Management of Placenta Previa - UpToDate

15/10/2016
ManagementofplacentapreviaUpToDate
OfficialreprintfromUpToDate
www.uptodate.com.scihub.cc2016UpToDate
Managementofplacentaprevia
Authors: CharlesJLockwood,MD,MHCM,KarenRussoStieglitz,MD
SectionEditors: DeborahLevine,MD,SusanMRamin,MD
DeputyEditor: VanessaABarss,MD,FACOG
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Sep2016.|Thistopiclastupdated:May09,2016.
INTRODUCTIONThemanagementofpregnanciescomplicatedbyplacentapreviaisbestaddressedintermsoftheclinical
setting:asymptomaticwomen,womenwhoareactivelybleeding,andwomenwhoarestableafteroneormoreepisodesofactive
bleeding.
ASYMPTOMATICPLACENTAPREVIAThemanagementgoalsinwomenwithasymptomaticplacentapreviaareto:
Determinewhetherthepreviaresolveswithincreasinggestationalage
Reducetheriskofbleeding
Reducetheriskofpretermbirth
FollowuptransvaginalultrasoundexaminationDevelopmentoftheloweruterinesegmentovertimeoftenrelocatesthe
loweredgeofamarginalorminimallyoverlyingpreviaawayfromtheinternalos.Themajorityofplacentapreviaidentifiedearlierin
pregnancywillresolvewithadvancinggestationalage.Weagreewiththeapproachofanexpertgroupformonitoringtheplacental
locationofthesepregnanciesacrossgestation[1]:
Forpregnancies>16weeks,
Iftheplacentaledgeis2cmfromtheinternalos,theplacentallocationisreportedasnormalandfollowupultrasoundfor
placentallocationisnotindicated.
Iftheplacentaledgeis<2cmfrom,butnotcovering,theinternalos,theplacentaislabeledaslowlying.Iftheplacental
edgecoverstheinternalos,theplacentaislabeledaprevia.Foreitherdiagnosis,followupultrasonographyforplacental
locationisperformedat32weeksofgestation.
Atthe32weekfollowupultrasound,
Iftheplacentaledgeis2cmfromtheinternalos,theplacentallocationisreportedasnormalandfollowupultrasoundfor
placentallocationisnotindicated.
Iftheplacentaledgeisstill<2cmfromtheinternalos(lowlying)orcoveringthecervicalos(previa),followuptransvaginal
ultrasoundisperformedat36weeks.
TransvaginalultrasonographywithcolorandpulsedDopplerisrecommendedtoruleoutplacentapreviaaswellasvasaprevia,as
resolutionofalowlyingplacentacanbeassociatedwithvasaprevia.(See"Clinicalfeatures,diagnosis,andcourseofplacenta
previa",sectionon'Ultrasoundpresentationandcourse'.)
Thesepregnanciesareatnoorminimallyincreasedriskofintrauterinegrowthrestriction.Thereisnoevidencethatspecifically
monitoringfetalgrowthwithserialultrasoundexaminationsisusefulhowever,thisinformationisgenerallyavailablesincefetal
growthisestimatedwheneverultrasoundexaminationisperformedforassessmentofplacentalposition.(See"Clinicalfeatures,
diagnosis,andcourseofplacentaprevia",sectionon'Associatedconditions'.)
PredictionofandreductionofriskofbleedingForanindividualpatient,itisnotpossibletoaccuratelypredictwhethera
bleedwilloccur,northegestationalage,volume,orfrequencyofbleeding.Sonographicfeaturesreportedtobeassociatedwitha
higherlikelihoodofbleedingincludeplacentacompletelycoveringtheos,placentawithathickedge(>1cm),placentawithanecho
freespaceintheedgeoverlappingtheos,andcervicallength3cm.(See"Clinicalfeatures,diagnosis,andcourseofplacenta
previa",sectionon'Bleeding'.)
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Weadvisewomenwithplacentapreviatoavoidvaginalintercourseandexerciseafter20weeksofgestation(earlieriftheyhave
experiencedvaginalbleeding),andtodecreaseoverallphysicalactivityinthethirdtrimester.Therationaleisthattheseactivities
causeuterinecontractions,which,inturn,provokebleeding.Additionally,thereisconcernthatvaginalintercoursemightcause
directtraumatotheprevia,resultinginbleeding.Thereisnoevidencetoeithersupportorrefutetheserecommendations.However,
itisclearfromanecdotalexperiencethatpalpationofplacentapreviathroughapartiallydilatedcervixcanresultinsevere
hemorrhage.
Womenshouldalsobeadvisedtoseekimmediatemedicalattentionifcontractionsorvaginalbleedingoccur,giventhepotentialfor
severebleedingandneedforemergencycesareandelivery.
