Placenta previa: Management

Authors:
Charles J Lockwood, MD, MHCM
Karen Russo-Stieglitz, MD
Section Editor:
Vincenzo Berghella, MD
Deputy Editor:
Vanessa A Barss, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Jan 2019. | This topic last updated: Jan 30,
2019.

INTRODUCTION — Placenta previa refers to the presence of placental tissue that

extends over the internal cervical os. The management of pregnancies complicated
by placenta previa is best addressed in terms of the patient's clinical setting:

●Women who are asymptomatic

●Women who are actively bleeding

●Women who are stable after one or more episodes of active bleeding

This topic will discuss the management of these women. The epidemiology, clinical
features, diagnosis, morbidity, and mortality of placenta previa are reviewed
separately. (See "Placenta previa: Epidemiology, clinical features, diagnosis,
morbidity and mortality".)
ASYMPTOMATIC PLACENTA PREVIA

Goals — The main goals during management of asymptomatic women with

placenta previa are to:

●Determine whether the previa resolves with increasing gestational age

●Determine whether the placenta is also morbidly adherent (placenta accreta)

●Reduce the risk of bleeding

●Determine the optimal time for planned cesarean delivery if the previa persists

Monitoring placental position — Follow-up transvaginal ultrasound examination of

placental position is indicated in women whose placental position is over or <2 cm
from the internal os on a second-trimester ultrasound examination. (See "Placenta
previa: Epidemiology, clinical features, diagnosis, morbidity and mortality", section
on 'Asymptomatic finding on midtrimester ultrasound examination'.)

We agree with the consensus approach of an expert group for monitoring placental
position of these pregnancies (algorithm 1) [1]:

●If the placental edge is over or <2 cm from the internal os in the second trimester,
follow-up transvaginal ultrasonography for placental position is indicated at 32
weeks of gestation.

At the 32-week follow-up examination:

•If the placental edge is ≥2 cm from the internal os, the placental position is
reported as normal and additional follow-up ultrasound examinations for placental
position are not indicated. (See "Placenta previa: Epidemiology, clinical features,
diagnosis, morbidity and mortality", section on 'Asymptomatic finding on
midtrimester ultrasound examination'.)

Color and pulsed Doppler examinations are useful to confirm the position of the
placental edge and rule out vasa previa, as resolution of a low-lying placenta can
be associated with vasa previa. (See "Velamentous umbilical cord insertion and
vasa previa".)
•If the placental edge is over or <2 cm from the internal os, a follow-up transvaginal
ultrasound for placental position is indicated at 36 weeks.

At the 36-week follow-up examination:

•If the placental edge is over the internal os, cesarean delivery is scheduled. (See
'Timing of delivery' below.)

•If the placental edge is not over but <2 cm from the internal os, the risks and
benefits of a trial of labor should be discussed with the patient. The risk of bleeding
increases as the distance between the placental edge and internal os decreases,
and if vasa previa is present. (See 'Timing of delivery' below.)

Excluding placenta accreta — The possibility of placenta previa-

accreta/increta/percreta should be excluded, given its association with placenta
previa. (See "Placenta previa: Epidemiology, clinical features, diagnosis, morbidity
and mortality", section on 'Placenta previa-accreta' and "Clinical features and
diagnosis of placenta accreta spectrum (placenta accreta, increta, and percreta)",
section on 'Prenatal diagnosis'.)

If present, antepartum management of placenta previa-accreta is the same as for

placenta previa, but delivery risks are somewhat different. Cesarean delivery is
scheduled earlier in gestation than for previa alone and preoperative preparation
includes planning for cesarean-hysterectomy (which is usually required) and
interventions that will reduce the risk of massive hemorrhage (which is more
common than with previa alone). (See "Management of the placenta accreta
spectrum (placenta accreta, increta, and percreta)".)

Reducing risk of bleeding — For an individual patient, it is not possible to accurately

predict whether spontaneous bleeding will occur, nor the gestational age, volume,
or frequency of bleeding. Sonographic features reported to be associated with a
higher likelihood of antepartum bleeding are described separately. (See "Placenta
previa: Epidemiology, clinical features, diagnosis, morbidity and mortality", section
on 'Bleeding'.)

We avoid digital cervical examination. It is clear from anecdotal experience that

palpation of placenta previa through a partially dilated cervix can result in severe
hemorrhage.
We advise women with placenta previa after 20 weeks of gestation (earlier if they
have experienced vaginal bleeding) to avoid any sexual activity that may lead to
orgasm. The rationale is that this activity, especially if orgasm occurs, may be
associated with transient uterine contractions, which, in turn, may provoke
bleeding. Additionally, there is concern that vaginal intercourse (or putting any
object deep into the vagina) might cause direct trauma to the previa, resulting in
bleeding. There are no published studies that either support or refute this
recommendation. However, as discussed above, palpation of placenta previa
through a partially dilated cervix can result in severe hemorrhage.

We also advise asymptomatic women to avoid moderate and strenuous exercise,

heavy lifting (eg, more than about 20 pounds), or standing for prolonged periods of
time (eg, >4 hours). This degree of activity has been linked to small but statistical
increases in preterm birth in a meta-analysis of observational studies (median odds
ratios 1.10 to 1.20) [2].

Women should also be advised to seek immediate medical attention if contractions

or vaginal bleeding occur, given the potential for severe bleeding and need for
emergency cesarean delivery.

Screening for growth restriction — Pregnancies complicated by placenta previa are

at no or minimally increased risk of intrauterine growth restriction. There is no
evidence that specifically monitoring fetal growth with serial ultrasound
examinations is useful; however, this information is generally available since fetal
growth is estimated whenever ultrasound examination is performed for
assessment of placental position.

