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Placenta previa is a condition in which the placenta is located low in the uterine cavity, partially

or completely covering the opening of the cervix. This can cause bleeding and interfere with a
normal vaginal delivery. It occurs in about 1 in every 200 pregnancies.

Although the cause of placenta previa is unknown, some experts believe that placental
implantation cannot take place on the same part of the uterine wall more than once. If a woman
has had several pregnancies, the lower part of the uterus may be the only place left on which the
placenta can become implanted. That would explain why placenta previa is more common in
women who have had previous pregnancies.

There are three types of placenta previa: complete, in which the cervix is completely covered;
partial, in which only a portion of the cervix is covered; and low-lying or marginal, in which the
placenta does not cover the cervix but is close enough to it to potentially interfere with delivery.
A normal vaginal delivery cannot be attempted with any type of placenta previa because extreme
hemorrhage will occur. For this reason, babies of most mothers with placenta previa are
delivered by means of cesarian section.

The major symptom of placenta previa is painless vaginal bleeding. Bleeding may begin as early
as the 24th to 26th week, though it is more common during the last 4 or 5 weeks. As the lower
portion of the uterus stretches and dilates during the later weeks of pregnancy, portions of the
placenta may be torn from their attachments to the wall of the uterus. This leads to bleeding in
variable amounts, ranging from light to profuse.

The blood is usually bright red, indicating the bleeding is fresh. It is not associated with any
previous injury, such as a fall. And abdominal pain or cramping does not usually accompany the
bleeding unless the woman is in labor.

Since any vaginal bleeding during pregnancy is abnormal, it should be reported immediately to
your physician. The doctor will order an ultrasound image of your abdomen to locate the
placenta. In most cases of placenta previa, the ultrasound shows the placenta covering part or all
of the opening of the cervix.

Once placenta previa has been diagnosed, the degree of vaginal bleeding usually dictates the type
of treatment, either delayed or active. If vaginal bleeding is slight, delayed treatment is generally
chosen because it allows the fetus time to mature enough to survive outside the mother's body.
Delayed treatment involves admitting the woman to the hospital, keeping her on bedrest, and
closely monitoring her for any recurrence of bleeding. When it is time to deliver the baby, a
cesarian section will be performed.

If vaginal bleeding is heavy, it can lead to severe blood loss from the mother. The bleeding only
stops after the baby has been delivered and the placenta has been removed. This requires active
treatment to save the life of the mother and baby, even if the baby is premature. A cesarian
section will be performed immediately if vaginal bleeding from placenta previa is heavy.

Placenta previa

Classification and external resources

Diagram showing a placenta praevia (Grade IV)

ICD-10 O44, P02.0

ICD-9 641.0, 641.1

MedlinePlus 000900

MeSH D010923

Placenta praevia (placenta previa AE) is an obstetric complication in which the placenta is
inserted partially or wholly in lower uterine segment.[1] It can sometimes occur in the later part
of the first trimester, but usually during the second or third. It is a leading cause of antepartum
haemorrhage (vaginal bleeding). It affects approximately 0.4-0.5% of all labours.[2]

In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment.
In a normal pregnancy the placenta does not overlie. If the placenta does overlie the lower
segment, as is the case with placenta praevia, it may shear off and a small section may bleed.

Contents [hide]

1 Etiopathogenesis

1.1 Grades

1.2 Risk factors

2 Clinical features

3 Diagnosis

3.1 Clinical

3.2 Confirmatory

4 Management

4.1 Mode of delivery

5 Complications

5.1 Maternal

5.2 Fetal

6 Epidemiology

7 History
8 References

Etiopathogenesis[edit]

Exact etiology of placenta praevia is unknown. It is hypothesized to be related to abnormal


vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery,
or infection. These factors may reduce differential growth of lower segment, resulting in less
upward shift in placental position as pregnancy advances.[3]

Grades[edit]

Traditionally, four grades of placenta praevia are defined:[1]

Grade Description

I Placenta is in lower segment, but the lower edge does not reach internal os

II Lower edge of placenta reaches internal os, but does not cover it

III Placenta covers internal os partially

IV Placenta covers internal os completely

Risk factors[edit]

Risk factors with their odds ratio[4]

Risk factor Odds ratio

Maternal age 40 (vs. < 20) 9.1

Illicit drugs 2.8

1 previous Cesarean section2.7

Parity 5 (vs. para 0) 2.3

Parity 24 (vs. para 0)1.9

Prior abortion 1.9

Smoking 1.6

Congenital anomalies 1.7

Male fetus (vs. female) 1.1

Pregnancy-induced hypertension 0.4

The following have been identified as risk factors for placenta praevia:

Previous placenta previa (recurrence rate 4-8%),[5] caesarean delivery,[6] myomectomy[7] or


endometrium damage caused by D&C.[5]

Alcohol use during pregnancy.[8]

Women who have had previous pregnancies, especially a large number of closely spaced
pregnancies, are at higher risk due to uterine damage.[7]
Smoking during pregnancy;[1] cocaine use during pregnancy[9][10]

Women who are younger than 20 are at higher risk and women older than 35 are at increasing
risk as they get older.

