5/26/2017 PlacentaPrevia:Background,Pathophysiology,Etiology

PlacentaPrevia
Updated:May12,2016
Author:RonanBakker,MDChiefEditor:CarlVSmith,MDmore...

OVERVIEW

Background
Placentapreviaisanobstetriccomplicationthatclassicallypresentsaspainlessvaginalbleeding
inthethirdtrimestersecondarytoanabnormalplacentationnearorcoveringtheinternalcervical
os.However,withthetechnologicadvancesinultrasonography,thediagnosisofplacentapreviais
commonlymadeearlierinpregnancy.Historically,therehavebeenthreedefinedtypesofplacenta
previa:complete,partial,andmarginal.Morerecently,thesedefinitionshavebeenconsolidated
intotwodefinitions:completeandmarginalprevia.

Acompletepreviaisdefinedascompletecoverageofthecervicalosbytheplacenta.Iftheleading
edgeoftheplacentaislessthan2cmfromtheinternalos,butnotfullycovering,itisconsidereda
marginalprevia(seethefollowingimage).Becauseoftheinherentriskofhemorrhage,placenta
previamaycauseseriousmorbidityandmortalitytoboththefetusandthemother.

Placentaprevia.
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5/26/2017 PlacentaPrevia:Background,Pathophysiology,Etiology

Completeplacentaprevianotedonultrasound.
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Anotherultrasoundimageclearlydepictingcompleteplacentaprevia.
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Pathophysiology
Placentalimplantationisinitiatedbytheembryo(embryonicplate)adheringinthelower(caudad)
uterus.Withplacentalattachmentandgrowth,thedevelopingplacentamaycoverthecervicalos.
However,itisthoughtthatadefectivedecidualvascularizationoccursoverthecervix,possibly
secondarytoinflammatoryoratrophicchanges.Assuch,sectionsoftheplacentahaving
undergoneatrophicchangescouldpersistasavasaprevia.

Aleadingcauseofthirdtrimesterhemorrhage,placentapreviapresentsclassicallyaspainless
bleeding.Bleedingisthoughttooccurinassociationwiththedevelopmentoftheloweruterine
segmentinthethirdtrimester.Placentalattachmentisdisruptedasthisareagraduallythinsin
preparationfortheonsetoflaborthisleadstobleedingattheimplantationsite,becausetheuterus
isunabletocontractadequatelyandstoptheflowofbloodfromtheopenvessels.Thrombin
releasefromthebleedingsitespromotesuterinecontractionsandleadstoaviciouscycleof
bleedingcontractionsplacentalseparationbleeding.

Etiology
Theexactetiologyofplacentapreviaisunknown.Theconditionmaybemultifactorialandis
postulatedtoberelatedtothefollowingriskfactors:

Advancingmaternalage(>35y)
Infertilitytreatment
Multiparity(5%ingrandmultiparouspatients)
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5/26/2017 PlacentaPrevia:Background,Pathophysiology,Etiology

Multiplegestation
Shortinterpregnancyinterval
Previousuterinesurgery,uterineinsultorinjury
Previouscesareandelivery,[1,2]includingfirstsubsequentpregnancyfollowingacesarean
delivery[1]
Previousorrecurrentabortions
Previousplacentaprevia(48%)
Nonwhiteethnicity
Lowsocioeconomicstatus
Smoking
Cocaineuse

Unlikefirsttrimesterbleeding,secondandthirdtrimesterbleedingisusuallyduetoabnormal
placentalimplantation.

Hemorrhaging,ifassociatedwithlabor,wouldbesecondarytocervicaldilatationanddisruptionof
theplacentalimplantationfromthecervixandloweruterinesegment.Asnotedpreviously,the
loweruterinesegmentisinefficientincontractingandthuscannotconstrictvesselsasinthe
uterinecorpus,resultingincontinuedbleeding(seePathophysiology).

Epidemiology
UnitedStatesstatistics
Placentapreviaisfrequentlyreportedtooccurin0.5%ofallUSpregnancies.Alarge,US
populationbased,19891997studyindicatedanincidenceof2.8per1000livebirths.[3]Therisks
increase1.5to5foldwithahistoryofcesareandelivery.Ametaanalysisshowedthattherateof
placentapreviaincreaseswithincreasingnumbersofcesareandeliveries,witharateof1%after1
cesareandelivery,2.8%after3cesareandeliveries,andashighas3.7%after5cesarean
deliveries.[1]

Racialandagerelateddifferencesinincidence

Thesignificanceofraceinhavingaroleinplacentapreviaissomewhatcontroversial.Some
studiessuggestanincreasedriskamongblackandAsianwomen,whereasotherstudiesciteno
difference.[4]

Advancedmaternalagehasalsobeenstronglyassociatedwithanincreasingincidenceof
placentaprevia.Theincidenceofplacentapreviaafterage35yearsreportedtobe2%.Afurther
increaseto5%isseenafterage40years,whichisa9foldincreasewhencomparedtofemales
youngerthan20years.[5,6]

