasa previa, in which
the cord insertion was normal but unprotected fetal
vessels ran through the membranes between the main
placental mass and an accessory lobe9 . In 2004, we
described a variant of vasa previa in which there was
a normal cord insertion and a single placental lobe,
Ultrasound Obstet Gynecol 2024; 63: 128–130.
130
but fetal vessels ran from one edge of the placenta to
another10 . This was subsequently termed ‘Type-3 vasa
previa’1–3 . We hypothesized that this variant arose from
placenta previa in early pregnancy, followed by atrophy
of the placental tissue overlying the cervix, leaving behind
unprotected fetal vessels running over the cervix10 . Serial
ultrasound examinations in the patient described above
support this hypothesis. Initially, placenta previa was
observed, with just a thin rim of placental edge overlying
the cervix. Subsequently, with advancing gestation, this
placental tissue underwent atrophy, leaving behind three
exposed vessels. The three vessels seen running through
the placenta after delivery were remarkably similar to
those seen on 3D color Doppler angiography (Figures 5
and 6).
This report should help to improve our understanding
of the pathophysiology of vasa previa, particularly Type
3. It has been hypothesized previously that some cases
of vasa previa arise when placental tissue overlying the
cervix in a pregnancy with placenta previa or a low-lying
placenta undergoes atrophy with advancing gestation4 .
Indeed, studies indicate that approximately 60% of
patients with vasa previa at delivery had a low-lying
placenta or placenta previa in the second trimester4,6,11 .
This report illustrates that merely identifying the placental
cord insertion is insufficient to screen for vasa previa.
Pregnancies with Type-2 and Type-3 vasa previa will
have a normal or marginal placental cord insertion. As
such, I recommend a Doppler sweep of the lower uterine
segment in all pregnancies4 . Finally, I advise that all
patients with second-trimester placenta previa undergo
© 2023 International Society of Ultrasound in Obstetrics and Gynecology.
Oyelese
transvaginal ultrasound assessment with Doppler imaging
at around 32 weeks of gestation to rule out vasa previa.
Disclosure
Y.O. has received royalties as an author on placental
abruption from UpToDate and BMJ Best Practice.
References
1. Pozzoni M, Sammaria C, Villanacci R, Borgese C, Ghisleri F, Farina A, Candiani M,
Cavoretto PI. Prenatal diagnosis and postnatal outcome of type III vasa previa:
systematic review of literature. Ultrasound Obstet Gynecol 2024; 63: 24–33.
2. Takemoto Y, Matsuzaki S, Matsuzaki S, Kakuda M, Lee M, Hayashida H, Maeda M,
Kamiura S. Current evidence on vasa previa without velamentous cord insertion or
placental morphological anomalies (type III vasa previa): systematic review and
meta-analysis. Biomedicines 2023; 11: 152.
3. Kamijo K, Miyamoto T, Ando H, Tanaka Y, Kikuchi N, Shinagawa M, Yamada S,
Asaka R, Fuseya C, Ohira S, Shiozawa T. Clinical characteristics of a novel ”Type
3” vasa previa: case series at a single center. J Matern Fetal Neonatal Med 2022; 35:
7730–7736.
4. Oyelese Y, Javinani A, Shamshirsaz AA. Vasa previa. Obstet Gynecol 2023; 142:
503–518.
5. Oyelese Y, Lees CC, Jauniaux E. The case for screening for vasa previa: time to
implement a life-saving strategy. Ultrasound Obstet Gynecol 2023; 61: 7–11.
6. Oyelese Y, Catanzarite V, Prefumo F, Lashley S, Schachter M, Tovbin Y, Goldstein V,
Smulian JC. Vasa previa: the impact of prenatal diagnosis on outcomes. Obstet
Gynecol 2004; 103: 937–942.
7. Zhang W, Geris S, Beta J, Ramadan G, Nicolaides KH, Akolekar R. Prevention of
stillbirth: impact of two-stage screening for vasa previa. Ultrasound Obstet Gynecol
2020; 55: 605–612.
8. Gross A, Markota Ajd B, Specht C, Scheier M. Systematic screening for vasa previa
at the 20-week anomaly scan. Acta Obstet Gynecol Scand 2021; 100: 1694–1699.
9. Catanzarite V, Maida C, Thomas W, Mendoza A, Stanco L, Piacquadio KM. Prenatal
sonographic diagnosis of vasa previa: ultrasound findings and obstetric outcome in
ten cases. Ultrasound Obstet Gynecol 2001; 18: 109–115.
10. Oyelese Y, Chavez MR, Yeo L, Giannina G, Kontopoulos EV, Smulian JC, Scorza
WE. Three-dimensional sonographic diagnosis of vasa previa. Ultrasound Obstet
Gynecol 2004; 24: 211–215.
11. Pavalagantharajah S, Villani LA, D’Souza R. Vasa previa and associated risk factors:
a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2020; 2: 100117.
Ultrasound Obstet Gynecol 2024; 63: 128–130.