Placenta Previa

Frances M. Anderson-Bagga; Angelica Sze.

Author Information
Last Update: June 27, 2020.

Continuing Education Activity

Placenta previa is the complete or partial covering of the internal os of the cervix with
the placenta. It is a major risk factor for postpartum hemorrhage and can lead to morbidity
and mortality of the mother and neonate. This situation prevents a safe vaginal delivery and
requires the delivery of the neonate to be via cesarean delivery. Most cases are diagnosed
early on in pregnancy via sonography and others may present to the emergency room with
painless vaginal bleeding in the second or third trimester of pregnancy. The presence of
placenta previa can also increase a woman's risk for placenta accreta spectrum (PAS). This
spectrum of conditions includes placenta accreta, increta, and percreta. This activity reviews
the evaluation and management of patients with placenta previa. It also highlights the role of
an interprofessional team in managing patients with this condition in order to improve
outcomes for mother and fetus.

Objectives:

Describe the risk factors for placenta previa.

Describe the pathophysiology of placenta previa.
Describe the management of patients with placenta previa and how this varies with
gestational age, presentation, and stability of the patient.
Explain the importance of improving care coordination, collaboration, and communication
amongst an interprofessional team to enhance the delivery of care and improve outcomes
for patients with placenta previa.
Earn continuing education credits (CME/CE) on this topic.

Introduction

Placenta previa is the complete or partial covering of the internal os of the cervix with
the placenta.[1][2][3] It is a major risk factor for postpartum hemorrhage and can lead to
morbidity and mortality of the mother and neonate.[4] This situation prevents a safe vaginal
delivery and requires the delivery of the neonate to be via cesarean delivery. Most cases are
diagnosed early on in pregnancy via sonography and others may present to the emergency
room with painless vaginal bleeding in the second or third trimester of pregnancy. The
presence of placenta previa can also increase a woman's risk for placenta accreta spectrum
(PAS).[5] This spectrum of conditions includes placenta accreta, increta, and percreta.
Uncontrolled postpartum hemorrhage from placenta previa or PAS may necessitate a blood
transfusion, hysterectomy thus leaving the patient infertile, admission to the ICU, or even
death.
Etiology

The underlying cause of placenta previa is unknown. There is, however, an

association between endometrial damage and uterine scarring.[6] The risk factors that
correlate with placenta previa are advanced maternal age, multiparity, smoking, cocaine use,
prior suction, and curettage, assisted reproductive technology, history of cesarean
section(s), and prior placenta previa.[3][6][7] The implantation of a zygote (fertilized egg)
requires an environment rich in oxygen and collagen. The outer layer of the dividing zygote,
blastocyst, is made up of trophoblast cells which develops into the placenta and fetal
membranes. The trophoblast adheres to the decidua basalis of the endometrium, forming a
normal pregnancy. Prior uterine scars provide an environment that is rich in oxygen and
collagen. The trophoblast can adhere to the uterine scar leading to the placenta covering the
cervical os or the placenta invading the walls of the myometrium.[7][8]

Epidemiology

Placenta previa affects 0.3% to 2% of pregnancies in the third trimester and has
become more evident secondary to the increasing rates of cesarean sections.[3][4][6]

Pathophysiology

Placenta previa is the complete or partial covering of the cervix. A low-lying placenta
is where the edge is within 2 to 3.5 cm from the internal os.[8] Marginal placenta previa is
where the placental edge is within 2cm of the internal os.[8] Nearly 90% of placentas
identified as "low lying" will ultimately resolve by the third trimester due to placental
migration.[1][9][10] The placenta itself does not move but grows toward the increased blood
supply at the fundus, leaving the distal portion of the placenta at the lower uterine segment
with relatively poor blood supply to regress and atrophy.[9][10] Migration can also take place
by the growing lower uterine segment thus increasing the distance from the lower margin of
the placenta to the cervix.[9][10]