Inpatient versus outpatient maternal monitoring — It is unclear whether

asymptomatic women with placenta previa benefit from hospitalization. Findings
from observational studies suggest that women who have not experienced any
antepartum bleeding are at low risk of sudden hemorrhage requiring an emergency
cesarean delivery for control of bleeding [3-6]. These women can generally be
managed on an outpatient basis until vaginal bleeding occurs or until admission for
scheduled cesarean birth.

However, patient-specific risk factors need to be taken into account. Such factors
may include short cervical length on ultrasound examination (eg, we discuss
increased risk of preterm labor if ≤25 mm and we consider hospitalization if ≤15
mm), rapid cervical shortening (eg, >10 mm over a one- to two-week period on
transvaginal ultrasound) [7-9], inability to get to the hospital promptly (within
about 20 minutes), and lack of home support in case of an emergency. These
parameters, which are based on personal experience/expert opinion and data from
studies on risk of preterm birth across the spectrum of cervical length, represent
our approach and should not be considered a standard of care. The Society for
Maternal-Fetal Medicine does not recommend routine cervical length screening in
the late preterm period for women with placenta previa [10].

Antenatal corticosteroids — We administer an initial course of antenatal

corticosteroids to asymptomatic women 48 hours before a cesarean delivery
scheduled at less than 37 weeks of gestation. (See "Antenatal corticosteroid
therapy for reduction of neonatal respiratory morbidity and mortality from
preterm delivery", section on 'Gestational age at administration'.)

Timing of delivery — We perform a cesarean delivery at 36+0 to 37+6 weeks in

pregnancies with uncomplicated placenta previa, without documentation of fetal
lung maturity by amniocentesis, in agreement with recommendations of the
American College of Obstetricians and Gynecologists and Society of Maternal-Fetal
Medicine [10,11]. Uncomplicated placenta previa is defined as without fetal growth
restriction, superimposed preeclampsia, and or other issues that take precedent
for delivery decision-making. Review of available evidence suggests that the risks
associated with continuing the pregnancy (severe bleeding, emergency
unscheduled delivery) are greater than the risks associated with prematurity at this
gestational age range. (See 'Cesarean delivery' below.)
ACUTE CARE OF BLEEDING PLACENTA PREVIA

An actively bleeding placenta previa is a potential obstetric emergency. These

women should be admitted to the Labor and Delivery Unit for maternal and fetal
monitoring, and the anesthesia team should be notified.

Goals — The major goals in managing a patient with an acutely bleeding placenta
previa are to:

●Achieve and/or maintain maternal hemodynamic stability

●Determine if emergency cesarean delivery is indicated

Maternal and fetal assessment — Maternal blood pressure, heart rate, respiratory
rate, peripheral oxygen saturation, and urine output are closely monitored.
Tachypnea, tachycardia, hypotension, low oxygen saturation, and air hunger are
signs of hypovolemia.

The fetal heart rate is monitored continuously for patterns suggestive of hypoxemia
or anemia. (See "Management of intrapartum category I, II, and III fetal heart rate
tracings".)

Accurate estimation of vaginal blood loss is difficult to determine visually,

particularly when blood is partially saturating or soaking towels, maternity pads, or
gauze sponges, or dripping onto the floor [12,13]. One or more of the following
techniques can be used to quantify blood loss [13,14]:

●Collect blood in graduated volumetric containers.

●Use visual aids that correlate the size and appearance of blood on specific surfaces
(eg, maternity pad, emesis basin, bed sheet, lap sponge) with the volume of blood
absorbed by that surface (picture 1). Regularly scheduling standardized training in
the use of these charts can be helpful for this assessment.

●Measure the total weight of bloody materials and subtract the known weight of
the same materials when dry. The difference in weight between wet and dry in
grams approximates the volume of blood in milliliters.
●Attempt to account for fluids other than blood (eg, amniotic fluid, irrigation fluid,
urine) that are collected or absorbed.

Laboratory testing — There is no consensus about the components of routine

laboratory assessment of patients with bleeding placenta previa [15,16]. At a
minimum, we obtain a complete blood count, send blood for type and antibody
screen, and notify the blood bank that a patient with placenta previa has been
admitted. We cross-match two to four units of packed red blood cells when
bleeding is heavy or increasing, delivery is likely for any reason, or we anticipate
difficulty in procuring compatible blood.

Evaluation for coagulopathy (fibrinogen level, activated partial thromboplastin

time, prothrombin time) is indicated in patients suspected of coexistent abruption
or with heavy blood loss resulting in hemodynamic instability. A crude test for
identifying patients with impaired clotting function can be performed at the
bedside with a clot observation test. Prolonged oozing from needle puncture sites
also suggests coagulopathy. Thromboelastography (TEG) or rotational
thromboelastometry (ROTEM)-based transfusion algorithms may be helpful, if
available. (See "Postpartum hemorrhage: Medical and minimally invasive
management", section on 'Postvaginal delivery'.)

Fetal bleeding can occur if disruption of fetal vessels in placental villi, vasa previa,
or a velamentous cord occurs, and can be detected by performing a Kleihauer-
Betke or flow cytometry test on a specimen of vaginal blood. However, fetal
bleeding from disruption of one of these sources is rare and typically results in fetal
demise or a nonreassuring fetal heart rate tracing necessitating emergency
delivery. Therefore, it is unlikely that results of the test will impact management.
(See "Spontaneous massive fetomaternal hemorrhage", section on 'Kleihauer-
Betke assay'.)

