Letters to the Editors

www. AJOG.org

Placenta previa
TO THE EDITORS: In the recent article by Dr Vergani et al,1
we read with interest the information presented regarding placental distance from the cervical os and mode of delivery. However, we had numerous concerns with the data presented in the
study.
The prevalence of prelabor cesarean section deliveries that
were performed in the study was high. This, in turn, revealed a
small sample size of patients with a placenta previa who had a
trial of labor (TOL). In addition, the study did not actually
reveal how many patients had a TOL. Based on the information
provided, we were able to deduce that there were likely 6 patients with a placenta 110 mm (group 1) from the os and 20
patients with a placenta 1120 mm (group 2) from the cervical
os who would have had a TOL. It would be beneficial if the
authors could confirm theses numbers. Outcomes for those
patients who actually had a TOL are, in our opinion, of most
clinical relevance. If the authors would provide these data, it
may indicate some initial evidence to suggest whether patients
with a placenta previa and TOL had reasonable outcomes.
Interestingly, of the data that were presented, estimated blood
loss (EBL) for group 1 and group 2 was similar. Given that group
2 had fewer cesarean section deliveries, we would have expected
group 2 to have significantly less EBL. This may have been influenced by placenta position, because it was noted there were more
anterior placentas in group 2 than in group 1 (48% vs 29%), and it
is expected that cesarean deliveries with an anterior placenta will
have a higher EBL. It would be valuable to know which patients
(TOL vs cesarean delivery) had an anterior placenta. If there is no
evidence of higher EBL for those with a cesarean delivery and
anterior placenta, then, alternatively, it may indicate that a higher
than average EBL occurred for the patients with a TOL, which
would be an outcome of concern.
This study presented a number of patients who had a vaginal
delivery with a placenta previa. Unfortunately, the necessary data
for those who had a TOL were not presented, thereby limiting
clinical application. However, this study provides evidence that
there may be clinical equipoise to justify future studies.
f

REFERENCE

Nicole D. Paterson, MD
R. Douglas Wilson, MD, FRCSC
University of Calgary
Department of Obstetrics and Gynecology
Calgary, Alberta, Canada
nicole.paterson@albertahealthservices.ca

Patrizia Vergani, MD
Sara Ornaghi, MD
Alessandro Ghidini, MD
University of Milano-Bicocca
Monza, Italy

1. Vergani P, Ornaghi S, Pozzi I, et al. Placenta previa: distance to internal

os and mode of delivery. Am J Obstet Gynecol 2009;201:266-8.
2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.11.025

REPLY
We thank Drs Paterson and Wilson for their interest in our study.
They request additional information on the subset of women who
were admitted to trial of labor (TOL). The aim of our study was to
evaluate the incidence of cesarean section delivery (CS) in relation
to a standardized way to diagnose placenta praevia using transvaginal ultrasound. Subanalysis of specific groups leads to small sample sizes, which negatively influences statistical significance of the
results. The following data should answer their requests: 28 of 53
women (53%) with a placental edge-to-cervical os distance between 120 mm were admitted to TOL; 8 cases belonged to group
1 (110 mm), and the remaining 20 cases to group 2 (1120 mm).
Among these 28 women, 26 women delivered vaginally, and 2
women underwent CS in labor for nonreassuring fetal testing and
intrapartum hemorrhage, respectively (both women belonged to
group 1). Estimated blood loss (EBL) for women who were admitted to TOL, compared with those women who underwent prelabor CS, was 812 909 mL vs 492 633 mL (P .29). Among
cases in group 1, EBL in TOL vs prelabor CS was 812 909 mL vs
697 545 mL (P .70); in group 2, it was 492 633 mL vs 550
306 mL (P .80).
If we analyze the EBL in relation to the placental position, 14
of 28 women who were admitted to TOL and 7 of 25 women
who underwent prelabor CS had an anterior placenta. EBL was
633 779 mL vs 514 291 mL in the 2 groups, respectively (P
.70). Therefore, in our series, anterior placenta previa cannot
be considered an additional risk factor for bleeding.
The 2 important highlights of our study were to provide a
more accurate classification of placenta previa and, as expressed by Oppenheimer et al in their editorial, a more precise
photograph of the link between the likelihood of bleeding
and the need of CS in the subgroups of women.
f

2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.11.023

Forgotten Father of Progesterone

TO THE EDITORS: I read with interest your Editors
Choice article, a review on Progesterone for pre-term birth
prevention: an evolving intervention.1
e10

American Journal of Obstetrics & Gynecology JUNE 2010

Although the authors state that their concise review was restricted only to more recent data (since 2000), they also state
that there is still considerable uncertainty surrounding how