Itisunclearwhetherasymptomaticwomenbenefitfromhospitalizationpriortodelivery.Findingsfromobservationalstudiessuggest
thatwomenwithplacentapreviawhohavenotexperiencedanyantepartumbleedingareatlowriskofneedinganemergency
cesareandelivery[25].Thesewomencangenerallybemanagedonanoutpatientbasisuntilvaginalbleedingoccursoruntil
admissionforscheduledcesareanbirth.However,patientspecificriskfactors(eg,shortcervicallength,abilitytogettothehospital
promptlyinanemergency,homesupport)needtobetakenintoaccount.
DeliveryAworkshopheldbytheEuniceKennedyShriverNationalInstituteofChildHealthandHumanDevelopmentandthe
SocietyforMaternalFetalMedicinedevelopedconsensusrecommendationsregardingthegestationalagefordeliverytooptimize
maternal,fetalandneonataloutcomesinthesettingofvariouspregnancycomplications,includingplacentaprevia[6].They
stratifiedplacentapreviaascomplicatedoruncomplicated,whereuncomplicatedwasdefinedasnofetalgrowthrestriction,no
superimposedpreeclampsia,andnootherissuesthattakeprecedentfordeliverydecisionmaking.
Weagreewiththerecommendationsbythecommittee,whichwasbasedonavailabledataandexpertopinion,andtheAmerican
CollegeofObstetriciansandGynecologists(ACOG).Deliveryofpregnancieswithuncomplicatedplacentapreviashouldbe
accomplishedat360/7thsto376/7thsweeks,withoutdocumentationoffetallungmaturitybyamniocentesis[6,7].Therationalebehind
thisrecommendationisthattherisksassociatedwithcontinuingthepregnancy(severebleeding,emergencyunscheduleddelivery)
aregreaterthantherisksassociatedwithprematurityatthisgestationalage[6].(See"Latepreterminfants".)
Therouteofdeliveryandprocedurearedescribedbelow.(See'Route'belowand'Cesareanprocedure'below.)
ACUTECAREOFBLEEDINGPLACENTAPREVIAAnactivelybleedingplacentapreviaisapotentialobstetricalemergency.
ThesewomenshouldbeadmittedtotheLaborandDeliveryUnitformaternalandfetalmonitoring,andtheanesthesiateamshould
benotified.Themajorgoalsinmanagingthesepregnanciesareto:
Achieveand/ormaintainmaternalhemodynamicstability
Determineifcesareandeliveryisindicated
Ifthereisevidenceofpersistentseverevaginalbleeding(picture1),maternalhypotension,oranonreassuringfetalheartrate
pattern,deliveryisgenerallyexpeditedviacesareanregardlessofgestationalage.Ifbleedingisnotpersistentandsevere,the
motherishemodynamicallystableorquicklystabilized,andthefetalheartratepatternisnormal,expectantmanagementis
preferabletodeliverybefore34weeksofgestation.Tosomedegree,theseassessmentsaresubjectiveandmadeonacaseby
casebasiswhileobservingthepatientscourseonthelaborunit.Administrationofmagnesiumsulfatetopregnancies<32weeksof
gestationforneuroprotectionandacourseofantenatalcorticosteroidsmaysignificantlyimproveneonataloutcome.Thisbenefit
needstobecomparedwiththeestimatedmaternalriskfrompersistentorworseningbleeding.Theneonatalbenefitsofavoiding
expeditiousdeliverydecreasewithadvancinggestationalage,whilematernalrisksprobablyincrease.Duringtheperiodofdecision
making,everyattempttoensurematernalsafetyshouldbemade,asdescribedbelow.
Assessment
MaternalWeuseacardiacmonitorandautomatedbloodpressurecufftomonitormaternalheartrateandbloodpressure.
UrineoutputisevaluatedhourlywithaFoleycatheterattachedtoanurometer.
Accurateestimationofvaginalbloodlossisdifficulttodeterminevisually,particularlywhenbloodispartiallysaturatingorsoaking
towels,maternitypads,orgauzesponges,ordrippingontothefloor[8,9].Thefollowingtechniquesareusedforquantitatingblood
lossandcanbeusedincombination[9,10]:
Collectbloodingraduatedvolumetriccontainers.
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Useofvisualaidsthatcorrelatethesizeandappearanceofbloodonspecificsurfaces(eg,maternitypad,emesisbasin,bed
sheet,lapsponge)withthevolumeofbloodabsorbedbythatsurface(picture1).Regularlyschedulingstandardizedtrainingin
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theuseofthesechartscanbehelpfulforthisassessment.
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Measurethetotalweightofbloodymaterialsandsubtracttheknownweightofthesamematerialswhendry.Thedifferencein
weightbetweenwetanddryingramsapproximatesthevolumeofbloodinmilliliters.
Forallofthesemethods,theclinicianshouldattempttoaccountforfluidsotherthanblood(eg,amnioticfluid,irrigationfluid,urine)
thatarecollectedorabsorbed.