Stabilization

Intravenous access and crystalloid — One or two large bore intravenous lines are
inserted and crystalloid (Ringers lactate or normal saline) is infused to
achieve/maintain hemodynamic stability and adequate urine output (at least 30
mL/hour). (See "Treatment of severe hypovolemia or hypovolemic shock in
adults".)
Transfusion — Transfusion of blood products in a woman with an actively bleeding
placenta previa should be guided by the volume of blood loss over time and
changes in hemodynamic parameters (eg, blood pressure, maternal and fetal heart
rates, peripheral perfusion, and urine output), as well as the hemoglobin level. It is
important to not get behind in replacement of blood products.

Acute hemorrhage may not be associated with an immediate reduction in either

blood pressure or hematocrit in an otherwise healthy young woman. Thus, a low
threshold for ordering a transfusion should be maintained in patients with
antepartum hemorrhage once the diagnosis of placenta previa is made. A failure to
rapidly correct tachycardia or hypotension with a normal saline bolus, or
documentation of a hemoglobin value <10 g/dL should prompt immediate
transfusion.

Types and actions of blood replacement products are shown in the table (table 1).
The blood bank should be notified about the possible need for massive transfusion
(algorithm 2).

Initially, we suggest transfusing 2 to 4 units of typed and crossed packed red blood
cells (PRBC), without fresh frozen plasma or platelets as long as the fibrinogen level
is >250 mg/dL and the platelet count is >100,000/microL. The goal of transfusion is
a final hemoglobin value >10 g/dL. If the patient fails to stabilize, a massive
transfusion protocol should be initiated. If a massive transfusion protocol is not
available, type O Rh-negative blood should be administered until type-specific or
typed and cross-matched blood is available.

If the patient continues to bleed, we suggest using the same blood product
transfusion ratios used for patients with severe hemorrhage of other etiologies: a
1:1:1 ratio of PRBC:fresh frozen plasma:platelets. Point-of care testing with TEG or
ROTEM, if available, can be used to guide blood product replacement. (See
"Intraoperative transfusion of blood products in adults".)

If delivery is not imminent, we continue transfusion until the patient has stabilized,
bleeding is decreased, and hemoglobin is at least 10 g/dL. We chose this
hemoglobin to provide a margin of safety since the patient is at increased risk for
another, more severe bleeding event. However, if delivery is imminent, a
preoperative or intraoperative target hemoglobin of 8 g/dL is reasonable.

Other
●We do not administer tocolytic drugs to actively bleeding patients.

●Anti-shock garments have been used to restore adequate blood pressure in

pregnant/postpartum women who are hemodynamically unstable due to severe
bleeding in low resource settings [17-19]. However, these devices have not been
used when the fetus was viable and there is no information on their effect on
uteroplacental blood flow and the fetus.

●Tranexamic acid is generally not administered before delivery because it freely

crosses the placenta. However, it has been recommended for treatment of
antepartum, intrapartum, and postpartum bleeding related to several inherited
bleeding disorders [20]. Fetal/neonatal harm has not been reported, but data are
limited.

Outcome — Most women who initially present with symptomatic placenta previa
respond to supportive therapy, as described above, and do not require immediate
delivery [21-25]. In observational series, 50 percent of women with a symptomatic
previa (any amount of bleeding) were not delivered for at least four weeks
[22,24,25]. Even a large bleed does not preclude conservative management. In one
series, 50 percent of women whose initial hemorrhagic episode exceeded 500 mL
were successfully managed with aggressive use of antepartum transfusions and
had a mean prolongation of pregnancy of 17 days [21].

Indications for delivery — Cesarean delivery is indicated for:

●Active labor.

●A nonreassuring fetal heart rate tracing unresponsive to resuscitative measures.

(See "Management of intrapartum category I, II, and III fetal heart rate tracings",
section on 'In utero resuscitation'.)

●Severe and persistent vaginal bleeding such that maternal hemodynamic stability
cannot be achieved or maintained.

●Significant vaginal bleeding after 34 weeks of gestation – Because the neonatal

benefits from avoiding preterm delivery decrease with advancing gestational age,
whereas maternal risks from persistent or recurrent bleeding probably increase,
we feel the balance of fetal benefit versus maternal risk favors delivery in women
with significant vaginal bleeding after 34 weeks. The gestational age threshold and
amount of bleeding considered significant are matters of clinician judgment. The
decision to deliver these pregnancies is made on a case-by-case basis while
observing the patient's course on the labor unit. Delivery should not be delayed to
administer antenatal corticosteroids [10].

Magnesium sulfate — We suggest a course of magnesium sulfate therapy for

neuroprotection in patients with preterm (24 to 32 weeks) placenta previa in whom
a decision has been made to deliver within 24 hours, but not emergently.
Emergency delivery because of maternal or fetal status should not be delayed to
administer magnesium sulfate. (See "Neuroprotective effects of in utero exposure
to magnesium sulfate".)

Anesthesia — (See "Anesthesia for the patient with peripartum hemorrhage",

section on 'Placenta previa'.)

EXPECTANT MANAGEMENT OF STABLE PATIENTS AFTER A BLEED

Candidates and goals — We believe that symptomatic women less than 34 weeks
of gestation who are hemodynamically stable or quickly stabilized and have a
normal fetal heart rate pattern are candidates for expectant management. The goal
is to prolong pregnancy to enable further fetal growth and maturation, without
placing the mother at excessive risk from persistent or recurrent bleeding.