History and Physical

The risks factors for placenta previa include a history of advanced maternal age (age
greater than 35 years old), multiparity, smoking, history of curettage, use of cocaine, and
history of cesarean section(s).[7] The relationship between advanced maternal age and
placenta previa may be confounded by higher parity and a higher probability of previous
uterine procedures or fertility treatment. However, it may also represent an altered hormonal
or implantation environment.[11] The nicotine and carbon monoxide, found in cigarettes, act
as potent vasoconstrictors of placental vessels; this compromises the placental blood flow
thus leading to abnormal placentation.[12]

Painless vaginal bleeding during the second or third trimester of pregnancy is the
usual presentation. The bleeding may be provoked from intercourse, vaginal examinations,
labor, and at times there may be no identifiable cause.[13] On speculum examination, there
may be minimal bleeding to active bleeding. Sometimes the placenta can be visualized on
speculum examination if the cervix is dilated. A digital examination should be avoided to
prevent massive hemorrhage.
Evaluation

Routine sonography in the first and second trimester of pregnancy provides early
identification of placenta previa. It is important to realize that the earlier the diagnosis of
placenta previa is, the more likely it is to resolve at delivery secondary to placental migration.
Nearly 90% of placentas identified as "low lying" will ultimately resolve by the third trimester.
[1][9] Follow up sonogram is recommended at 28 to 32 weeks of gestation to look for
persistent placenta previa.[6]

A patient presenting with vaginal bleeding in the second or third trimester should
receive a transabdominal sonogram before a digital examination. If there is a concern for
placenta previa, then a transvaginal sonogram should be performed to confirm the location
of the placenta. Transvaginal sonogram has been shown to be superior to a transabdominal
sonogram and is safe.[6][10][9] Low lying and marginal placentas are identified with
sonography and are determined by measuring the distance of the edge of the placenta to
the internal os.

At the time of sonography, evaluation for PAS is also necessary. High suspicion for
placenta accreta should be a consideration early on in diagnosis. Placenta accreta is the
attachment of the placenta beyond the normal boundary of the myometrium that is
established by the Nitabuch fibrinoid layer.[14] Placenta increta is the invasion of the
placenta into the myometrium, and placenta percreta is the invasion into the uterine serosa
and or surrounding organs.[14] Placenta accreta spectrum can lead to massive
hemorrhage, and an integrated team approach is necessary before delivery. Placenta
accreta spectrum diagnosis is via ultrasonography with very high sensitivities and
specificities.[5] MRI is useful for cases of posterior placenta previa or to assess potential
invasion to the bladder. However, they are costly and have not been shown to improve
diagnosis or outcomes compared to ultrasonography alone.[5] If there is a high suspicion for
a PAS, then a plan for cesarean hysterectomy should be discussed with the patient. The
plan should be to leave the placenta in situ to avoid massive hemorrhage.

Treatment / Management

With the diagnosis of placenta previa, the patient is scheduled for elective delivery at
36 to 37 weeks via cesarean section.[15] However, some patients with placenta previa
present with complications and require urgent cesarean sections at an earlier gestational
age.

Patients who present with a known history of placenta previa and vaginal bleeding
should have vitals performed, and should have electronic fetal monitoring initiated. The
patient should receive two large-bore intravenous lines with a complete blood count, type
and screen, and have coags drawn. If she presents with substantial bleeding, then 2-4 units
of blood should be crossed and matched.

Patients with excessive or continuous vaginal bleeding should be delivered via

cesarean section regardless of gestational age. If bleeding subsides then expectant
management is permissible if the gestational age is less than 36 weeks. If at or greater than
36 weeks of gestation then cesarean delivery is recommended.[15] The patient should be
admitted and, if qualified, receive magnesium sulfate for fetal neuroprotection and steroids
for fetal lung maturity. Bedrest, reduced activity, and avoidance of intercourse are commonly
mandated, though there is no clear benefit.[6][16] If the vaginal bleeding subsides for more
than 48 hours and the fetus is judged to be healthy, then inpatient monitoring is continued,
or the patient may be discharged for outpatient management. Inpatient vs. outpatient
management depends on the stability of the patient, the number of episodes of bleeding,
proximity to the hospital, as well as compliance.
Delivery

