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Placenta Previa

By Antonette T. Dulay, MD, Attending Physician, Maternal-Fetal Medicine Section, Department of Obstetrics and Gynecology;Senior Physician, Main Line Health System;Axia Women’s Health

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Placenta previa is implantation of the placenta over or near the internal os of the cervix. Typically, painless vaginal bleeding with bright red blood occurs after 20 wk gestation. Diagnosis is by transvaginal or abdominal ultrasonography. Treatment is modified activity for minor vaginal bleeding before 36 wk gestation, with cesarean delivery at 36 wk. If bleeding is severe or refractory or if fetal status is nonreassuring, immediate delivery, usually cesarean, is indicated.

Placenta previa refers to placental tissue that covers any portion of the internal cervical os. A placenta is termed low lying when the placental edge does not cover the internal os but is within 2 cm of it.

Incidence of placenta previa is 1/200 deliveries. If placenta previa occurs during early pregnancy, it usually resolves by 28 wk as the uterus enlarges.

Risk factors

Risk factors for placenta previa include the following:

  • Multiparity

  • Prior cesarean delivery

  • Uterine abnormalities that inhibit normal implantation (eg, fibroids, prior curettage)

  • Smoking

  • Multifetal pregnancy

  • Older maternal age

Complications

For patients with placenta previa or a low-lying placenta, risks include fetal malpresentation, preterm premature rupture of the membranes, fetal growth restriction, vasa previa, and velamentous insertion of the umbilical cord (in which the placental end of the cord consists of divergent umbilical vessels surrounded only by fetal membranes).

In women who have had a prior cesarean delivery, placenta previa increases the risk of placenta accreta; risk increases significantly as the number of prior cesarean deliveries increases (from about 10% if they have had one cesarean delivery to > 60% if they have had > 4).

Symptoms and Signs

Symptoms usually begin during late pregnancy. Then, sudden, painless vaginal bleeding often begins; the blood may be bright red, and bleeding may be heavy, sometimes resulting in hemorrhagic shock. In some patients, uterine contractions accompany bleeding.

Diagnosis

  • Transvaginal ultrasonography

Placenta previa is considered in all women with vaginal bleeding after 20 wk. If placenta previa is present, digital pelvic examination may increase bleeding, sometimes causing sudden, massive bleeding; thus, if vaginal bleeding occurs after 20 wk, digital pelvic examination is contraindicated unless placenta previa is first ruled out by ultrasonography.

Although placenta previa is more likely to cause heavy, painless bleeding with bright red blood than abruptio placentae, clinical differentiation is still not possible. Thus, ultrasonography is frequently needed to distinguish the two. Transvaginal ultrasonography is an accurate, safe way to diagnose placenta previa.

Pearls & Pitfalls

  • If vaginal bleeding occurs after 20 wk gestation, exclude placenta previa by ultrasonography before doing a digital examination.

In all women with suspected symptomatic placenta previa, fetal heart rate monitoring is indicated.

Treatment

  • Hospitalization and modified activity for a first episode of bleeding before 36 wk

  • Delivery if mother or fetus is unstable

  • If the woman is stable, delivery at 36wk/0 days to 37 wk/0 days

For a first (sentinel) episode of vaginal bleeding before 36 wk, management consists of hospitalization, modified activity (modified rest), and avoidance of sexual intercourse, which can cause bleeding by initiating contractions or causing direct trauma. (Modified activity involves refraining from any activity that increases intra-abdominal pressure for a long period of time—eg, women should stay off their feet most of the day.) If bleeding stops, ambulation and usually hospital discharge are allowed.

Typically for a 2nd bleeding episode, patients are readmitted and kept for observation until delivery.

Some experts recommend giving corticosteroids to accelerate fetal lung maturity when early delivery may become necessary and gestational age is < 34 wk. Corticosteroids may be used if bleeding occurs after 34 wk and before 36 wk (late preterm period) in patients who have not required corticosteroids before 34 wk (1).

Timing of delivery depends on the maternal and/or fetal condition. If the patient is stable, delivery can be done at 36 wk/0 days to 37 wk/0 days. Documentation of lung maturity is no longer necessary (2).

Delivery is indicated for any of the following:

  • Heavy or uncontrolled bleeding

  • Nonreassuring results of fetal heart monitoring

  • Maternal hemodynamic instability

Delivery is cesarean for placenta previa. Vaginal delivery may be possible for women with a low-lying placenta if the placental edge is within 1.5 to 2.0 cm of the cervical os and the clinician is comfortable with this method.

Hemorrhagic shock is treated. Prophylactic Rh0(D) immune globulin should be given if the mother has Rh-negative blood.

Treatment references

Key Points

  • Placenta previa is more likely to result in heavy, painless bleeding with bright red blood than abruptio placentae, but clinical differentiation is still not possible.

  • Consider placenta previa in all women who have vaginal bleeding after 20 wk.

  • For most first bleeding episodes before 36 wk, recommend hospitalization, modified activity, and abstinence from sexual intercourse.

  • Consider corticosteroids to accelerate fetal lung maturity if delivery may be needed before about 34 wk or if bleeding occurs between 34 and 36 wk in patients who have not required corticosteroids before 34 wk.

  • Delivery is indicated when bleeding is severe or when the mother or fetus is unstable.

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