FetalThefetalheartrateshouldbemonitored.Thepresenceoffetalhypoxiaoranemiamayresultincategory2or3fetal
heartratetracings.(See"Intrapartumfetalheartrateassessment".)
LaboratoryThereisnoconsensusaboutthecomponentsofroutinelaboratoryassessmentofpatientswithbleedingplacenta
previa[11,12].
Ataminimum,bloodshouldbesentforbaselinecompletebloodcountandtypeandantibodyscreen.Thebloodbankshould
benotifiedthatapatientwithplacentapreviahasbeenadmitted.
Whenbleedingisheavyorincreasing,deliveryislikely,ordifficultyinprocuringcompatiblebloodisanticipated,weadvise
crossmatchingtwotofourunitsofpackedredbloodcells.
Massivebloodlossorsuspicionofcoexistentabruptionshouldpromptevaluationforcoagulopathy:fibrinogenlevel,activated
partialthromboplastintime,prothrombintime.Acrudeclottingtestcanbeperformedatthebedsidebyplacing5mLofthe
patient'sbloodinatubewithnoanticoagulantfor10minutes[46].Failuretoclotwithinthistimeordissolutionofaninitialclot
impliesimpairmentofcoagulation,andissuggestiveofalowfibrinogenlevel.Prolongedoozingfromneedlepuncturesitesalso
suggestscoagulopathy.(See"Placentalabruption:Clinicalfeaturesanddiagnosis"and"Placentalabruption:Management".)
AKleihauerBetketestonaspecimenofvaginalbloodcandiagnosefetalbleedingfromdisruptionoffetalvesselsinplacentalvilli,
vasaprevia,oravelamentouscordhowever,thefetalbleedingtypicallyresultsinfetaldemiseoranonreassuringfetalheartrate
tracingnecessitatingemergencydelivery.(See"Velamentousumbilicalcordinsertionandvasaprevia".)
AntishockgarmentsAntishockgarmentshavebeenusedtorestoreadequatebloodpressureinpregnant/postpartumwomen
whoarehemodynamicallyunstableduetoseverebleedinginlowresourcesettings[1315].However,thesedeviceshavenotbeen
usedwhenthefetuswasviableandthereisnoinformationontheireffectonuteroplacentalbloodflowandthefetus.
IntravenousaccessandcrystalloidOneortwolargeboreintravenouslinesareinsertedandcrystalloid(Ringerslactateor
normalsaline)isinfusedtoachieve/maintainhemodynamicstabilityandadequateurineoutput(atleast30mL/hour).(See
"Treatmentofseverehypovolemiaorhypovolemicshockinadults".)
TransfusionTransfusionofbloodproductsinawomanwithanactivelybleedingplacentapreviashouldbeguidedbythe
volumeofbloodlossovertimeandchangesinhemodynamicparameters(eg,bloodpressure,maternalandfetalheartrates,
peripheralperfusion,andurineoutput),aswellasthehemoglobinlevel.Areasonableapproachistobeginredcelltransfusionsin
hypotensivepatientswhosebloodpressurefailstoimproveaftertwolitersofcrystalloidhavebeenrapidlyinfused.
Typesandactionsofbloodreplacementproductsareshowninthetable(table1).Thebloodbankshouldbenotifiedaboutthe
possibleneedformassivetransfusion(algorithm1).(See"Indicationsandhemoglobinthresholdsforredbloodcelltransfusionin
theadult"and"Massivebloodtransfusion".)
TocolysisTocolysisissometimesusedinpregnancieswithsymptomaticplacentapreviatoreduceoreliminateuterine
contractions,whichmaypromoteplacentalseparationandbleeding.Observationalstudiesinwomenwithsymptomaticplacenta
previasuggestthistherapymayprolongpregnancyandresultinanincreaseinbirthweight,withoutcausingadverseeffectsonthe
motherorfetus[16,17].However,itislikelythatunderlyingdifferencesinthetreatedanduntreated(control)patientsaccountedfor
thisbenefit.Furthermore,thesestudieshavegenerallynotshownadecreaseinthenumberofepisodesofhemorrhageafter
admission,thetotalamountofbloodloss,orthenumberofbloodtransfusions.Iftocolyticsareused,indomethacinhasaninhibitory
effectonplateletfunctionandthusshouldbeavoidedinwomenwithplacentapreviaduetotheriskofincreasedbloodloss.(See
"Inhibitionofacutepretermlabor".)
Wedonotadministertocolyticdrugstoactivelybleedingpatients.Wemayusetocolytics(otherthanindomethacin)tominimize
contractileactivitywhileadministeringacourseofbetamethasoneifbleedingisdiminishingorhasceasedanddeliveryisnot
otherwisemandatedbythematernalorfetalcondition.
MagnesiumsulfateWesuggestacourseofmagnesiumsulfatetherapyforneuroprotectioninpatientswithpreterm(24to32
weeks)placentapreviainwhomadecisionhasbeenmadetodeliverwithin24hours,butnotemergently.Emergencydelivery
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becauseofmaternalorfetalstatusshouldnotbedelayedtoadministermagnesiumsulfate.(See"Neuroprotectiveeffectsofin
uteroexposuretomagnesiumsulfate".)
