Beruflich Dokumente
Kultur Dokumente
Larry C. Gilstrap M.D. Center for Perinatal and Womens Health Research,
Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX.
Address reprint requests to Sean C. Blackwell, MD, Larry C. Gilstrap M.D.
Center for Perinatal and Womens Health Research, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas
Health Science Center at Houston, Houston, TX 77030. E-mail:
Sean.blackwell@uth.tmc.edu
Placenta previa is associated with PTB. In a U.S. population-based study of live births, approximately 16.9% of
women with placenta previa deliver 34 weeks, 27.5% deliver 34-37 weeks, and 55.6% occur 37 weeks7 Stafford
and colleagues9 found that women with placenta previa and a
midtrimester cervical length 30 mm delivered 34 weeks,
34-37 weeks, and 37 weeks in 45%, 24%, and 31% cases,
respectfully. Interestingly, 76% of these women had an emergent cesarean delivery (emergent delivery occurred in 28% of
women with a cervix 30 mm). Unfortunately, most studies
in which the authors reported outcomes of placenta previa,
they did not clarify what proportion of women who have
LPTB or ETB required emergent care and delivery because of
maternal bleeding vs what proportion were scheduled and
delivery was performed under controlled circumstances.
Table 1 summarizes the potential advantages of scheduled
LPTB in asymptomatic women with placenta previa. The primary advantage of earlier delivery is that it decreases the
probability of a woman presenting with acute hemorrhage
and need for emergent cesarean delivery. In fact, catastrophic
blood loss can rapidly lead to maternal cardiovascular decompensation (shock) and disseminated intravascular coagulopathy. Mobilization of resources (eg, blood bank, anesthesia, surgical) may not be prompt enough to avoid major
maternal and/or neonatal morbidities. However, if delivery is
performed under optimal circumstances (eg, in asymptomatic state with ready availability of resources), the risk of
complications may be lower. The benefits of lower surgical
complication rates with scheduled compared with emergent
249
S.C. Blackwell
250
Table 1 Potential Benefits of Iatrogenic LPTB in Women with
Placenta Previa: Advantages of Earlier Delivery
Decrease probability of cesarean delivery with an unstable
patient
Avoid presentation with hemorrhage (anemia, shock),
labor, fetal compromise
Avoid unexpected presentation at a nontertiary care
hospital
Avoid cesarean delivery under emergent circumstances
Optimize availability of hospital resources
OR resources (surgeons, surgical assistants, anesthesia)
Blood bank and blood products
Consultants
Reduce potential conflict of responsibilities from other
patient care activities
Other laboring patients
Other surgical procedures
LPTB, late preterm birth; OR, operating room.
Figure 1 Conceptual diagram that presents the trade-off of maternal and neonatal risks and benefits related to the timing
of delivery for women with stable placenta previa.
251
Maternal emergent
Fetal/neonatal13
NICU admission
Need for mechanical ventilation
Neonatal mortality
34 weeks
35 weeks
36 weeks
37 weeks
38 weeks
39 weeks
4.7%
15.0%
29.9%
58.6%
87.2%
67.4%
6.6%
0.8%
42.4%
4.5%
0.4%
22.1%
3%
0.3%
11.8%
1.1%
0.2%
7.2%
0.5%
0.1%
6.1%
0.3%
0.1%
In women with uncomplicated complete placenta previa, scheduled delivery between 36 and 37 weeks
should be considered.
In women with a placenta previa with additional comorbidities (eg, high body mass index, multiple previous
cesarean deliveries) or complicated clinical course (eg,
episode[s] of vaginal bleeding), earlier delivery may be
necessary and should be individualized.
References
1. Oyelese Y, Smulian JC: Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 107:927-941, 2006
2. Choi SJ, Song SE, Jung KL, et al: Antepartum risk factors associated
with peripartum cesarean hysterectomy in women with placenta previa. Am J Perinatol 25:37-41, 2008
3. Grobman WA, Gersnoviez R, Landon MB, et al: Pregnancy outcomes
for women with placenta previa in relation to the number of prior
cesarean deliveries. Obstet Gynecol 110:1249-1255, 2007
4. Crane JM, Van den Hof MC, Dodds L, et al: Maternal complications
with placenta previa. Am J Perinatol 17:101-105, 2000
5. Iyasu S, Saftlas AK, Rowley DL, et al: The epidemiology of placenta
previa in the United States, 1979 through 1987. Am J Obstet Gynecol
168:1424-1429, 1993
6. Zlatnik MG, Little SE, Kohli P, et al: When should women with placenta
previa be delivered? A decision analysis. J Reprod Med 55:373-381,
2010
7. Ananth CV, Smulian JC, Vintzileos AM: The effect of placenta previa on
neonatal mortality: A population-based study in the United States,
1989 through 1997. Am J Obstet Gynecol 188:1299-1304, 2003
8. Wing DA, Paul RH, Millar LK: Management of the symptomatic placenta previa: A randomized, controlled trial of inpatient versus outpatient expectant management. Am J Obstet Gynecol 175:806-811, 1996
9. Stafford IA, Dashe JS, Shivvers SA, et al: Ultrasonographic cervical
length and risk of hemorrhage in pregnancies with placenta previa.
Obstet Gynecol 116:595-600, 2010
10. Seubert DE, Stetzer BP, Wolfe HM, et al: Delivery of the marginally
preterm infant: What are the minor morbidities? Am J Obstet Gynecol
181:1087-1091, 1999
11. McIntire DD, Leveno KJ: Neonatal mortality and morbidity rates in late
preterm births compared with births at term. Obstet Gynecol 111:3541, 2008
12. Zlatnik MG, Cheng YW, Norton ME, et al: Placenta previa and the risk
of preterm delivery. J Matern Fetal Neonat Med 20:719-723, 2007
13. Hibbard JU, Wilkins I, Sun L, et al: Respiratory morbidity in late preterm births. JAMA 304:419-425, 2010
14. Joseph KS: Theory of obstetrics: An epidemiologic framework for justifying medically indicated early delivery. BMC Pregnancy Childbirth
7:4, 2007