PLACENTA PREVIA

1. Placentia previa refers to implantation of the placenta over the cervical os in

advance of the fetal presenting part. It complicates in 200 pregnancies, and
accounts for 20% of all cases of antepartum hemorrhage.
2. Symptoms may include the acute onset of bright-red vaginal bleeding, which is
usually painless. It is often accompanied by decreased fetal movement. Bleeding
is of maternal origin. Fetal malpresentation is common, because the placenta
prevents engagement of the presenting part. It may be an incidental finding on
routine ultrasound.
3. Risk factor for placenta previa include multiparity, advanced maternal age, prior
placenta previa, prior cesarean delivery, and smoking.
4. When a woman presents with antepartum hemorrhage, pelvic examination should
be avoided until placenta previa is excluded on ultrasound.
5. Other causes of antepartum hemorrhage include placental abruption (see chapter
47), vasa previa(see chapter 67), early labor, and genital tract lesions (cervical
polyps or erosions).
6. Placenta previa is an ultrasound diagnosis. Transperineal and/or transvaginal
ultrasound may be necessary to confirm the diagnosis, and is regarded as safe in
this setting. Of note, only 5% of placenta previa indentified by ultrasound at
routine second-trimester fetal anatomy survey will persist to term. Placenta
accreta (abnormal attachment of placental villi to the uterine wall) is rare (l in
2500 pregnancies), but complicates 5% of pregnancies with placenta previa, 1025 % with placentia previa and one prior cesarean, and >50% with placenta previa
and two or more prior cesarean (see chapter 45).
7. Emergency cesarean delivery may be needed. Contraindications to emergency
cesarean include a previable fetus (<23-24 weeks), intrauterine fetal demise,
maternal hemodynamic instability or uncontrolled coagulopathy, or failure to
obtain maternal consent for surgery.
8. The goal of antepartum management in the setting of placenta previa is to
maximize fetal maturation while minimizing risk to mother and fetus.
Nonreassuring fetal testing (fetal distress) and excessive maternal hemorrhage
are contraindications to expectant management, and may necessitate immediate
cesarean irrespective of gestational age. However, most episodes of bleeding are
not life-threatening. With careful monitoring, delivery can be safely delayed in

most cases. Outpatient management may be an option for women with a single
small bleed if they can comply with restrictions on activity and maintain
proximity to a hospital. Placenta previa may resolve with time, thereby permitting
vaginal delivery.
9. Serial ultrasound examinations are useful to follow placental location, fetal
presentation (malpresentation is common), and possibly fetal growth (although
placenta previa is not associated with intrauterine growth restriction).
10. Vaginal delivery is rarely appropriate in the setting of placenta previa, but may be
indicated in the setting of intrauterine fetal demise, fetal malformation(s)
incompatible with life, advanced labor with engagement of the fetal head and
minimal vaginal bleeding, or an indicated delivery with a previable fetus. A
double set-up examination in labor may be appropriate when ultrasound cannot
exclude placentia previa and the patient is strongly motivated for vaginal delivery.
This procedure is performed in the operating room with surgical anesthesia and
two surgical teams. One team is scrubbed and ready for immediate cesarean in the
event of hemorrhage or nonreassuring fetal testing (fetal distress). The other
team then performs a gentle bimanual examination initially of the vaginal fornices
and then the cervical os. If a previa is present, immediate cesarean is indicated. If
no placenta is palpated, amniotomy can be performed and labor induced.

REFERENCES

Obstetric clinical alogarithms: management and evidence. By E.R. Norwitz M. Blefort,

G.R. Saade and H. Miller Published 2010 Blackwell Publishing.