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 or total placenta previa. The
entire cervical os is covered.

Low-lying placenta previa. The

placenta partially separated from the lower uterine segment.
Placenta previa invading the lower uterine segment and covering the
cervical os.

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
 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).
Epidemiology
United States statistics
Placenta previa is frequently reported to occur in 0.3-0.5% 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 0.3-0.5% 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, [11] 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 [11, 12]
 Placental abruption
 Preterm delivery
 Increased incidence of postpartum endometritis [12]
 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 (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[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.
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.[15]
Placenta previa often leads to preterm delivery, with 44% of pregnancies
with placenta previa delivered before 37 weeks.[14]
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 (vaginal and rectal) 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)

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
 Lower genital tract lesions
 Bloody show
Differential Diagnoses
 Abruptio Placentae
 Cervicitis
 Disseminated Intravascular Coagulation
 Pregnancy, Delivery
 Premature Rupture of Membranes
 Preterm Labor
 Vaginitis
 Vulvovaginitis

In the workup of vaginal bleeding in pregnancy, ultrasonographic

visualization of placentation is critical. A digital examation 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.
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.[16, 17]
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.[18]
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.[16] In one study, 26% of placenta
previas diagnosed by transabdominal ultrasonography were found to be
misdiagnosed when rescanned using TVS.[19]
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,[20]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.[21]
 A large trial determining the efficacy and safety of the use of MRI during
pregnancy has not been performed, and further investigation is required

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.
Hemostasis may be established by one or more of the following:
 Oversewing the placental implantation site
 Bilateral uterine artery ligation
 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
Medical Management
Expectant management vs inpatient admission
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. If bleeding is minimal and fetal reassurance is
noted, expectant management may also be considered to allow for fetal
maturity.
However, if bleeding or contractions occur, the patient must rapidly go to
the hospital for evaluation and for the testing mentioned in the Workup
section. Monitor hemoglobin and hematocrit levels for anemia, and
transfuse if necessary (eg, hemoglobin level < 8 g/dL). Order clotting
studies (ie, prothrombin time/activated partial thromboplastin time
[PT/aPTT], fibrinogen, and fibrin split products) if concern arises for
disseminated intravascular coagulation (DIC).
There have been studies that report using prothrombin complex and
recombinant factor VII to control hemorrhage associated with obstetric
complications and placenta previa.
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.
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.[24] 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.[14]
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.[25]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.[26] 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
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.
The timing of delivery is often driven by the patient's history and an
increased risk for bleeding with advancing gestation. Most authorities
recommend delivery at 36-37 weeks' gestation after confirming fetal lung
maturity via amniocentesis. However, if the fetal lung maturity testing is
immature or is not available, then delivery is often scheduled for 38 weeks'
gestation.
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.[27] Risk for cesarean hysterectomy is increased
by the presence of complete placenta previa and a history of cesarean
delivery or prior abortion.[28]
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 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.[13]
 Aortic balloon occlusion prior to cesarean hysterectomy has also been
demonstrated to reduce blood loss.[29] Other means to control hemorrhage
include the following:
 B-Lynch or parallel vertical compression sutures
 Uterine artery ligation
 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