AntenatalcorticosteroidsAcourseofantenatalcorticosteroidtherapyshouldbeadministeredtosymptomaticwomenbetween
23and34weeksofgestationtoenhancefetalpulmonarymaturity.Wedonotadministersteroidstoasymptomaticwomen.We
wouldgiveafirstcourseofsteroidstowomenwhosefirstbleedisat>34and<37weeksofgestationandforasymptomaticwomen
whosecesareandeliveryisplannedbetween36and37completedweekswhohavenotreceivedpriorantenatalcorticosteroids.
(See"Antenatalcorticosteroidtherapyforreductionofneonatalmorbidityandmortalityfrompretermdelivery",sectionon'After34
weeks'.)
IndicationsfordeliveryCesareandeliveryisindicatedifanyofthefollowingoccur:
Anonreassuringfetalheartratetracingunresponsivetoresuscitativemeasures.(See"ManagementofintrapartumcategoryI,
II,andIIIfetalheartratetracings".)
Lifethreateningmaternalhemorrhagerefractorytostandardinterventions(transfusion,tocolysis,rest)
Significantvaginalbleedingafter34weeksofgestation
AnesthesiaGeneralanesthesiaistypicallyadministeredforemergencycesareandelivery,especiallyinhemodynamically
unstablewomenorifthefetalstatusisnonreassuring.However,regionalanesthesiaisanacceptablechoiceinhemodynamically
stablewomenwithreassuringfetalheartratetracings[1820].
Anepiduralanestheticmaybeplacedinahemodynamicallystablewoman,evenifthedecisiontodeliverisnotdefinite.The
advantageofthisapproachisthatitmayallowavoidanceofgeneralanesthesiafordelivery.Thedisadvantagesarethatthepatient
maynotbedeliveredandthecatheterwillhavetoberemoved,asubstantialhemorrhagemayinducehypotensionandthe
anestheticmayexacerbatehypotensiveendorganeffects,andgeneralanesthesiaispreferabletoepiduralanesthesiaif
hysterectomyisnecessaryatdeliverybecausetheplacentapreviaiscomplicatedbyaccretaoratonyunresponsivetoconservative
measures.
CONSERVATIVEMANAGEMENTAFTERANACUTEBLEEDMostwomenwhoinitiallypresentwithsymptomaticplacenta
previarespondtosupportivetherapyanddonotrequireimmediatedelivery[2125].Inobservationalseries,50percentofwomen
withasymptomaticprevia(anyamountofbleeding)werenotdeliveredforatleastfourweeks[22,24,25].Evenalargebleeddoes
notprecludeconservativemanagement.Inonelargeseries,50percentofwomenwhoseinitialhemorrhagicepisodeexceeded500
mLweresuccessfullymanagedwithaggressiveuseofantepartumtransfusionsandhadameanprolongationofpregnancyof17
days[21].
Managementofplacentapreviaafteracutebleedingisbaseduponfindingsfromobservationalstudiesandclinicalexperience.A
2003Cochranereviewthatattemptedtoassesstheimpactofclinicalinterventionsinthesepregnanciesconcludedtherewere
insufficientdatauponwhichtomakeevidencebasedrecommendationsforclinicalpracticeonlythreerandomizedtrialsinvolvinga
totalof114womenwereidentified[26].
Afterthepatienthasbeenstabilized,wetakethefollowingapproachwiththegoalofprolongingthepregnancy.
InpatientversusoutpatientmanagementSymptomaticwomenoftenremainhospitalizedfromtheirinitialorsecondsignificant
bleedingepisodeuntildelivery.Sincethefrequencyandseverityofrecurrentbleedingepisodesareunpredictable,maintaining
closeproximitytothelaboranddeliveryunitmayminimizetheriskofseriousmaternalorfetalcomplicationsbyenablingprompt
accesstotransfusiontherapyandemergencycesareandeliverywhenneeded.
Wedischargeselectedwomenwithplacentapreviawhosebleedinghasstoppedforaminimumof48hoursandwhohavenoother
pregnancycomplications,althoughthesafetyandefficacyofthisapproachhasnotbeenestablished[24,2729].Inouropinion,
candidatesforoutpatientcareshould:
Beabletoreturntothehospitalwithin20minutes[30].
Bereliableandabletomaintainbedrestathome.
Understandtherisksentailedbyoutpatientmanagement.
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Haveanadultcompanionavailable24hours/daywhocanimmediatelytransportthewomantothehospitalifthereislight
bleedingorcallanambulanceforseverebleeding.
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Theonlyrandomizedclinicaltrialofoutpatientversusinpatientmanagementofwomenwithplacentapreviaafterresolutionofthe
initialbleedingepisodereportedthatoutpatientcarewasnotassociatedwithgreatermorbiditythaninpatientmanagement[24].
