Placenta praevia - Wikipedia, the free encyclopedia 10/03/15 10:22

Placenta praevia
From Wikipedia, the free encyclopedia

Placenta praevia (placenta previa

AE) is an obstetric complication in Placenta previa
which the placenta is inserted
partially or wholly in the lower
uterine segment.[1] It is a leading
cause of antepartum haemorrhage
(vaginal bleeding). It affects
approximately 0.4-0.5% of all
labours.[2]

In the last trimester of pregnancy the

isthmus of the uterus unfolds and
forms the lower segment. In a normal
pregnancy the placenta does not
overlie. If the placenta does overlie
the lower segment, as is the case with
placenta praevia, it may shear off and Diagram showing a placenta praevia (Grade IV)
a small section may bleed. Classification and external resources
ICD-10 O44
(http://apps.who.int/classifications/icd10/browse/2015/en#/O44),
Contents P02.0
(http://apps.who.int/classifications/icd10/browse/2015/en#/P02.0)
1 Etiopathogenesis ICD-9 641.0 (http://www.icd9data.com/getICD9Code.ashx?
1.1 Grades icd9=641.0), 641.1
1.2 Risk factors (http://www.icd9data.com/getICD9Code.ashx?icd9=641.1)
2 Clinical features MedlinePlus 000900
3 Diagnosis (http://www.nlm.nih.gov/medlineplus/ency/article/000900.htm)
3.1 Clinical MeSH D010923 (https://www.nlm.nih.gov/cgi/mesh/2015/MB_cgi?
3.2 Confirmatory field=uid&term=D010923)

4 Management
4.1 Mode of delivery
5 Complications
5.1 Maternal
5.2 Fetal
6 Epidemiology

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7 History
8 References

Etiopathogenesis
Exact etiology of placenta praevia is unknown. It is hypothesized to be related to abnormal vascularisation of
the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection. These factors may
reduce differential growth of lower segment, resulting in less upward shift in placental position as pregnancy
advances.[3]

Grades

Traditionally, four grades of placenta praevia are defined:[1]

Grade Description
I Placenta is in lower segment, but the lower edge does not reach internal os
II Lower edge of placenta reaches internal os, but does not cover it
III Placenta covers internal os partially
IV Placenta covers internal os completely

Risk factors
The following have been identified as risk factors for placenta
praevia: Risk factors with their odds ratio[4]
Risk factor Odds ratio
Previous placenta previa (recurrence rate 4-8%),[5] Maternal age ≥ 40 (vs. < 20) 9.1
caesarean delivery,[6] myomectomy[7] or endometrium Illicit drugs 2.8
damage caused by D&C.[5] ≥ 1 previous Cesarean section 2.7
Alcohol use during pregnancy.[8] Parity ≥ 5 (vs. para 0) 2.3
Women who have had previous pregnancies, especially Parity 2–4 (vs. para 0) 1.9
a large number of closely spaced pregnancies, are at Prior abortion 1.9
higher risk due to uterine damage.[7] Smoking 1.6

Smoking during pregnancy;[1] cocaine use during Congenital anomalies 1.7

Male fetus (vs. female) 1.1
pregnancy[9][10]
Pregnancy-induced hypertension 0.4
Women who are younger than 20 are at higher risk and
women older than 35 are at increasing risk as they get

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older.
Women with a large placentae from twins or erythroblastosis are at higher risk.
Race is a controversial risk factor, with some studies finding that people from Asia and Africa are at
higher risk and others finding no difference.
Placental pathology (Vellamentous insertion, succinturiate lobes, bipartite i.e. bilobed placenta etc.)[5]

Placenta previa is itself a risk factor of placenta accreta.

Clinical features
Women with placenta praevia often present with painless, bright red vaginal bleeding. This commonly occurs
around 32 weeks of gestation, but can be as early as late mid-trimester.[11] This bleeding often starts mildly and
may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after
24 weeks of gestation.