A cesarean section should optimally occur under controlled conditions. A discussion

with the patient should take place during prenatal care of the diagnosis, possible
complications, and the plan for cesarean section and possible hysterectomy if there is
uncontrolled postpartum hemorrhage or PAS. The surgeon, anesthesiologist, nursing staff,
pediatricians, and blood bank should receive notification of these patients. If there is a
concern for PAS then urology, general surgery, as well as interventional radiology should
have involvement as well. Communication should take place among the teams regarding the
expected date of surgery, planned procedures such as uterine artery embolization, and
updated imaging studies, which allows the various units to be aware of the patient if the
patient presents earlier in an emergency setting.

The patient should have two large bore IV lines in place and blood crossed and
matched. Uterine artery catheters can be placed before the procedure by interventional
radiology for precautions as well. Regional anesthesia, spinal-epidural combination, is
recommended at the time of delivery for nonurgent cases.[17] In the event a hysterectomy is
necessary, the patient can convert to general anesthesia.[17][18] Regional anesthesia is
considered superior to general anesthesia because of the decreased operative blood loss
and the need for blood transfusion.[6] Inhaled anesthetics can lead to uterine relaxation
worsening postpartum hemorrhage. During the procedure, if there is a postpartum
hemorrhage, then the catheters can be inflated to decrease the blood supply to the uterus.

A vertical skin incision is the recommended incision for optimal exposure. A high
vertical uterine incision may be required if the placenta is covering the lower uterine
segment, or if the lower uterine segment is underdeveloped. After delivery of the fetus, the
placenta spontaneously detaches, and the uterine incision can be closed. There may be
hemorrhage after detachment of the placenta secondary to the decreased contractability of
the lower uterine segment, which can be managed with bimanual uterine massage,
uterotonics, intrauterine tamponade using balloon or gauze, B-Lynch sutures, Hackethal
suture, Cho sutures, uterine artery or internal iliac artery ligation, and uterine artery or
internal iliac artery embolization.[19][4] At times the massive hemorrhage may not be
controlled with conservative measures, and a hysterectomy is necessary.[4] If the placenta
does not detach or partially detaches then the patient has PAS, and the placenta should
remain in situ, the uterine incision closed, and a cesarean hysterectomy should follow. If
there is high suspicion for PAS, then a cesarean section should be performed without
manipulation of the placenta.

There is an option for conservative management in patients with PAS if the patient
desires fertility. The placenta can be left in situ until there is devascularisation of the
placental bed so that the remaining placental tissue may either be more safely removed or
resorbs itself. Several studies have reported excellent fertility rates following conservative
treatment.[20] However, there is a high recurrence rate of placenta accreta, ranging from 17
to 29%.[20] The discussion of an emergent cesarean hysterectomy and a possible second
operation for hysterectomy must be discussed with the patient. A third of women that
undergo conservative management will experience ongoing vaginal bleeding where they
may require a delayed hysterectomy, blood transfusion, or develop an infection.[20] There is
no clear evidence of the benefits of using methotrexate because there is limited or absent
trophoblastic proliferation at term to take effect.[20]

Patients with a low-lying placenta, placenta lies greater than 2cm from the cervical os, may
qualify for a trial of labor but are at an increased risk for postpartum hemorrhage and
emergent cesarean section compared to women with normal placentation.[6][21] There is no
consensus for the recommended mode of delivery for marginal placenta previa.[6] One study
by Jansen et al. showed that if the distance of the edge of the placenta to the internal os is
greater than 10mm a trial of labor should be the recommended procedure.[21]

Differential Diagnosis

Vaginal bleeding during pregnancy can be due to numerous factors. Based on the
trimester of pregnancy the differential diagnosis can vary greatly. In the first and second
trimester, vaginal bleeding can be secondary to subchorionic hematoma, cervicitis, cervical
cancer, threatened abortion, ectopic pregnancy, or molar pregnancy. In the third trimester,
vaginal bleeding can be due to labor, placental abruption, vasa previa, or placenta previa.