Patientsrandomlyassignedtotheoutpatientarmwhohadarecurrentbleedweretreatedinitiallyasinpatients,andwereagain
dischargedhomeifstableafteraminimumof48to72hours.Ifthesepatientshadathirdepisodeofbleeding,theywere
hospitalizeduntildelivery.Significantdifferencesinoutcomemaynothavebeenappreciatedgiventhesmallnumberofwomen(n=
53)whoparticipatedinthistrial.
CorrectionofanemiaIronsupplementationmaybeneededforoptimalcorrectionofanemia.Stoolsoftenersandahighfiber
diethelptominimizeconstipationandavoidexcessstrainingthatmightprecipitatebleeding.(See"Treatmentofirondeficiency
anemiainadults".)
AutologousblooddonationSomewomenmayconsiderautologousblooddonation,giventhehighfrequencyofblood
transfusioninplacentaprevia.Aprogramofautologousbloodcollectionandtransfusioncandecreasetheneedforhomologous
bloodtransfusion[31].However,mostwomenwhohavebledfromaplacentaprevia,willnotmeetstandardcriteriaforautologous
donation[32,33].Autologousblooddonationissafeinstablewomenwhomeetusualcriteria(hemoglobin11.0g/dL)[31,34,35].
Somecentershaveloweredthehemoglobinthresholdto>10g/dLforpregnantwomenwithplacentapreviatoenableautologous
donationformoreofthesewomen[31].(See"Surgicalbloodconservation:Preoperativeautologousblooddonation".)
AntiDimmuneglobulinTheoretically,disruptionofthefetomaternalinterfacemayresultinfetomaternaltransfusion.Forthis
reason,preventionofRhalloimmunizationguidelinessuggestthatRh(D)negativewomenreceiveantiDimmuneglobulinfor
symptomaticplacentaprevia(ie,bleedingprevia)[36,37].ThepresenceofpositiveantiDantibodytitersonperiodicassessment
canhelpensurethatthepatientisprotectedfrompotentialalloimmunizationinthesettingofrecurrentbleeds.Readministrationis
notnecessaryifdeliveryorrebleedingoccurswithinthreeweeksofadministration,unlessalargefetomaternalhemorrhageis
detected.(See"PreventionofRh(D)alloimmunizationinpregnancy".)
FetalassessmentThereisnoprovenvalueofnonstresstestingorperformingabiophysicalprofileinpregnancieswith
asymptomaticplacentaandnoevidenceofuteroplacentalinsufficiency(eg,preeclampsia,fetalgrowthrestriction,oligohydramnios)
orotherindicationsforantepartumfetalassessment.Asdiscussedabove,activevaginalbleedingisanindicationforfetal
monitoring(see'Fetal'above).
CerclageCervicalcerclagehasbeenusedinanattempttominimizeearlydevelopmentoftheloweruterinesegment,whichis
thoughttopromoteplacentalseparation.However,theefficacyofthisapproachisunproven.Althoughametaanalysisoftwo,small
randomizedtrialsthatevaluatedcerclageforimprovingpregnancyoutcomeinplacentaprevia[38,39]reportedthatcervical
cerclagereducedtheriskofdeliverybefore34weeks(RR0.45,95%CI0.230.87)andthebirthofababyweighinglessthan2000
g(RR0.34,95%CI0.140.83),thelackofconsistencybetweentrialsandmethodologicalissuespreventmakingaclearconclusion
ofbenefit[26].Intheabsenceofhighqualityevidenceofefficacyandsafety,weadvisenotperformingprophylacticcerclageto
improvepregnancyoutcomeinplacentaprevia.However,thepresenceofastableplacentapreviaisnotacontraindicationto
cerclageplacementwhenindicatedforcervicalinsufficiency.(See"Cervicalinsufficiency".)
PretermprematureruptureofmembranesAntepartumdecidualhemorrhageisamajorriskfactorforpretermpremature
ruptureofmembranes(PPROM).PPROMcanoccurdespitethepresenceofacompleteplacentaprevia.Inthesecases,each
conditionismanagedindependently.(See"Pretermpremature(prelabor)ruptureofmembranes".)
Delivery
TimingTimingofdeliverydependsonthepatientsstatus.
Deliveryofpatientswithstable(nobleedingorminimalbleeding)placentapreviashouldbeaccomplishedat36to37weeks,without
documentationoffetallungmaturitybyamniocentesis(see'Delivery'above).