Women may also present as a case of failure of engagement of fetal head.[7]

Diagnosis
Clinical
History may reveal antepartum hemorrhage. Abdominal examination and usually finds the uterus non-tender,
soft and relaxed. Leopold's Maneuvers may find the fetus in an oblique or breech position or lying transverse as
a result of the abnormal position of the placenta. Malpresentation is found in about 35% cases.[12] Vaginal
examinaton is avoided in known cases of placenta praevia.[1]

Confirmatory

Previa can be confirmed with an ultrasound.[13] Transvaginal ultrasound has superior accuracy as compared to
transabdominal one, thus allowing measurement of distance between placenta and cervical os. This has rendered
traditional classification of placenta praevia obsolete.[14][15][16][17]

False positives may be due to following reasons:[18]

Overfilled bladder compressing lower uterine segment

Myometrial contraction simulating placental tissue in abnormally low location
Early pregnancy low position, which in third trimester may be entirely normal due to differential growth
of the uterus.

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In such cases, repeat scanning is done after an interval of 15–30 minutes.

In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with an
examination in the surgical theatre. The proper timing of an examination in theatre is important. If the woman is
not bleeding severely she can be managed non-operatively until the 36th week. By this time the baby's chance
of survival is as good as at full term.

Management
An initial assessment to determine the status of the mother and fetus is required. Although mothers used to be
treated in the hospital from the first bleeding episode until birth, it is now considered safe to treat placenta
praevia on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the
fetus are in distress. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or
mother are in distress. Blood volume replacement (to maintain blood pressure) and blood plasma replacement
(to maintain fibrinogen levels) may be necessary.

The corticosteroids are indicated at 24-34 weeks gestation if the patient has bleeding, given the higher risk of
premature birth.

Mode of delivery
The mode of delivery is determined by clinical state of the mother, fetus and ultrasound findings. In minor
degrees (traditional grade I and II), vaginal delivery is possible. RCOG recommends that the placenta should be
at least 2 cm away from internal os for an attempted vaginal delivery.[19] When a vaginal delivery is attempted,
consultant obstetrician and anesthetists are present in delivery suite. In cases of fetal distress and major degrees
(traditional grade III and IV) a caesarean section is indicated. Caesarian section is contraindicated in cases of
disseminated intravascular coagulation. An obstetrician may need to divide the anterior lying placenta. In such
cases, blood loss is expected to be high and thus blood and blood products are always kept ready. In rare cases,
hysterectomy may be required.[20] In the U.S., women covered by private insurance are 22% more likely to
receive a caesarean section than women covered by Medicaid.[21]

Complications
Maternal

Antepartum hemorrhage
Malpresentation
Abnormal placentation
Postpartum hemorrhage
Placenta praevia increases the risk of puerperal sepsis and postpartum hemorrhage because the lower
segment to which the placenta was attached contracts less well post-delivery.

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Fetal

IUGR (15% incidence)[5]

Premature delivery
Death

Epidemiology
Placenta previa occurs approximately one of every 250 births. One third of all antepartum hemorrhage occurs
due to placenta previa. It has been suggested that incidence of placenta praevia is increasing due to increased
rate of Caesarian section.[22]

Perinatal mortality rate of placenta praevia is 3-4 times higher than normal pregnancies.[23]

History
In places where a Caesarean section could not be performed due to the lack of a surgeon or equipment, infant
could be delivered vaginally. There were two ways of doing this with a placenta praevia:

The baby's head can be brought down to the placental site (if necessary with Willet's forceps or a
vulsellum) and a weight attached to its scalp
A leg can be brought down and the baby's buttocks used to compress the placental site

The goal of this type of delivery is to save the mother, and both methods will often kill the baby. These methods
were used for many years before Caesarean section and saved the lives of both mothers and babies with this
condition.

References
1. ^ a b c d Arulkumaran, edited by Richard Warren, Sabaratnam (2009). Best practice in labour and delivery (1st ed., 3rd
printing. ed.). Cambridge: Cambridge University Press. pp. 142–146. ISBN 978-0-521-72068-7.
2. ^ Faiz, AS; Ananth, CV (March 2003). "Etiology and risk factors for placenta previa: an overview and meta-analysis of
observational studies.". The journal of maternal-fetal & neonatal medicine : the official journal of the European
Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of
Perinatal Obstetricians 13 (3): 175–90. doi:10.1080/jmf.13.3.175.190 (https://dx.doi.org/10.1080%2Fjmf.13.3.175.190).
PMID 12820840 (https://www.ncbi.nlm.nih.gov/pubmed/12820840).