Management of placenta previa after acute bleeding is based upon findings from
observational studies and clinical experience. A systematic review that attempted
to assess the impact of clinical interventions in these pregnancies concluded there
were insufficient data upon which to make evidence-based recommendations for
clinical practice; only three randomized trials involving a total of 114 women were
identified [26]. After the patient has been stabilized, we take the following
approach.

Antenatal corticosteroids — A course of antenatal corticosteroid therapy is

administered to symptomatic women between 23+0 and 33+6 weeks of gestation
to enhance fetal pulmonary maturity. We would give a course of steroids to women
whose first bleed is at 34+0 to 36+6 weeks of gestation and who have not received
a prior course, as these women will deliver by cesarean delivery before 37 weeks
[10]. (See "Antenatal corticosteroid therapy for reduction of neonatal respiratory
morbidity and mortality from preterm delivery", section on '34+0 or more weeks'.)
Correction of anemia — Oral or parenteral iron supplementation may be needed
for optimal correction of anemia. If oral iron is prescribed, stool softeners and a
high-fiber diet help to minimize constipation and avoid excess straining that might
precipitate bleeding. Parenteral iron therapy has the advantages that hemoglobin
levels rise faster and less gastric upset occurs compared with oral therapy. (See
"Treatment of iron deficiency anemia in adults", section on 'Pregnancy'.)

Anti-D immune globulin — Theoretically, disruption of the placental fetomaternal

interface can result in fetomaternal transfusion. For this reason, guidelines for
prevention of Rhesus (D) alloimmunization suggest administering anti-D-immune
globulin to D-negative women who have bleeding from placenta previa [27,28].

Readministration is not necessary if rebleeding occurs within three weeks of

administration. If repeated episodes of bleeding occur, the anti-D antibody can be
checked: a low titer suggests that the anti-D level is sufficient to provide ongoing
protection against alloimmunization.

Readministration is also not necessary if delivery occurs within three weeks of

administration, unless routine postpartum Kleihauer-Betke/flow cytometry detects
a large fetomaternal hemorrhage. (See "Prevention of Rhesus (D) alloimmunization
in pregnancy".)

Fetal assessment — There is no proven value of nonstress testing or performing a

biophysical profile in pregnancies with asymptomatic placenta previa and no
evidence of uteroplacental insufficiency (eg, preeclampsia, fetal growth restriction,
oligohydramnios) or other indications for antepartum fetal assessment (eg, vasa
previa). As discussed above, active vaginal bleeding is an indication for continuous
fetal monitoring. (See 'Maternal and fetal assessment' above.)

Autologous blood donation — Some women may consider autologous blood

donation, given the high frequency of bleeding requiring blood transfusion (12
percent in one series [29] and 22 percent in another [30]).

A program of autologous blood collection and transfusion can decrease the need
for homologous blood transfusion [31]. However, most women who have bled from
a placenta previa, will not meet standard criteria for autologous donation [32,33].
Autologous blood donation is safe in stable women who meet usual criteria
(hemoglobin ≥11.0 g/dL) [31,34,35]. Some centers have lowered the hemoglobin
threshold to >10 g/dL for pregnant women with placenta previa to enable
autologous donation for more of these women [31]. (See "Surgical blood
conservation: Preoperative autologous blood donation".)

Other interventions

Tocolysis — We do not use tocolytic drugs in the management of placenta previa,

given the lack of proven benefits and the known possible harms (see "Inhibition of
acute preterm labor"). In patients with contractions, we may use tocolytics while
administering a course of betamethasone if bleeding is diminishing or has ceased
and delivery is not otherwise mandated by the maternal or fetal condition.
Tocolysis may reduce or eliminate uterine contractions, which may promote
placental separation and bleeding. Indomethacin is not used due to its inhibitory
effect on platelet function.

Some observational studies in women with symptomatic placenta previa suggest

this therapy may prolong pregnancy and result in an increase in birth weight,
without causing adverse effects on the mother or fetus [36,37]. However, it is likely
that underlying differences in the treated and untreated (control) patients
accounted for this benefit. Furthermore, these studies have generally not shown a
decrease in the number of episodes of hemorrhage after admission, the total
amount of blood loss, or the number of blood transfusions. Other studies have
reported that maintenance tocolysis in women with placenta previa is not
beneficial [38].

Cerclage — In the absence of high-quality evidence of efficacy and safety, we

advise not performing cerclage to improve pregnancy outcome in placenta previa.
However, the presence of a stable placenta previa is not a contraindication to
cerclage placement when indicated for cervical insufficiency. (See "Cervical
insufficiency".)

Cervical cerclage has been used in an attempt to minimize early development of

the isthmus, which is thought to promote placental separation [39]. However, the
efficacy of this approach is unproven. Although a meta-analysis of two, small
randomized trials that evaluated cerclage for improving pregnancy outcome in
primarily symptomatic placenta previa [40,41] reported that cervical cerclage
reduced the risk of delivery before 34 weeks (relative risk [RR] 0.45, 95% CI 0.23-
0.87) and the birth of a baby weighing less than 2000 g (RR 0.34, 95% CI 0.14-0.83),
the lack of consistency between trials and methodological issues prevent making a
clear conclusion of benefit [26].

Inpatient versus outpatient management — If the patient's bleeding stops after the
first or second bleeding event, we discharge her to home if she meets the criteria
described below. If a third bleeding episode occurs, we generally hospitalize the
patient until delivery [24]. Data suggest that the risk for emergency cesarean
delivery progressively increases with one, two, and three more episodes of
antepartum bleeding (odds ratio [OR] 7.5, 14, and 27, respectively) and in women
who have had a blood transfusion (OR 6.4) compared with women with no
antepartum bleeding [42]. In this study, 57 percent of women with bleeding
placenta previa had an emergency delivery, and the frequency of emergency
delivery was 42 percent after three or more bleeding episodes versus 25 to 30
percent after one or two bleeds.

