Australian and New Zealand Journal of Obstetrics and Gynaecology 2015; 55: 193197

Letters to the Editor

Re: Kapoor S, Thomas JT, Petersen SG,
Gardener GJ. Is the third trimester repeat
ultrasound scan for placental localisation needed if
the placenta is low lying but clear of the os at the
mid-trimester morphology scan? Aust N Z J Obstet
Gynaecol 2014; 54(5): 42832

Dear Editor,
The study by Kapoor et al.1 conrms previous similar
studies, showing that mothers with a placenta identied on
transabdominal abdominal ultrasound in the second
trimester as within 20 mm of the internal cervical os are at
risk of placenta praevia requiring abdominal delivery at
term and thus require follow-up.
Unfortunately in their introduction, the authors
misquote national guidelines from the RCOG2 and
SOGC3 as suggesting that such women do not require
follow-up unless the placenta reaches or covers the
internal cervical os. What both guidelines actually advise is
that if the placenta is assessed on transvaginal ultrasound
between 18 and 24 weeks, only those found to reach or
cover the internal cervical os remain at risk of praevia at
term and require follow-up. This is based on studies by
Taiale et al.,4 Becker et al.,5 Smith et al.6 and Lauria
et al.7 amongst others involving over 10 000 women in
total.
Whilst this (transvaginal assessment at 1814 weeks
gestation) is not currently routine practice in most
centres, it may become so as recent evidence about the
use of transvaginal cervical length measurement at 18
22 weeks gestation, with progesterone treatment for those
with a short cervix to reduce the risk of preterm birth,8
begins to be incorporated into practice. Thus, an added
benet of routine transvaginal ultrasound at the second
trimester morphology scan should be to dramatically
reduce the number of women requiring follow-up for a
low-lying placenta in the third trimester, along with the
restricted activities that many obstetricians continue to
advise.
FRANZCOG, FRCSC, FRCOG
David SOMERSET
Southern Alberta Centre for Maternal Fetal Medicine,
Calgary, AB, Canada
E-mail: david.somerset@efwrad.com
DOI: 10.1111/ajo.12310

References
1 Kapoor S, Thomas JT, Petersen SG, Gardener GJ. Is the third
trimester repeat ultrasound scan for placental localisation

needed if the placenta is low lying but clear of the os at the

mid-trimester morphology scan? Aust N Z J Obstet Gynaecol
2014; 54(5): 428432.
RCOG Green-top Guideline No. 27, 2011. Placenta praevia,
placenta praevia accreta and vasa praevia: diagnosis and
management. [Accessed 16 December 2014.] Available from
URL: https://www.rcog.org.uk/globalassets/documents/guidelines/
gtg27placentapraeviajanuary2011.pdf
SOGC Clinical Practice Guideline No. 189, 2007. Diagnosis
and Management of Placenta Previa. [Accessed 16 December
2014.] Available from URL: http://sogc.org/wp-content/uploads/
2013/01/189E-CPG-March2007.pdf
Taipale P, Hiilesmaa V, Ylostalo P. Transvaginal
ultrasonography at 1823 weeks in predicting placenta previa at
delivery. Ultrasound Obstet Gynecol 1998; 12: 422425.
Becker RH, Vonk R, Mende BC et al. The relevance of
placental location at 2023 gestational weeks for prediction of
placenta previa at delivery: evaluation of 8650 cases. Ultrasound
Obstet Gynecol 2001; 17: 496501.
Smith RS, Lauria MR, Comstock CH et al. Transvaginal
ultrasonography for all placentas that appear to be low-lying or
over the internal cervical os. Ultrasound Obstet Gynecol 1997; 9:
2224.
Lauria MR, Smith RS, Treadwell MC et al. The use of
second-trimester transvaginal sonography to predict placenta
praevia. Ultrasound Obstet Gynecol 1996; 8: 337340.
Hassan SS, Romero R, Vidyadhari D et al. Vaginal
progesterone reduces the rate of preterm birth in women with a
sonographic short cervix: a multicenter, randomized, doubleblind, placebo-controlled trial. Ultrasound Obstet Gynecol 2011;
38 (1): 1831.

Re: Is the third trimester repeat ultrasound scan for

placental localisation needed if the placenta is low
lying but clear of the os at the mid-trimester
morphology scan?
The aim of our study was to determine the need for
repeat ultrasound scan for placental localisation in the
third trimester when the placenta was reported to be low
lying at the morphology scan. We did not differentiate
between the modality of scanning given the current
clinical practice in the community was mostly
transabdominal scanning (TAS) at the 1820 week
morphology scan.
We regret the perceived lack of clarity in our paper with
regard to the national guidelines of the SOGC and
RCOG. We agree that the SOGC recommends follow-up
third trimester scan when the placental edge reaches or
overlaps the internal os clearly stating the modality as
transvaginal scan (TVS) between 18 and 24 weeks of
gestation.1 However, the RCOG guideline recommends

2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
The Australian and
New Zealand Journal
of Obstetrics and
Gynaecology

