PLACENTA PREVIA BASICS DESCRIPTION Placental implantation in the lower uterine segment in advance of the presenting fetal part.

Total previa: placenta covers entire cervical os Partial previa: placenta covers part of the cervical os Marginal previa: placental edge just reaches cervical os Low lying placenta: placental edge is in the lower uterine segment but does not encroach on the cervical os System(s) affected: Reproductive, Cardiovascular Genetics: N/A Incidence/Prevalence in USA: 0.5% to 0.8% of all pregnancies, approximately 4/1,000 births; low lying placenta 4-8% in early pregnancy with < 10% persisting to term Predominant age: Childbearing ages Predominant sex: Female only SIGNS & SYMPTOMS Typically painless bright red bleeding 2nd or 3rd trimester Average time of first bleed, 27-32 weeks Contractions variably present First bleed usually self-limited Maternal hemodynamic status consistent with clinical blood loss estimate Complete previas may bleed earlier and not migrate CAUSES Prior uterine insult or injury or other uterine factors RISK FACTORS Prior previa (4%-8%) First subsequent pregnancy following a caesarean section delivery Multiparity (5% in grand multiparous patient) Advanced maternal age Multiple gestation Smoking Cocaine use Male fetus C-section odds ratio (OR) Primipara with one C-section OR=1.28 (95% confidence interval [CI] 0.82-1.99) Multipara with 4 or more deliveries and one C-section OR=1.72 (95% CI 1.12-2.64) Multipara with >4 deliveries and >4 C-sections OR=8.76 (95% CI 1.58-48.53) Induced abortion Sharp curettage - three or more procedures OR=2.9 (95% CI 1.0-8.5) Vacuum aspiration - not associated with increased risk of placenta previa DIAGNOSIS DIFFERENTIAL DIAGNOSIS Abruptio placentae, vasa previa, vaginal and cervical causes including marked bloody show and infections LABORATORY Maternal blood type and Rh Hemoglobin, hematocrit, and platelet PT, PTT, fibrinogen Type and cross match packed RBC (at least three units) Apt test: To determine fetal origin of blood (as in vasa previa). Mix vaginal blood with small amount tap water to cause hemolysis, centrifuge for several minutes, mix 1 cc of 1% NaOH with each 5 cc of the pink-hemoglobin-containing supernatant, observing pink fluid if fetal hemoglobin, and yellow-brown if adult origin.

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 Wrights stain applied to a slide smear of vaginal blood looking for nucleated RBCs which are usually from cord blood and not adult blood L/S ratio for fetal maturity if needed Drugs that may alter lab results: Drugs altering cell counts or clotting studies Disorders that may alter lab results: Coagulopathies from other causes Red cell and hemoglobin disorders from other causes PATHOLOGICAL FINDINGS Normocytic, normochromic anemia with acute bleed Coagulopathy rare, but may occur Positive Kleihauer-Betke if fetal/maternal transfusion SPECIAL TESTS Kleihauer-Betke if concerned about fetal-maternal transfusion Bedside clot test: Draw red top tube from mother and observe for clot quality at 7-10 minutes. If there is no clot or if clot is friable may indicate disseminated intravascular coagulation (DIC). IMAGING External sector sonography with moderately full and empty bladder Vaginal probe sonography may be done if not actively bleeding. Place the probe just inside vaginal os and use 5 or 6.5-MHz transducers. Magnetic resonance imaging (MRI) accurate, but more expensive, less available, and time consuming DIAGNOSTIC PROCEDURES If placental location unknown and sonography not available, a double setup bimanual vaginal exam may be done in operating room with complete cesarean section readiness Careful vaginal speculum exam is not contraindicated and allows checking for cervical or vaginal source of bleeding, fern and nitrazine testing, cultures, and fluid for determining bleeding source Since fibrin degradation products rise in pregnancy, these levels are less helpful TREATMENT APPROPRIATE HEALTH CARE Inpatient observation at bedrest initially; once stable, and preterm, may be followed as outpatient May consider transfer to high risk center based on condition and local services GENERAL MEASURES Optimizing maternal stability while delaying delivery, if possible, or if preterm to improve perinatal outcome Cesarean section indicated for partial or complete previa if fetus is mature or if the situation is urgent and the fetus is immature A trial of labor may be considered with anterior marginal previa, including oxytocin (Pitocin) augmentation IV Amniocentesis for L/S ratio for maturity as needed IV fluid support, oxygen, transfusions of packed RBCs, platelets and fresh frozen plasma if needed External fetal and labor monitoring Other intervention or observation based on maternal condition DIC risk low unless massive bleed. Follow coagulation studies and give fresh frozen plasma (FFP), platelets as needed, or cryoprecipitate if fibrinogen < 100-150 mg/dL (< 1.0-1.5 g/L). Transfuse platelets at < 20,000 or < 50,000 if surgery needed Low lying posterior marginal previa associated with dystocia and greater need for cesarean section Blood volume increased in pregnancy; can lose > 30% maternal blood volume before shock findings Central line placement only after checking coagulation studies May use sector probe with condom at introitus if vaginal probe unavailable With significant hemorrhage, Rh negative women should receive Rho(D) immune globulin (Rhogam) with each bleed