Since the frequency and severity of recurrent bleeding episodes are unpredictable,
maintaining close proximity to the labor and delivery unit may minimize the risk of
serious maternal or fetal complications by enabling prompt access to transfusion
therapy and emergency cesarean delivery when needed.

●Discharge criteria -- We discharge selected women with placenta previa whose

bleeding has stopped for a minimum of 24 hours and who have no other pregnancy
complications, although the safety and efficacy of this approach has not been
established [24,43-45]. In our practice, candidates for outpatient care should:

•Be able to return to the hospital within 20 minutes [46].

•Be reliable (ie, will comply with instructions about sexual activity, etc). (See
'Reducing risk of bleeding' above.)

•Be able to maintain modified bed rest at home.

•Understand the risks entailed by outpatient management.

•Have an adult companion available 24 hours/day who can immediately transport

the woman to the hospital if there is light bleeding or call an ambulance for severe
bleeding.
The only randomized clinical trial of outpatient versus inpatient management of
women with placenta previa after resolution of the initial bleeding episode
reported that outpatient care was not associated with greater morbidity than
inpatient management [24]. Patients randomly assigned to the outpatient arm who
had a recurrent bleed were treated initially as inpatients, and were again
discharged home if stable despite minimal ambulation after a minimum of 48 to 72
hours. Outpatients were instructed to maintain bedrest. However, if these patients
had a third episode of bleeding, they were hospitalized until delivery. Significant
differences in outcome may not have been appreciated given the small number of
women (n = 53) who participated in this trial.

Management of coexistent PPROM — Antepartum decidual hemorrhage is a major

risk factor for preterm premature rupture of membranes (PPROM), which can
occur despite the presence of a complete placenta previa. In these cases, each
condition is managed independently. (See "Preterm prelabor rupture of
membranes".)

Timing of delivery — As discussed above, planned cesarean delivery of patients

with stable (no bleeding or minimal bleeding) placenta previa should be
accomplished at 36+0 to 37+6 weeks, without documentation of fetal lung maturity
by amniocentesis. (See 'Timing of delivery' above.)

Expectant management is terminated and emergency cesarean delivery is

indicated if any of the following occur:

●Labor

●Any vaginal bleeding with a nonreassuring fetal heart rate tracing unresponsive
to resuscitative measures

●Severe and persistent vaginal bleeding such that maternal hemodynamic stability
cannot be achieved or maintained

●Significant vaginal bleeding after 34 weeks of gestation (see 'Indications for

delivery' above)

CESAREAN DELIVERY — A cesarean delivery is always indicated when there is

sonographic evidence of placenta previa and a viable fetus. Vaginal delivery may
be considered in rare circumstances, such as in the presence of a fetal demise or a
previable fetus, as long as the mother remains hemodynamically stable.

Preparation — Planning for the possibility of postpartum hemorrhage is critical for

reducing morbidity. (See "Overview of postpartum hemorrhage", section on
'Planning' and "Overview of postpartum hemorrhage", section on 'General
principles of management'.)

Two to four units of packed red blood cells should be available for the cesarean
delivery. Appropriate surgical instruments for performance of a cesarean
hysterectomy should also be available since these patients are at increased risk of
placenta accreta, even in the absence of a prior cesarean delivery. Evaluation for
placenta previa-accreta should have been performed antenatally, with appropriate
preparations for management, if present. (See "Clinical features and diagnosis of
placenta accreta spectrum (placenta accreta, increta, and percreta)" and
"Management of the placenta accreta spectrum (placenta accreta, increta, and
percreta)" and "Peripartum hysterectomy for management of hemorrhage" and
"Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and
mortality", section on 'Placenta previa-accreta'.)

Management of the placenta — The surgeon should try to avoid disrupting the
placenta when entering the uterus. If the placenta is incised, hemorrhage from fetal
vessels can result in significant neonatal anemia. Preoperative or intraoperative
sonographic localization is helpful in determining the position of the hysterotomy
incision. For intraoperative imaging, the transducer is placed in a sterile bag and
sleeve and sterile gel is applied to the uterine serosa; the best incision site can then
be mapped sonographically.

If the placenta is in an anterolateral location, a vertical incision can be made in the

lower uterine segment on the opposite side from the placenta. If the placenta
wraps around the cervix from the anterior to posterior lower uterine segment in
the midline, a transverse or vertical incision may be possible above it [47,48],
although this often results in extension into the upper uterine segment. When
incision of the placenta is unavoidable, the infant should be delivered rapidly and
the cord promptly clamped.
Oxytocin is given routinely to reduce the risk of postpartum hemorrhage. (See
"Management of the third stage of labor: Drug therapy to minimize hemorrhage",
section on 'Oxytocin'.)

Management of postpartum hemorrhage — After delivery of the placenta, severe

bleeding may occur from the placental bed: in a systematic review, 16 to 29 percent
of women with a placenta previa had a postpartum hemorrhage [49]. The reason
for the increased risk of postpartum hemorrhage is thought to be that the
myometrium of the lower uterine segment does not contract as effectively as the
upper uterine segment, and thus may impede physiological hemostasis from a
lower segment placental bed. In some cases, hemorrhage is due to focal placenta
accreta.

Postpartum hemorrhage is approached in the following ways.