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3. ^ Dashe, JS; McIntire, DD; Ramus, RM; Santos-Ramos, R; Twickler, DM (May 2002). "Persistence of placenta previa
according to gestational age at ultrasound detection.". Obstetrics and gynecology 99 (5 Pt 1): 692–7. doi:10.1016/s0029-
7844(02)01935-x (https://dx.doi.org/10.1016%2Fs0029-7844%2802%2901935-x). PMID 11978274
(https://www.ncbi.nlm.nih.gov/pubmed/11978274).
4. ^ Jr, [edited by] E. Albert Reece, John C. Hobbins ; foreword by Norm F. Gant, (2006). Clinical obstetrics : the fetus
and mother. (3 ed.). Malden, MA: Blackwell Pub. p. 1050. ISBN 978-1-4051-3216-9.
5. ^ a b c d Kendrick, Chantal Simon, Hazel Everitt, Tony (2005). Oxford handbook of general practice (2nd ed.). Oxford:
Oxford University Press. p. 793. ISBN 9780198565819.
6. ^ Weerasekera, D. S. (2000). "Placenta praevia and scarred uterus - an obstetrician's dilemma". Journal of Obstetrics &
Gynaecology 20 (5): 484–5. doi:10.1080/014436100434659 (https://dx.doi.org/10.1080%2F014436100434659).
PMID 15512632 (https://www.ncbi.nlm.nih.gov/pubmed/15512632).
7. ^ a b c Brinsden, Judith Collier, Murray Longmore, Mark (2006). Oxford handbook of clinical specialties (7th ed.).
Oxford: Oxford University Press. p. 1970. ISBN 9780198530855.
8. ^ Aliyu, MH; Lynch, O; Nana, PN; Alio, AP; Wilson, RE; Marty, PJ; Zoorob, R; Salihu, HM (July 2011). "Alcohol
consumption during pregnancy and risk of placental abruption and placenta previa.". Maternal and child health journal
15 (5): 670–6. doi:10.1007/s10995-010-0615-6 (https://dx.doi.org/10.1007%2Fs10995-010-0615-6). PMID 20437196
(https://www.ncbi.nlm.nih.gov/pubmed/20437196).
9. ^ Handler, A; Kistin, N; Davis, F; Ferré, C (Apr 15, 1991). "Cocaine use during pregnancy: perinatal outcomes.".
American Journal of Epidemiology 133 (8): 818–25. PMID 2021149 (https://www.ncbi.nlm.nih.gov/pubmed/2021149).
10. ^ Kistin, N; Handler, A; Davis, F; Ferre, C (July 1996). "Cocaine and cigarettes: a comparison of risks.". Paediatric and
perinatal epidemiology 10 (3): 269–78. doi:10.1111/j.1365-3016.1996.tb00050.x (https://dx.doi.org/10.1111%2Fj.1365-
3016.1996.tb00050.x). PMID 8822770 (https://www.ncbi.nlm.nih.gov/pubmed/8822770).
11. ^ Callander, Kevin P. Hanretty ; illustrated by Ian Ramsden, Robin (2004). Obstetrics illustrated (6th ed., Reprinted.
ed.). Edinburgh [etc.]: Churchill Livingstone. p. 187. ISBN 0443072671.
12. ^ Cotton, DB; Read, JA; Paul, RH; Quilligan, EJ (Jul 15, 1980). "The conservative aggressive management of placenta
previa.". American journal of obstetrics and gynecology 137 (6): 687–95. PMID 7395932
(https://www.ncbi.nlm.nih.gov/pubmed/7395932).
13. ^ Bhide, Amar; Thilaganathan, Basky (2004). "Recent advances in the management of placenta previa". Current
Opinion in Obstetrics and Gynecology 16 (6): 447–51. doi:10.1097/00001703-200412000-00002
(https://dx.doi.org/10.1097%2F00001703-200412000-00002). PMID 15534438
(https://www.ncbi.nlm.nih.gov/pubmed/15534438).
14. ^ Oppenheimer, LW; Farine, D; Ritchie, JW; Lewinsky, RM; Telford, J; Fairbanks, LA (October 1991). "What is a low-
lying placenta?". American journal of obstetrics and gynecology 165 (4 Pt 1): 1036–8. doi:10.1016/0002-
9378(91)90465-4 (https://dx.doi.org/10.1016%2F0002-9378%2891%2990465-4). PMID 1951509
(https://www.ncbi.nlm.nih.gov/pubmed/1951509).
15. ^ Neale, E. J.; Rogers, M. S. (1 July 1989). "Vaginal ultrasound for ruling out placenta praevia. Case report". BJOG: an
International Journal of Obstetrics and Gynaecology 96 (7): 881–881. doi:10.1111/j.1471-0528.1989.tb03334.x
(https://dx.doi.org/10.1111%2Fj.1471-0528.1989.tb03334.x).

