Background

Placenta previa involves implantation of the placenta over the internal cervical os. Variants include complete implantation over the os (complete placenta previa), a placental edge partially covering the os (partial placenta previa) or the placenta approaching the border of the os (marginal placenta previa). A low-lying placenta implants in the caudad one half to one third of the uterus or within 2-3 cm from the os.

Placenta previa.

Placenta previa covering the entire cervical

os.

Placenta previa partially separated from the lower uterine segment.

Placenta previa invading the lower uterine segment and covering the cervical os.

Pathophysiology
Placental implantation is initiated by the embryo (embryonic plate) adhering in the lower (caudad) uterus. With placental attachment and growth, the developing placenta may cover the cervical os. However, it is thought that a defective decidual vascularization occurs over the cervix, possibly secondary to inflammatory or atrophic changes. As such, sections of the placenta having undergone atrophic changes could persist as a vasa previa. A leading cause of third trimester hemorrhage, placenta previa presents classically as painless bleeding. Bleeding is thought to occur in association with the development of the lower uterine segment in the third trimester. Placental attachment is disrupted as this area gradually thins in preparation for the onset of labor. When this occurs, bleeding occurs at the implantation site as the uterus is unable to contract adequately and stop the flow of blood from the open vessels. Thrombin release from the bleeding sites

promotes uterine contractions and leads to a vicious cycle of bleeding-contractions-placental separationbleeding.

Epidemiology
Frequency
United States Placenta previa occurs in 0.3-0.5% of all pregnancies. The risks increase 1.5- to 5-fold with a history of cesarean delivery. A recent meta-analysis showed that the rate of placenta previa increases with increasing numbers of cesarean deliveries, with a rate of 1% after 1 cesarean delivery, 2.8% after 3 cesarean deliveries, and as high as 3.7% after 5 cesarean deliveries.[1] Despite this increased incidence after cesarean delivery, recent studies show that a previous cesarean delivery did not increase the odds of detecting a placenta previa on second-trimester ultrasonography. However, ultrasonography is useful in determining the rate of placental migration observed at 28-36 weeks' gestation, which may identify patients who are more likely to deliver vaginally with resolution of the previa. Of all placenta previas, the frequency of complete placenta previa ranges from 20-45%, partial placenta previa accounts for approximately 30%, and marginal placenta previa accounts for the remaining 25-50%.

Mortality/Morbidity
Table. Relative Risk of Morbidities in Patients With Placenta Previa (Open Table in a new window) Morbidities Antepartum bleeding Relative Risk 10

Need for hysterectomy 33 Blood transfusion Septicemia Thrombophlebitis Endometritis 10 5.5 5 6.6[2]

The maternal mortality rate associated with placenta previa ranges from 2-3%. Maternal mortality is 0.03% in the United States. Neonatal mortality associated with placenta previa is as high as 1.2%.[3]

Race
Placenta previa has no predilection for any race.

Sex
Placenta previa only occurs in pregnant women.

Age
Age is associated with a varying prevalence of placenta previa. The risk of placenta previa in relation to age is as follows: Aged 12-19 years - 1%

Aged 20-29 years - 0.33% Aged 30-39 years - 1% Older than 40 years - 2%