Step one: Administer uterotonic drugs and tranexamic acid — The dose of oxytocin
can be increased as needed to control heavy bleeding. If oxytocin alone does not
control hemorrhage, we administer tranexamic acid along with additional
uterotonic drugs (carboprost tromethamine [prostaglandin F2 alpha] or
methylergonovine). Administration of these drugs is discussed in detail separately.
(See "Postpartum hemorrhage: Medical and minimally invasive management",
section on 'Manage atony' and "Postpartum hemorrhage: Medical and minimally
invasive management", section on 'Administer tranexamic acid'.)

Tourniquets have been used to control bleeding at myomectomy, and for other
types of pelvic hemorrhage, and may be useful as a temporizing measure in
postpartum hemorrhage [50-52], while medical therapy is administered and taking
effect or while surgical interventions are being considered. A bladder catheter or
Penrose drain is tied tightly around the uterus as low as possible to occlude the
uterine vessels in the broad ligaments, and then secured with a clamp (figure 1). A
second or third tourniquet can also be applied, as needed. (See "Techniques to
reduce blood loss during abdominal or laparoscopic myomectomy", section on
'Tourniquets and clamps'.)

Although no randomized trials of tranexamic acid in the setting of placenta previa

have been performed and administration in this setting is not an established
standard of care, tranexamic acid reduces death due to bleeding in women with
postpartum hemorrhage, with no adverse effects. If administered, it should be
given as soon as possible after bleeding onset [53]. It also appears to decrease total
blood loss when given prophylactically in a healthy population of pregnant women
[54,55]. One gram (10 mL of a 100 mg/mL solution) is infused over 10 to 20 minutes,
as infusion >1 mL/minute can cause hypotension. If bleeding persists after 30
minutes, a second 1 g dose is administered. Tranexamic acid can be given
concomitantly with the other drugs and actions, and should not be regarded as an
alternative therapy, followed by the interventions described below.

Step two: Treat focal bleeding, if present — The following options may control
bleeding from a small focal area:

●Hemostatic square sutures

●Placement of fibrin glue or patch over area of oozing to promote clotting

●Application of ferric subsulfate (Monsel's solution) to oozing area

●Placental site injection of vasopressin

●Excision, if the area is small and easily accessible, particularly in cases of focal
placenta accreta with persistent bleeding

Hemostatic square sutures — Ligation of myometrial vessels at the placental site

will control focal bleeding in patients who have a focal placenta accreta and some
patients who responded poorly to intravenous uterotonic therapy.

The Affronti endouterine hemostatic square suture technique involves making four
to six 2 by 2 cm squares in the area of placental bed bleeding [56]. The 1.0
polyglactin 910 sutures should penetrate the decidua and extend into the
myometrium but not beyond the uterine serosa (figure 2). The ends of the sutures
are tied down tightly to compress the enclosed vessels.

In one study, multiple square sutures stopped postpartum hemorrhage in 28 of 30

cases (93 percent) [57]. Twenty women subsequently underwent hysteroscopy:
eight (40 percent) had no intrauterine adhesions, nine (45 percent) had thin
adhesions that were removed easily by the tip of the hysteroscope, two (10
percent) had moderate intrauterine adhesions that were resected, and one (10
percent) had severe intrauterine adhesions.
Placental site injection of vasopressin — The authors have not used this technique
in patients with placenta previa. Placental site injection of vasopressin to reduce
bleeding, while biologically plausible and potentially clinically relevant, is based on
two small case series. After removal of the placenta, subendometrial injection of
vasopressin at the placental implantation site may reduce bleeding [58,59]. The
favorable effect has been attributed to binding to the vasopressin V1α receptor,
which is highly expressed in smooth muscle cells in the lower segment of the
uterus. Intravascular injection should be avoided, as it can cause severe adverse
cardiovascular effects (bradycardia, cardiac arrhythmia, ischemia, right heart
failure, shock, cardiac arrest, limb ischemia).

In one study, local injection of 4 units of vasopressin in 20 mL of saline into the

placental implantation site significantly reduced blood loss without increasing
morbidity (blood loss: with vasopressin 1149 mL, without vasopressin 1634 mL)
[59]. In a case report, 5 units of vasopressin in 20 mL saline injected in 1 to 2 mL
amounts into the area of placental implantation stopped bleeding within 90
seconds [58].

Step three: Ligation of the uterine and utero-ovarian arteries (O'Leary

stitch) — Ligation of the uterine and utero-ovarian arteries (O'Leary stitch) can
decrease diffuse uterine bleeding by reducing perfusion pressure in the
myometrium. The technique, which can be applied rapidly, is described separately.
(See "Postpartum hemorrhage: Management approaches requiring laparotomy",
section on 'Laceration of the uterine artery or utero-ovarian artery branches'.)

Step four: Intrauterine balloon tamponade and/or uterine compression

sutures — If bleeding persists, the next step is either intrauterine balloon
tamponade or placement of uterine compression sutures. As no trials have
compared the two approaches directly in this setting, the choice depends on the
clinical judgment/preference of the surgeon. Uterine compression sutures may be
more effective for atony and fundal bleeding, whereas the balloon may be more
effective for lower segment bleeding. However, an advantage of placing the
balloon first is that it is a quick and easy procedure and if it doesn't work, the
balloon can be deflated, compression sutures can be placed, and then the balloon
can be reinflated, if needed. If the compression sutures are placed first, then they
will have to be removed in order to place a balloon.
Intrauterine balloon tamponade — Intrauterine balloon tamponade is a fast and
often effective procedure for control of hemorrhage in patients who have not
responded to drug therapy or focal placental site suture ligation. Hemostasis was
achieved in 88 percent of cases in two small studies [60,61]. In a trial of 13 patients
with placenta previa randomly assigned to insertion of a balloon or hemostatic
square sutures for control of intractable postpartum bleeding, operative time and
amount of intraoperative bleeding were lower in the balloon group (time: 63 versus
78 minutes; intraoperative bleeding: 1520 versus 1946 mL) [62].