Women with a large placentae from twins or erythroblastosis are at higher risk.

Race is a controversial risk factor, with some studies finding that people from Asia and Africa are
at higher risk and others finding no difference.

Placental pathology (Vellamentous insertion, succinturiate lobes, bipartite i.e. bilobed placenta
etc.)[5]

Placenta previa is itself a risk factor of placenta accreta.

Read a personal account of complete Placenta Previa for more information.

Clinical features[edit]

Women with placenta previa often present with painless, bright red vaginal bleeding. This
commonly occurs around 32 weeks of gestation, but can be as early as late mid-trimester.[11]
This bleeding often starts mildly and may increase as the area of placental separation increases.
Praevia should be suspected if there is bleeding after 24 weeks of gestation.

Women may also present as a case of failure of engagement of fetal head.[7]

Diagnosis[edit]

Clinical[edit]

History may reveal antepartum hemorrhage. Abdominal examination and usually finds the uterus
non-tender, soft and relaxed. Leopold's Maneuvers may find the fetus in an oblique or breech
position or lying transverse as a result of the abnormal position of the placenta. Malpresentation
is found in about 35% cases.[12] Vaginal examinaton is avoided in known cases of placenta
praevia.[1]

Confirmatory[edit]

Previa can be confirmed with an ultrasound.[13] Transvaginal ultrasound has superior accuracy
as compared to transabdominal one, thus allowing measurement of distance between placenta
and cervical os. This has rendered traditional classification of placenta praevia obsolete.[14][15]
[16][17]

False positives may be due to following reasons:[18]

Overfilled bladder compressing lower uterine segment

Myometrial contraction simulating placental tissue in abnormally low location

Early pregnancy low position, which in third trimester may be entirely normal due to differential
growth of the uterus.

In such cases, repeat scanning is done after an interval of 1530 minutes.


In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the
diagnosis with an examination in the surgical theatre. The proper timing of an examination in
theatre is important. If the woman is not bleeding severely she can be managed non-operatively
until the 36th week. By this time the baby's chance of survival is as good as at full term.

Management[edit]

An initial assessment to determine the status of the mother and fetus is required. Although
mothers used to be treated in the hospital from the first bleeding episode until birth, it is now
considered safe to treat placenta praevia on an outpatient basis if the fetus is at less than 30
weeks of gestation, and neither the mother nor the fetus are in distress. Immediate delivery of the
fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood
volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain
fibrinogen levels) may be necessary.

Mode of delivery[edit]

The mode of delivery is determined by clinical state of the mother, fetus and ultrasound findings.
In minor degrees (traditional grade I and II), vaginal delivery is possible. RCOG recommends
that placenta should be at least 2 cm away from internal os for an attempted vaginal delivery.[19]
When a vaginal delivery is attempted, consultant obstetrician and anesthetists are present in
delivery suite. In cases of fetal distress and major degrees (traditional grade III and IV) a
caesarean section is indicated. Caesarian section is contraindicated in cases of disseminated
intravascular coagulation. Obstetrician may need to divide the anterior lying placenta. In such
cases, blood loss is expected to be high and thus blood and blood products are always kept ready.
In rare cases, hysterectomy may be required.[20]

Complications[edit]

Maternal[edit]

Antepartum hemorrhage

Malpresentation

Abnormal placentation

Postpartum hemorrhage

Placenta praevia increases the risk of puerperal sepsis and postpartum haemorrhage because the
lower segment to which the placenta was attached contracts less well post-delivery.

Fetal[edit]

IUGR (15% incidence)[5]

Premature delivery

Death

Epidemiology[edit]
Placenta previa occurs approximately one of every 250 births. One third of all antepartum
hemorrhage occurs due to placenta previa.[citation needed] It has been suggested that incidence
of placenta praevia is increasing due to increased rate of Caesarian section.[21]

Perinatal mortality rate of placenta praevia is 3-4 times higher than normal pregnancies.[22]

History[edit]

In places where a Caesarean section could not be performed due to the lack of a surgeon or
equipment, infant could be delivered vaginally. There were two ways of doing this with a
placenta praevia:

The baby's head can be brought down to the placental site (if necessary with Willet's forceps or a
vulsellum) and a weight attached to his scalp

A leg can be brought down and the baby's buttocks used to compress the placental site

The goal of this type of delivery is to save the mother, and both methods will often kill the baby.
These methods were used for many years before Caesarean section and saved the lives of both
mothers and babies with this condition.

References[edit]