193

Letters to the Editor

follow-up if the placenta covers or overlaps the cervical os

at 20 weeks of gestation, without indicating the modality
of scan although TVS is stated as the preferred modality.2
The evidence supporting the RCOG guideline includes
papers, which have mixed TAS and TVS data.3,4 The
NICE guideline on antenatal care provides similar
recommendations, but again does not specify the modality
as TVS or TAS at the mid-trimester scan.5
The introduction in our paper dealt with the differences
between the current Australian practices and the
international guidelines with regard to the need for a
follow-up third trimester scan for placental localisation.6
Some recent observational studies, with predominantly
TAS, suggest omitting a follow-up scan for asymptomatic
women with placenta close to but not covering the os.7,8
However, other recent reports, including ours, indicate the
need to continue follow-up scans for women with placenta
< 2 cm from the os on TAS.6,9
Shveta KAPOOR1, Joseph T. THOMAS2,
Scott G. PETERSEN2 and Glenn J. GARDENER2
1
Mater Mothers Hospital,
2
Department of Maternal Fetal Medicine, Mater Health
Services, South Brisbane, Queensland, Australia
E-mail: joseph.thomas@mater.org.au
DOI: 10.1111/ajo.12352

References
1 Diagnosis and Management of Placenta Previa. SOGC Clinical
Practice Guideline No. 189, March 2007.
2 Placenta praevia, placenta accreta and vasa praevia: diagnosis
and management. RCOG Green Top Guideline No. 27. Jan
2011.
3 Becker RH, Vonk R, Mende BC et al. The relevance of
placental location at 2023 gestational weeks for prediction of
placenta previa at delivery: evaluation of 8650 cases. Ultrasound
Obstet Gynecol 2001; 17: 496501.
4 Dashe JS, McIntire DD, Ramus RM et al. Persistence of
placenta previa according to gestational age at ultrasound
detection. Obstet Gynecol 2002; 99 (5 Pt 1): 692697.
5 Antenatal care. NICE guidelines [CG62] March 2008.
6 Kapoor S, Thomas JT, Petersen SG, Gardener GJ. Is the third
trimester repeat ultrasound scan for placental localisation
needed if the placenta is low lying but clear of the os at the
midtrimester morphology scan? Aust N Z J Obstet Gynaecol
2014 Oct; 54 (5): 428432.
7 Robinson AJ, Muller PR, Allan R et al. Precise mid-trimester
placenta localisation: does it predict adverse outcomes? Aust N
Z J Obstet Gynaecol 2012; 52: 156160.
8 Blouin D, Rioux C. Routine third trimester control ultrasound
examination for low-lying or marginal placentas diagnosed at
mid-pregnancy: is this indicated? J Obstet Gynaecol Can 2012;
34 (5): 425428.
9 Copland JA, Craw SM, Herbison P. Low-lying placenta: who
should be recalled for a follow-up scan? J Med Imaging Radiat
Oncol 2012; 56: 158162.

194

Regarding Improving VBAC rates: The combined

impact of two management strategies
Please allow me to comment on a recent paper in
ANZJOG, Improving VBAC rates: the combined impact
of two management strategies.1
The authors report on a series of 396 VBAC (Vaginal
Birth after Caesarean) candidates who attended a
dedicated clinic. The stated goal of this clinic was, as
mandated by NSW Health under Towards Normal
Birth, to increase VBAC rates. The authors convinced
57% of candidates to attempt VBAC, although about 10%
of them changed their mind, and only 160 actually
underwent VBAC. Of those 160, only 75 managed an
spontaneous vaginal delivery, and both instrumental
delivery rate (17.5%) and emergency caesarean delivery
rate (35.6%) were high.
And there were two deaths one postdates stillbirth and
one due to a ruptured uterus. I do not think it can be
disputed that VBAC caused the death of those two babies
and that it endangered the life of at least one mother
rather seriously.
The authors do point out that we must be mindful that
pursuing increased VBAC rates. . .might have signicant
costs such as increased uterine rupture rates., but they do
not mention those two deaths in the abstract, nor are they
featured in the conclusions. Quite on the contrary. They
conclude: A dedicated NBAC clinic and more consistent
approach to labour management can help improve VBAC
rates, and Further targeted counselling towards women
with previous malpresentation and/or East Asian descent
may further improve VBAC attempt rates. Yes, let us try
and talk more people into VBAC then.
I wonder though how that is going to be possible while
maintaining valid informed consent, in particular in view
of the ndings of this study. Are you going to disclose
those deaths? Without informed consent, our interventions
may be politically correct and they may well comply with
NSW Health policy directives, but they will be illegal.
What on earth are we doing this for? Why all this
misguided effort? Why are well-trained and competent
obstetricians risking the lives of their patients, and
ultimately their own careers? Do caesarean delivery rates
(or rather, compliance with ill-advised bureaucratic
targets) matter more now than perinatal deaths?
Of course we will all wake up from this bad dream.
Barristers and judges are going to make us wake up,
sooner or later.
Hans Peter DIETZ
Obstetrics and Gynaecology, Sydney Medical School Nepean,
Nepean Hospital, Penrith, New South Wales, Australia
E-mail: hpdietz@bigpond.com
DOI: 10.1111/ajo.12317

2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists