Placenta Previa

Background
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.

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 bleedingcontractionsplacental
separationbleeding.

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
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%)
Nonwhite ethnicity
Low socioeconomic status
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).

Symptoms
Bright red vaginal bleeding without pain during the second half of pregnancy
is the main sign of placenta previa. Bleeding ranges from light to heavy. The

bleeding usually stops without treatment, but it nearly always returns days
or weeks later. Some women also experience contractions.

When to see a doctor

If you have vaginal bleeding during your second or third trimester, call your
doctor right away. If the bleeding is severe, seek emergency medical care.

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]
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.
[5, 6]

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. [7, 8] 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.[9]
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]
There is a significant increase in the risk of postpartum hemorrhage and
need for emergency hysterectomy in women with placenta previa.[10]
Maternal complications of placenta previa are summarized as follows:

Hemorrhage, 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
Placental abruption
Preterm delivery
Increased incidence of postpartum endometritis
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 ofdisseminated intravascular coagulopathy
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
Morbidities

Relative Risk

Antepartum bleeding

10

Need for hysterectomy

33

Blood transfusion

10

Septicemia

5.5

Thrombophlebitis

Endometritis

6.6[12]

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) [12]
Neonatal respiratory distress syndrome [12]
Jaundice [12]
Admission to the neonatal intensive care unit (NICU) [12]
Longer hospital stay [12]
Increased risk for infant neurodevelopmental delay and sudden infant
death syndrome (SIDS) [13]
Neonatal mortality rate: As high as 1.2% in the United States [14]

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

Treatments and drugs

Treatment for placenta previa depends on various factors, including:

The amount of bleeding

Whether the bleeding has stopped

How far along your pregnancy is

Your health

Your baby's health

The position of the placenta and the baby

For little or no bleeding

If you have little or no bleeding, your health care provider may recommend
bed rest at home. In some cases, you may need to lie in bed most of the
time sitting and standing only when necessary.
You'll need to avoid sex, which can trigger bleeding. Exercise is usually offlimits, too. Be prepared to seek emergency medical care if you begin to
bleed. You'll need to be able to get to the hospital quickly if bleeding
resumes or gets heavier.
If the placenta doesn't completely cover your cervix, you may be allowed to
attempt a vaginal delivery. If you begin to bleed heavily, you may need an
emergency C-section.
For heavy bleeding
If you're bleeding, you may need hospital bed rest. Severe bleeding may
require a blood transfusion to replace lost blood. You may also benefit from
medications to prevent premature labor.
Your health care provider will likely plan a C-section as soon as the baby can
be delivered safely, ideally after 36 weeks of pregnancy. If you need a Csection before 36 weeks, you may be given corticosteroids to speed your
baby's lung development.

For bleeding that won't stop

If your bleeding can't be controlled or your baby is in distress, you may need
an emergency C-section even if the baby is premature.