The stem of a balloon catheter can be passes through the uterine incision, through
the cervical os, and then into the vagina; an assistant then pulls the end of the
catheter out of the introitus. If it is difficult to pass the catheter through the cervical
os, an assistant can pass the tip of a small forceps from the vagina through the
cervical os to the uterine incision [63]. The surgeon then places the stem of the
catheter into the open tip so the assistant can pull it into the vagina while the
surgeon places the balloon end in an appropriate place within the uterine cavity.
The balloon can be left deflated or inflated with 50 to 100 mL sterile saline to
reduce the risk of puncture when the hysterotomy incision is closed. After the
uterine incision is closed, the assistant inflates the balloon to its maximum volume
with sterile fluid (eg, 500 mL for the Bakri tamponade balloon catheter and BT-Cath,
750 mL for the ebb Complete Tamponade System) while the surgeon inspects the
uterus from above. (See "Intrauterine balloon tamponade for control of
postpartum hemorrhage".)

Uterine compression sutures — If balloon tamponade is ineffective, the balloon

can be deflated and a B-Lynch uterine compression suture is applied (figure 3). The
hysterotomy site is then closed, the uterus replaced in the pelvis (if previously
exteriorized), and the balloon is reinflated, thereby applying pressure to both the
outer and inner surfaces of the myometrium. [63,64]. It is important to observe the
myometrium and stop instilling fluid before undue blanching occurs at the
compression suture sites, which might lead to rupture or uterine necrosis. It is also
important to observe for vaginal bleeding to see if hemorrhage has been
controlled. (See "Intrauterine balloon tamponade for control of postpartum
hemorrhage", section on 'External compression plus internal tamponade'.)

Refractory patients
Consider arterial embolization — When the above measures have failed, uterine or
hypogastric artery embolization in an operating room with the full surgical team in
attendance is an option if the facility has a hybrid operating room, or an operating
room that allows simultaneous surgery and embolization (an appropriately
sensitive portable C-arm and carbon fiber table). We believe embolization is
preferable to surgical internal iliac artery ligation.

Hysterectomy — Hysterectomy is a definitive treatment of uterine bleeding when

fertility preserving procedures have not reduced the bleeding to a manageable
level. Ideally, it should be performed before severe hypovolemia, tissue hypoxia,
hypothermia, electrolyte abnormalities, and acidosis have developed, which
further compromise the patient's status. (See "Peripartum hysterectomy for
management of hemorrhage".)

ROUTE OF DELIVERY IN WOMEN WITH A LOW-LYING PLACENTA — The optimal

route for delivery of pregnancies where the distance between the placental edge
and internal os is 1 to 20 mm is unclear. The fetal head may tamponade the
adjacent placenta, thus preventing hemorrhage.

One of the larger retrospective studies that looked at the outcome of this specific
group of pregnancies reported vaginal birth in 6/24 (25 percent) women with a
cervix-to-placenta distance of 1 to 10 mm and in 20/29 (69 percent) women with
cervix-to-placenta distance of 11 to 20 mm [65]. In another study of 14 women with
singleton pregnancies and a placental edge between 11 and 20 mm from the
internal cervical os, 13 had an uncomplicated vaginal delivery, and 1 required
emergency cesarean delivery for intrapartum bleeding [66].

Although a variety of factors influence the decision to perform cesarean delivery,

these data support allowing a trial of labor in pregnancies in which the placenta is
more than 10 mm from the internal os. If this distance is ≤10 mm, these
pregnancies are at high risk of intrapartum hemorrhage; therefore, we suggest
scheduled cesarean delivery to minimize the risk of emergency delivery and need
for transfusion.

PREGNANCY TERMINATION IN WOMEN WITH PLACENTA PREVIA — Clinicians

should discuss with patients the various options for pregnancy termination in the
setting of placenta previa (eg, hysterotomy, dilation and evacuation, use of
abortifacient) and document the discussion in the medical record. The presence of
a placenta previa does not preclude second trimester pregnancy termination by
standard techniques, although data are limited to a few studies [67-70].

●One series of 131 consecutive women undergoing elective pregnancy termination

by dilation and evacuation (D&E) after laminaria placement at 13 to 24 weeks of
gestation compared the outcome of those with (n = 23) and without placenta previa
based upon an ultrasound examination before the procedure [67]. Women with a
placenta previa had greater intraoperative blood loss (21 mL), but no significant
increase in operative time, time to discharge, infection, hemorrhage, or other
complications.

●The second series consisted of 306 consecutive women undergoing pregnancy

termination by D&E at 19 to 24 weeks [68]. An ultrasound diagnosis of complete
previa was made in eight patients. None of these women had excessive bleeding
with laminaria insertion or required blood transfusion due to procedure related
hemorrhage. Operative time was comparable to women without complete previa.

●The third series included 15 second- or third-trimester terminations of pregnancy

by administration of systemic abortifacients in women with complete previa [69].
Preinduction feticide was performed 2 to 14 days prior to the procedure. Four of
nine women who underwent labor induction without previous feticide required
blood transfusions and one required hysterectomy; none of the six patients with
preinduction feticide required transfusion. The authors concluded that
preinduction feticide might help to reduce blood loss in these cases.