The most life-threatening cause of vaginal bleeding in pregnancy that should be ruled
out is placental abruption, which is placental separation before delivery, a complication in
about 1% of births.[3] Placental abruption presents with severe abdominal pain, vaginal
bleeding, and electronic fetal monitoring may show tachysystole and a nonreassuring fetal
heart tracing; this too can lead to high morbidity in mortality to the fetus and mother
secondary to hemorrhage.

Vasa previa is the overlying of the internal cervical os with the fetal vessels that run
through the membranes.[22] It is uncommon and occurs in 1 in 2500 to 1 to 5000
pregnancies.[6] It can lead to fetal-neonatal hemorrhage and exsanguination if the fetal
vessels tear by spontaneous or artificial rupture of membranes.[6][22]

Prognosis
Neonatal Prognosis

There is a threefold to fourfold increased neonatal mortality and morbidity rate with
placenta previa primarily from preterm delivery.[6] The neonate is at increased risk of
preterm birth, lower birth weight, lower APGAR scores, and increased risk for respiratory
distress syndrome.[1][10][23]

Maternal Prognosis

About 90% of placenta previa cases resolve through delivery.[1] Jing et al. found that
women with anterior placentas have poorer prognostic factors and are more likely to have
massive blood loss and higher hysterectomy rates compared to any other location.[7] This
outcome is secondary to the placenta attaching to a prior uterine incision causing PAS and
an incision going through the placenta. Patient's with confirmed placenta previa are at risk
for blood transfusion, injury to nearby organs, cesarean hysterectomy (0.2%), intensive care
admission, and death.[6] There is also an increased risk in subsequent pregnancies.
Complications

Vaginal bleeding secondary to placenta previa can lead to postpartum hemorrhage

requiring a blood transfusion, hysterectomy, maternal intensive care admission, septicemia,
and maternal death.[6] Postpartum hemorrhage is blood loss greater than or equal to 1000
ml accompanied by signs or symptoms of hypovolemia occurring within 24 hours after
delivery, regardless of the route of delivery.[24] This condition may necessitate blood
transfusion, uterotonics, uterine artery embolization, iliac artery ligation, balloon tamponade,
and hysterectomy. Placenta previa that is not diagnosed early enough or managed
improperly can lead to morbidity and mortality for both the mother and fetus. Placenta previa
is also associated with preterm birth, low birth weight, lower APGAR scores, longer duration
of hospitalization, and higher blood transfusion rates.[1] Women with placenta previa and
prior history of cesarean sections are at an increased risk of PAS. Risk of placenta accreta is
3%, 11%, 40%, 61%, and 67%, for the first, second, third, fourth, and fifth or more cesarean,
respectively.[25]

Deterrence and Patient Education

Placenta previa is the covering of the internal cervical os preventing a safe vaginal
delivery.
Delivery should be performed from 36 to 37 full weeks, via cesarean section, in
uncomplicated cases.[15]
Bed rest, avoiding intercourse, and avoiding digital examinations are recommended. Any
manipulation of the placenta can lead to hemorrhage.
Patients with placenta previa should go to the emergency room if they have any episodes of
vaginal bleeding.
Prior history of placenta previa and a history of cesarean sections may increase a patient's
risk for placenta accreta.
If there is a concern for placenta accreta, increta, or percreta, then a cesarean hysterectomy
may need to be performed.

Enhancing Healthcare Team Outcomes

Placenta previa can lead to serious consequences and requires immediate attention
to the presentation of vaginal bleeding. an interprofessional team approach must be taken to
provide the utmost care for the patient. Patients diagnosed with placenta previa prior to
vaginal bleeding should have multiple discussions with the OB/GYN regarding management
and expectations. Patients should consent for possible blood transfusions, uterine artery
embolization, and possible cesarean hysterectomy. Various disciplinaries, participating in an
interprofessional team approach should be aware of the patient including, labor and delivery
physicians, anesthesiologist, interventional radiologist, vascular surgeon, urology surgeon,
and both surgical and neonatal nurses.