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Placenta praevia - Wikipedia, the free encyclopedia 10/03/15 10:22

16. ^ Smith, RS; Lauria, MR; Comstock, CH; Treadwell, MC; Kirk, JS; Lee, W; Bottoms, SF (January 1997). "Transvaginal
ultrasonography for all placentas that appear to be low-lying or over the internal cervical os.". Ultrasound in obstetrics &
gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology 9 (1): 22–4.
doi:10.1046/j.1469-0705.1997.09010022.x (https://dx.doi.org/10.1046%2Fj.1469-0705.1997.09010022.x).
PMID 9060125 (https://www.ncbi.nlm.nih.gov/pubmed/9060125).
17. ^ Farine, D; Fox, HE; Jakobson, S; Timor-Tritsch, IE (September 1988). "Vaginal ultrasound for diagnosis of placenta
previa.". American journal of obstetrics and gynecology 159 (3): 566–9. PMID 3048096
(https://www.ncbi.nlm.nih.gov/pubmed/3048096).
18. ^ Sutton, David (2003). Textbook of radiology and imaging (7th ed.). Edinburgh: Churchill Livingstone. p. 1064.
ISBN 0443071098.
19. ^ "Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and Management"
(http://www.rcog.org.uk/womens-health/clinical-guidance/placenta-praevia-and-placenta-praevia-accreta-diagnosis-and-
manageme). RCOG Guidelines - Green-top 27. Retrieved 15 January 2013.
20. ^ Kayem, G; Davy, C; Goffinet, F; Thomas, C; Clément, D; Cabrol, D (September 2004). "Conservative versus
extirpative management in cases of placenta accreta.". Obstetrics and gynecology 104 (3): 531–6.
doi:10.1097/01.AOG.0000136086.78099.0f (https://dx.doi.org/10.1097%2F01.AOG.0000136086.78099.0f).
PMID 15339764 (https://www.ncbi.nlm.nih.gov/pubmed/15339764).
21. ^ Moore JE, Witt WP, Elixhauser A. (April 2014). "Complicating Conditions Associate With Childbirth, by Delivery
Method and Payer, 2011." (https://www.hcup-us.ahrq.gov/reports/statbriefs/sb173-Childbirth-Delivery-
Complications.jsp). HCUP Statistical Brief #173. Rockville, MD: Agency for Healthcare Research and Quality.
22. ^ Miller, DA; Chollet, JA; Goodwin, TM (July 1997). "Clinical risk factors for placenta previa-placenta accreta.".
American journal of obstetrics and gynecology 177 (1): 210–4. doi:10.1016/s0002-9378(97)70463-0
(https://dx.doi.org/10.1016%2Fs0002-9378%2897%2970463-0). PMID 9240608
(https://www.ncbi.nlm.nih.gov/pubmed/9240608).
23. ^ Crane, JM; van den Hof, MC; Dodds, L; Armson, BA; Liston, R (April 1999). "Neonatal outcomes with placenta
previa". Obstetrics and gynecology 93 (4): 541–4. doi:10.1016/s0029-7844(98)00480-3
(https://dx.doi.org/10.1016%2Fs0029-7844%2898%2900480-3). PMID 10214830
(https://www.ncbi.nlm.nih.gov/pubmed/10214830).

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