Deliveryisindicatedemergentlyifanyofthefollowingoccur(see'Indicationsfordelivery'above):
Anyvaginalbleedingwithanonreassuringfetalheartratetracingunresponsivetoresuscitativemeasures
Lifethreateningrefractorymaternalhemorrhage
Labor
Inwomenwithmoderatevaginalbleeding>34weeksorprogressivelyincreasingfrequencyorvolumeofbleedingaftercessationof
aninitialbleed,wedeliverthepatientifshehaspreviouslyreceivedacourseofbetamethasoneanytimeduringthepregnancy.If
sheisclinicallystableandhasnotreceivedacourseofbetamethasonebecauseherfirstbleedingepisodeoccurredafter34weeks
andbefore37weeks,weadministeracourseofsteroidsandthenperformcesareandeliveryin48hours,basedonlimiteddatathat
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evenlateingestationneonatalrespiratoryproblemsmaybereducedwithsteroiduse.(See"Antenatalcorticosteroidtherapyfor
reductionofneonatalmorbidityandmortalityfrompretermdelivery".)
Route
PreviaAcesareandeliveryisalwaysindicatedwhenthereissonographicevidenceofacompleteplacentapreviaanda
viablefetus.Vaginaldeliverymaybeconsideredinrarecircumstances,suchasinthepresenceofafetaldemiseorapreviable
fetus,aslongasthemotherremainshemodynamicallystable.
Whentheplacentareachestheinternalosbutdoesnotcrossit,ithasbeenhypothesizedthatvaginaldeliverycanoccasionallybe
performedbecausethefetalheadtamponadestheadjacentplacenta,thuspreventinghemorrhage.Thesepregnanciesremainat
highriskofintrapartumhemorrhagetherefore,wesuggestscheduledcesareandeliverytominimizetheriskofemergentdelivery
andneedfortransfusion.
LowplacentaRatesofcesareandeliveryandantepartumbleedingdecreaseasthedistancebetweentheplacentaledge
andinternalosincreases.Thereisageneralconsensusofareasonablepossibilityofvaginaldeliverywithouthemorrhagewhenthe
placentaismorethan20mmfromtheinternalos,soatrialoflaborisappropriateiftherearenoothercontraindicationstovaginal
birth[4045].Whenthisdistanceisbetween1and20mm,therateofcesareandeliveryrangesfrom40to90percent,so
managementofthesepatientsismorecontroversial.Oneofthelargerretrospectivestudiesthatlookedattheoutcomeofthis
specificgroupofpregnanciesreportedvaginalbirthin6/24(25percent)womenwithacervixtoplacentadistanceof1to10mm
andin20/29(69percent)womenwithcervixtoplacentadistanceof11to20mm[46].Althoughavarietyoffactorsinfluencedthe
decisiontoperformcesareandelivery,thesedatasupportallowingatrialoflaborinpregnanciesinwhichtheplacentaismorethan
10mmfromtheinternalos.
CesareanprocedureTwotofourunitsofpackedredbloodcellsshouldbeavailableforthedelivery.Appropriatesurgical
instrumentsforperformanceofacesareanhysterectomyshouldalsobeavailablesincethesepatientsareatincreasedriskof
placentaaccreta,evenintheabsenceofapriorcesareandelivery.Evaluationforplacentapreviaaccretashouldhavebeen
performedantenatally,withappropriatepreparationsformanagement,ifpresent.(See"Clinicalfeatures,diagnosis,andcourseof
placentaprevia",sectionon'Associatedconditions'and"Clinicalfeaturesanddiagnosisofthemorbidlyadherentplacenta(placenta
accreta,increta,andpercreta)"and"Managementofthemorbidlyadherentplacenta(placentaaccreta,increta,andpercreta)"and
"Peripartumhysterectomyformanagementofhemorrhage".)
Thesurgeonshouldtrytoavoiddisruptingtheplacentawhenenteringtheuterus.Iftheplacentaisincised,hemorrhagefromfetal
vesselscanresultinsignificantneonatalanemia.Preoperativeorintraoperativesonographiclocalizationishelpfulindetermining
thepositionofthehysterotomyincision(forintraoperativeimaging,thetransducerisplacedinasterilebagandsleeve).Ifthe
placentaisinananterolaterallocation,averticalincisioncanbemadeintheloweruterinesegmentontheoppositesidefromthe
placenta.Iftheplacentawrapsaroundthecervixfromtheanteriortoposteriorloweruterinesegmentinthemidline,atransverseor
verticalincisionmaybepossibleaboveit[47,48],althoughthisoftenresultsinextensionintotheupperuterinesegment.When
incisionoftheplacentaisunavoidable,theinfantshouldbedeliveredrapidlyandthecordpromptlyclamped.
ManagementofhemorrhageAfterdeliveryoftheplacenta,severebleedingmayoccurfromtheplacentalbed.Standard
interventionsformanagementofpostpartumhemorrhageshouldbeperformed,andmayincludeplacementofendouterine
hemostaticsquaresutures,intrauterineballoontamponade,and/orplacementofuterinecompressionsutures[4951].(See
"Managementofpostpartumhemorrhageatcesareandelivery".)