Prognosis
Placentapreviacomplicatesapproximately0.5%ofallpregnancies.[4]Technologicadvancesin
ultrasonographyhaveincreasedtheearlydiagnosisofplacentaprevia,andseveralstudieshave
shownthatasignificantportionoftheseearlydiagnosesdonotpersistuntildelivery.[7,8]Infact,
90%ofallplacentasdesignatedaslowlyingonanearlysonogramarenolongerpresenton
repeatexaminationinthethirdtrimester.[9]

However,maternalandfetalcomplicationsofplacentapreviaarewelldocumented.Pretermbirthis
highlyassociatedwithplacentaprevia,with16.9%ofwomendeliveringatlessthan34weeksand
27.5%deliveringbetween34and37weeksinapopulationbasedstudyfrom1989to1997.[3]

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5/26/2017 PlacentaPrevia:Background,Pathophysiology,Etiology

Thereisasignificantincreaseintheriskofpostpartumhemorrhageandneedforemergency
hysterectomyinwomenwithplacentaprevia.[10]

Maternalcomplicationsofplacentapreviaaresummarizedasfollows:

Hemorrhage,[11]includingrebleeding(Planningdeliveryandcontrolofhemorrhageiscritical
incasesofplacentapreviaaswellasplacentaaccreta,increta,andpercreta.)
Higherratesofbloodtransfusion[11,12]
Placentalabruption
Pretermdelivery
Increasedincidenceofpostpartumendometritis[12]
Mortalityrate(23%)intheUS,thematernalmortalityrateis0.03%,thegreatmajorityof
whichisrelatedtouterinebleedingandthecomplicationofdisseminatedintravascular
coagulopathy

TheTable,below,summarizestherelativeriskofsomemorbiditiesinwomenwithplacentaprevia.

Table.RelativeRiskofMorbiditiesinPatientsWithPlacentaPrevia(OpenTableinanewwindow)

Morbidities RelativeRisk

Antepartumbleeding 10

Needforhysterectomy 33

Bloodtransfusion 10

Septicemia 5.5

Thrombophlebitis 5

Endometritis 6.6[12]

Complicationsofplacentapreviaintheneonate/infantaresummarizedasfollows:

Congenitalmalformations
Fetalintrauterinegrowthretardation(IUGR)
FetalanemiaandRhisoimmunization
Abnormalfetalpresentation
Lowbirthweight(<2500g)[12]
Neonatalrespiratorydistresssyndrome[12]
Jaundice[12]
Admissiontotheneonatalintensivecareunit(NICU)[12]
Longerhospitalstay[12]
Increasedriskforinfantneurodevelopmentaldelayandsuddeninfantdeathsyndrome
(SIDS)[13]
Neonatalmortalityrate:Ashighas1.2%intheUnitedStates[14]

PatientEducation
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Patientswithplacentapreviashoulddecreaseactivitytoavoidrebleeding.Inaddition,pelvic
examinationsandintercourseshouldbeavoided.

Counselpatientswithplacentapreviaabouttheriskofrecurrence.Instructthemtonotifythe
obstetriciancaringfortheirnextpregnancyabouttheirhistoryofplacentaprevia.

Encouragepatientswithknownplacentapreviatomaintainintakeofironandfolateasasafety
marginintheeventofbleeding.

Forpatienteducationresources,seePregnancyCenterandWomen'sHealthCenter,aswellas
BleedingDuringPregnancy,andVaginalBleeding.

ClinicalPresentation

References

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systematicreview.AmJObstetGynecol.2011Sep.205(3):262.e18.[Medline].

2.MilosevicJ,LilicV,TasicM,RadovicJanosevicD,StefanovicM,AnticV.[Placental
complicationsafterapreviouscesareansection].MedPregl.2009MayJun.62(56):2126.
[Medline].

3.AnanthCV,SmulianJC,VintzileosAM.Theeffectofplacentapreviaonneonatalmortality:a
populationbasedstudyintheUnitedStates,1989through1997.AmJObstetGynecol.2003
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8.HillLM,DiNofrioDM,CheneveyP.Transvaginalsonographicevaluationoffirsttrimester
placentaprevia.UltrasoundObstetGynecol.1995May.5(5):3013.[Medline].

9.WexlerP,GottesfeldKR.Earlydiagnosisofplacentaprevia.ObstetGynecol.1979Aug.
54(2):2314.[Medline].

10.ZakiZM,BaharAM,AliME,AlbarHA,GeraisMA.Riskfactorsandmorbidityinpatientswith
placentapreviaaccretacomparedtoplacentaprevianonaccreta.ActaObstetGynecol
Scand.1998Apr.77(4):3914.[Medline].

11.FrederiksenMC,GlassenbergR,StikaCS.Placentaprevia:a22yearanalysis.AmJObstet
Gynecol.1999Jun.180(6pt1):14327.[Medline].

12.ZlatnikMG,ChengYW,NortonME,ThietMP,CaugheyAB.Placentapreviaandtheriskof
pretermdelivery.JMaternFetalNeonatalMed.2007Oct.20(10):71923.[Medline].

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