●The fourth series included 158 women undergoing second trimester termination
in whom 11 had placenta previa, 4 underwent D&E and 7 had gemeprost
termination [70]. There was no statistical difference in mean intraoperative blood
loss between these groups and controls without previa, but one woman with
placenta previa who underwent gemeprost termination developed serious
bleeding requiring blood transfusion.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored

guidelines from selected countries and regions around the world are provided
separately. (See "Society guideline links: Obstetric hemorrhage".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, "The Basics" and "Beyond the Basics." The Basics patient education
pieces are written in plain language, at the 5th to 6th grade reading level, and they
answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th
to 12th grade reading level and are best for patients who want in-depth information
and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also locate
patient education articles on a variety of subjects by searching on "patient info"
and the keyword(s) of interest.)

●Basics topics (see "Patient education: Placenta previa (The Basics)")

SUMMARY AND RECOMMENDATIONS

Asymptomatic previa

●The main goals during management of asymptomatic women with placenta

previa are to:

•Determine whether the previa resolves with increasing gestational age. Follow-up
transvaginal ultrasonography is performed at 32 weeks of gestation and again at
36 weeks if the placenta remains over or <2 cm from the internal os (algorithm 1).
(See 'Monitoring placental position' above.)

•Determine whether the placenta is also morbidly adherent (placenta accreta).

(See 'Excluding placenta accreta' above.)

•Counsel the patient on measures to reduce the risk of bleeding. (See 'Reducing
risk of bleeding' above.)

●We perform cesarean delivery at 36+0 to 37+6 weeks of gestation. (See 'Timing
of delivery' above.)

●A course of antenatal corticosteroids is administered 48 hours before a cesarean

delivery scheduled at less than 37 weeks of gestation, if not previously given. (See
'Antenatal corticosteroids' above.)
Acute management of bleeding previa

●An actively bleeding placenta previa is a potential obstetric emergency. Women

with active bleeding are hospitalized for close maternal and fetal monitoring,
including (see 'Maternal and fetal assessment' above and 'Laboratory testing'
above):

•Monitoring maternal blood loss and hemodynamic status.

•Obtaining a complete blood count and sending blood for type and antibody screen
or cross-match, depending on the likelihood of transfusion.

•Evaluation of fibrinogen level, activated partial thromboplastin time, and

prothrombin time is indicated in patients suspected of coexistent abruption or with
heavy blood loss resulting in hemodynamic instability.

•Fetal heart rate monitoring.

●Transfusion of blood products in a woman with an actively bleeding placenta

previa should be guided by the volume of blood loss over time and changes in
hemodynamic parameters, as well as the hemoglobin level. Acute hemorrhage may
not be associated with an immediate reduction in either blood pressure or
hematocrit in an otherwise healthy young woman. Thus, a low threshold for
ordering a transfusion should be maintained in patients with antepartum
hemorrhage once the diagnosis of placenta previa is made. A failure to rapidly
correct tachycardia or hypotension with a normal saline bolus, or documentation
of a hemoglobin value <10 g/dL should prompt immediate transfusion. (See
'Transfusion' above.)

●Most women who initially present with symptomatic placenta previa respond to
supportive therapy. Indications for emergency cesarean delivery include active
labor, refractory life threatening maternal hemorrhage, nonreassuring fetal status,
and significant vaginal bleeding after 34 weeks of gestation. (See 'Acute care of
bleeding placenta previa' above.)

Expectant management after an acute bleed

●After a bleeding episode has resolved, outpatient management of select women

is reasonable. We counsel these patients to avoid excess physical activity, including
sexual intercourse, and to call their provider promptly if bleeding or labor occurs.
They should be able to return to the hospital quickly if rebleeding occurs and should
not have additional pregnancy complications. (See 'Expectant management of
stable patients after a bleed' above.)

●We recommend a course of antenatal corticosteroid therapy for symptomatic

patients between 23 and 34 weeks of gestation to enhance fetal pulmonary
maturity (Grade 1A). We would give a first course of steroids (but not a second
course) to women whose first bleed is at 34+0 to 36+6 weeks and to asymptomatic
women in whom cesarean delivery is planned between 36+0 and 37+6 weeks. We
also recommend anti-D immune globulin for symptomatic Rh(D)-negative women
to prevent possible alloimmunization (Grade 1B). Readministration of anti-D
immune globulin is not necessary if delivery or rebleeding occurs within three
weeks, unless a large fetomaternal hemorrhage is detected. (See 'Antenatal
corticosteroids' above and 'Anti-D immune globulin' above.)

●We schedule cesarean delivery at 36+0 to 37+6 weeks (see 'Timing of delivery'
above). Incision of the placenta should be avoided, as this increases the risk of fetal
hemorrhage. (See 'Cesarean delivery' above.)

●Vaginal delivery may be attempted when the placental edge is >10 mm from the
internal os because the risk of hemorrhage during labor is acceptable, and much
lower than in cases where the placental edge is closer to the internal os. (See 'Route
of delivery in women with a low-lying placenta' above.)

Cesarean delivery

●Planning for the possibility of postpartum hemorrhage, which occurs in up to

about 30 percent of cases, is critical for reducing morbidity. Disruption of the
placenta at hysterotomy should be avoided, if possible. (See 'Preparation' above
and 'Management of the placenta' above.)

●The management of postpartum hemorrhage involves a stepwise approach,

initially with uterotonic drugs and tranexamic acid, followed by standard surgical
interventions (eg, suturing focal bleeding, ligation of the uterine and utero-ovarian
arteries [O'Leary stitch], placement of uterine compression sutures and/or
intrauterine balloon tamponade), and ultimately arterial embolization or
hysterectomy. (See 'Management of postpartum hemorrhage' above.)