Inaddition,vasopressininjectionattheplacentalsitemaybebeneficial[52,53].Inonereview,localinjectionof4unitsof
vasopressinin20mLofsalineintotheplacentalimplantationsitesignificantlyreducedbloodlosswithoutincreasingthemorbidity
[53].TheauthorsnotedthatthevasopressinV1receptorwashighlyexpressedinsmoothmusclecellsinthelowersegmentofthe
uterus.Inacasereport,5unitsofvasopressinin20mLsalineinjectedin1to2mLamountsintotheareaofplacentalimplantation
stoppedbleedingwithin90seconds[52].Useofthistechnique,whilebiologicallyplausibleandpotentiallyclinicallyrelevant,is
consideredanecdotal.
PREGNANCYTERMINATIONINWOMENWITHPLACENTAPREVIACliniciansshoulddiscusswithpatientsthevarious
optionsforpregnancyterminationinthesettingofplacentaprevia(eg,hysterotomy,dilationandevacuation,useofabortifacient)
anddocumentthediscussioninthemedicalrecord.Thepresenceofaplacentapreviadoesnotprecludesecondtrimester
pregnancyterminationbystandardtechniques,althoughdataarelimitedtoafewstudies[5457].
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Oneseriesof131consecutivewomenundergoingelectivepregnancyterminationbydilationandevacuation(D&E)after
laminariaplacementat13to24weeksofgestationcomparedtheoutcomeofthosewith(n=23)andwithoutplacentaprevia
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baseduponanultrasoundexaminationbeforetheprocedure[54].Womenwithaplacentapreviahadgreaterintraoperative
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bloodloss(21mL),butnosignificantincreaseinoperativetime,timetodischarge,infection,hemorrhage,orother
complications.
Thesecondseriesconsistedof306consecutivewomenundergoingpregnancyterminationbyD&Eat19to24weeks[55].An
ultrasounddiagnosisofcompletepreviawasmadeineightpatients.Noneofthesewomenhadexcessivebleedingwith
laminariainsertionorrequiredbloodtransfusionduetoprocedurerelatedhemorrhage.Operativetimewascomparableto
womenwithoutcompleteprevia.
Thethirdseriesincluded15secondorthirdtrimesterterminationsofpregnancybyadministrationofsystemicabortifacientsin
womenwithcompleteprevia[56].Preinductionfeticidewasperformed2to14dayspriortotheprocedure.Fourofninewomen
whounderwentlaborinductionwithoutpreviousfeticiderequiredbloodtransfusionsandonerequiredhysterectomynoneof
thesixpatientswithpreinductionfeticiderequiredtransfusion.Theauthorsconcludedthatpreinductionfeticidemighthelpto
reducebloodlossinthesecases.
Thefourthseriesincluded158womenundergoingsecondtrimesterterminationinwhom11hadplacentaprevia,4underwentD&E
and7hadgemeprosttermination[57].Therewasnostatisticaldifferenceinmeanintraoperativebloodlossbetweenthesegroups
andcontrolswithoutprevia,butonewomanwithplacentapreviawhounderwentgemeprostterminationdevelopedseriousbleeding
requiringbloodtransfusion.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and"Beyondthe
Basics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereadinglevel,andtheyanswerthe
fourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesarebestforpatientswhowantageneral
overviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,
andmoredetailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepth
informationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicstoyour
patients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingonpatientinfoandthekeyword(s)of
interest.)
Basicstopics(see"Patienteducation:Placentaprevia(TheBasics)")
SUMMARYANDRECOMMENDATIONS
Asymptomaticprevia
Inpregnancieswithasymptomaticplacentaprevia,wemonitorplacentalpositionwithultrasoundexaminationasanoutpatient
andcounselthesepatientstoavoidexcessphysicalactivityandtocalltheirproviderpromptlyifbleedingorlaboroccurs.We
performcesareandeliveryat36to37weeks.(See'Asymptomaticplacentaprevia'above.)
Acutemanagementofbleedingprevia
Anactivelybleedingplacentapreviaisapotentialobstetricalemergency.Womenwithactivebleedingarehospitalizedforclose
maternalandfetalmonitoringandsupportivecare.Indicationsforemergencycesareandeliveryincluderefractorylife
threateningmaternalhemorrhage,nonreassuringfetalstatus,andsignificantvaginalbleedingafter34weeksofgestation.(See
'Acutecareofbleedingplacentaprevia'above.)
Conservativemanagementafteranacutebleed
Afterableedingepisodehasresolved,outpatientmanagementofselectwomenisreasonable.Thesewomenshouldbeableto
returntothehospitalquicklyifrebleedingoccursandshouldnothaveadditionalpregnancycomplications.(See'Conservative
managementafteranacutebleed'above.)