SURGICAL MEASURES Cervical cerclage may reduce risk of delivery before 34 weeks (RR=0.45 [95% CI 0.23-0.87]) or birth weight less than 2kg RR=0.34 (0.14-0.83) or low 5-minute Apgar score RR=0.19 (0.04-1.00)

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ACTIVITY Bedrest Pelvic rest; intercourse abstinence, avoid douching DIET NPO initially, then based on delivery decisions PATIENT EDUCATION First bleed rarely fatal Rebleed risk with activity or cervical stimulation Greatest cause of perinatal mortality is prematurity Risks and conditions associated with previa MEDICATIONS DRUG(S) OF CHOICE For IV fluids: Lactated Ringers or saline Oxygen for all, since O2 consumption up 20% in pregnancy and fetus is more prone to hypoxia Fresh frozen plasma and platelets as needed Cryoprecipitate and fibrinogen if above unsuccessful Tocolytics may have role in certain preterm patients, but tachycardia of -agonists (terbutaline) and risk of placental hypoperfusion with calcium channel blockers may make MgSO4 the drug of choice. For MgSO4, use 4 grams IV load and 1-4 grams/hour as indicated. Contraindications: Avoid tocolytics with term infant or unstable mother Precautions: Beta-agonists and calcium channel blockers may complicate clinical picture Cryoprecipitate and fibrinogen may increase infection transmission risk Significant possible interactions: Refer to manufacturers profile of each drug ALTERNATIVE DRUGS Ritodrine (Yutopar) IV may be an alternate beta-agonist, but carries same concerns as terbutaline FOLLOW-UP PATIENT MONITORING Inpatient follow-up Outpatient care with frequent visits PREVENTION/AVOIDANCE Decrease activity to avoid rebleeding All vaginal exams, sexual intercourse, douching, or other vaginal manipulation may cause rebleeding POSSIBLE COMPLICATIONS Maternal mortality is rare with cesarean section available. Greatest fetal risk is preterm delivery. History of prior C-section and/or general anesthesia increases risk for need of transfusion Attempted tocolysis may compromise maternal status Rebleeding risk may be more risky than delivery and management If previa present after 30 weeks, there is greater risk of persisting previa Placental accreta strongly associated with placenta previa (up to 15% of patients). Higher incidence in women with placenta previa and multiple prior cesarean sections. Vasa previa IUGR - 16% incidence Congenital anomalies: Most common major anomalies of the central nervous system, cardiovascular system, respiratory and gastrointestinal tracts. Fetal anemia and Rh isoimmunization EXPECTED COURSE/PROGNOSIS If term and complete or partial: Cesarean delivery If term and anterior marginal: Trial of labor may be okay If preterm and maternal and fetal status stable: May observe and delay delivery

MISCELLANEOUS ASSOCIATED CONDITIONS Abnormal presentations such as oblique and/or transverse lie Persistent high fetal station

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 Postpartum hemorrhage Increased incidence of small for gestational age (SGA) babies with previas AGE-RELATED FACTORS Pediatric: N/A Geriatric: N/A Others: Advanced maternal age increases risk PREGNANCY As above SYNONYMS N/A ICD-9-CM 641.00 Placenta previa without hemorrhage, unspecified 641.10 Hemorrhage from placenta previa, unspecified 641.20 Premature separation of placenta, unspecified 762.1 Premature separation of placenta (when causing newborn complications) SEE ALSO Abruptio placentae OTHER NOTES N/A ABBREVIATIONS DIC = disseminated intravascular coagulation L/S ratio = lecithin/sphingomyelin ratio PT = prothrombin time PTT = partial thromboplastin time REFERENCES Neilson JP. Interventions for suspected placenta praevia (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software Royal College of Obstetricians and Gynecologists. Placenta Praevia: diagnosis and management. London: RCOG, 2000. (Green-top guideline No 27.) Cunningham FG, et al: Williams Obstetrics. 21st ed. McGraw-Hill Professional; 2001 Creasy RD, Resnik R: Maternal - Fetal Medicine. 5th ed. WB Saunders Company; 2003 Baron F, et al: Placenta previa, placenta abruptio. Clin Ob Gyn, Vol 41, No3, 1998;527-532 Frederiksen MC, Glassenberg R, Stika CS. Placenta previa: a 22-year analysis. Am J Obstet Gynecol 1999;180(6 Pt 1):1432-7 Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies. J Matern Fetal Neonatal Med. 2003;13(3):175-90 Johnson L, Mueller B, Daling J. The relationship of placenta previa and history of induced abortion. Int J Gynaecol Obstet. 2003;81(2):191-8 Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. Obstet Gynecol. 2002;99(6):976-80

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