Werecommendacourseofantenatalcorticosteroidtherapyforsymptomaticpatientsbetween23and34weeksofgestationto
enhancefetalpulmonarymaturity(Grade1A).Wewouldgiveafirstcourseofsteroids(butnotasecondcourse)towomen
whosefirstbleedisat>34weeksandtoasymptomaticwomen>34weeksinwhomcesareandeliveryisplannedbetween36
and37weeks.WealsorecommendantiDimmuneglobulinforsymptomaticRh(D)negativewomentopreventpossible
alloimmunization(Grade1B).ReadministrationofantiDimmuneglobulinisnotnecessaryifdeliveryorrebleedingoccurs
withinthreeweeks,unlessalargefetomaternalhemorrhageisdetected.(See'Antenatalcorticosteroids'aboveand'AntiD
immuneglobulin'above.) https://www.uptodate.com/contents/managementofplacentaprevia?source=search_result&search=placenta+previa&selected
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Weschedulecesareandeliveryat36to37weeks.(See'Timing'above.)Incisionoftheplacentashouldbeavoided,asthis
increasestheriskoffetalhemorrhage.(See'Cesareanprocedure'above.)
Vaginaldeliverymaybeattemptedwhentheplacentaledgeis>10mmfromtheinternalosbecausetheriskofhemorrhage
duringlaborismuchlower.(See'Lowplacenta'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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28.DrosteS,KeilK.Expectantmanagementofplacentaprevia:costbenefitanalysisofoutpatienttreatment.AmJObstet
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29.D'AngeloLJ,IrwinLF.Conservativemanagementofplacentaprevia:acostbenefitanalysis.AmJObstetGynecol1984
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31.YamadaT,MoriH,UekiM.Autologousbloodtransfusioninpatientswithplacentaprevia.ActaObstetGynecolScand2005
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36.FungKeeFungK,EasonE,CraneJ,etal.PreventionofRhalloimmunization.JObstetGynaecolCan200325:765.
37.ACOGpracticebulletin.PreventionofRhDalloimmunization.Number4,May1999(replaceseducationalbulletinNumber
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38.AriasF.Cervicalcerclageforthetemporarytreatmentofpatientswithplacentaprevia.ObstetGynecol198871:545.
39.CoboE,CondeAgudeloA,DelgadoJ,etal.Cervicalcerclage:analternativeforthemanagementofplacentaprevia?AmJ
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40.BhideA,PrefumoF,MooreJ,etal.Placentaledgetointernalosdistanceinthelatethirdtrimesterandmodeofdeliveryin
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41.OppenheimerLW,FarineD,RitchieJW,etal.Whatisalowlyingplacenta?AmJObstetGynecol1991165:1036.
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44.PredanicM,PerniSC,BaergenRN,etal.Asonographicassessmentofdifferentpatternsofplacentaprevia"migration"inthe
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33:204.
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2004104:531.
48.KotsujiF,NishijimaK,KurokawaT,etal.Transverseuterinefundalincisionforplacentapraeviawithaccreta,involvingthe
entireanterioruterinewall:acaseseries.BJOG2013120:1144.
49.YoongW,RidoutA,MemtsaM,etal.Applicationofuterinecompressionsutureinassociationwithintrauterineballoon
tamponade('uterinesandwich')forpostpartumhemorrhage.ActaObstetGynecolScand201291:147.
50.MatsubaraS,KuwataT,BabaY,etal.Anovel'uterinesandwich'forhaemorrhageatcaesareansectionforplacentapraevia.
AustNZJObstetGynaecol201454:283.
51.KavakSB,AtilganR,DemirelI,etal.Endouterinehemostaticsquaresuturevs.Bakriballoontamponadeforintractable
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52.ZakiZM,BaharAM.Massivehaemorrhageduetoplacentapraeviaaccreta:ausefulroleforvasopressin.JObstetGynaecol
199717:486.
53.KatoS,TanabeA,KankiK,etal.Localinjectionofvasopressinreducesthebloodlossduringcesareansectioninplacenta
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54.ThomasAG,AlvarezM,FriedmanFJr,etal.Theeffectofplacentapreviaonbloodlossinsecondtrimesterpregnancy
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Topic6809Version22.0
SciHub
URL,DOI,
http://www.uptodate.com.secure.scihub.cc/contents/managementofplacentaprevia/print?source=search_result&search=placenta%20previa&selectedTitle
10/15
15/10/2016
GRAPHICS
Visualaidforestimatingintrapartumbloodloss
Visualaid.Pocketcardwithimagesofmeasuredvolumesofartificialblood.
From:ZuckerwiseLC,PettkerCM,IlluzziJ,etal.Useofanovelvisualaidtoimproveestimationofobstetricbloodloss.ObstetGynecol2014
123:982.DOI:10.1097/AOG.0000000000000233.ReproducedwithpermissionfromLippincottWilliams&Wilkins.Copyright2014American
CollegeofObstetriciansandGynecologists.Unauthorizedreproductionofthismaterialisprohibited.
Graphic103418Version1.0
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Bloodcomponents:Indicationsanddosinginadults
Component(volume)
Contents
Indicationsanddose
Wholeblood(1unit=500
mL)
RBCs,platelets,plasma
Rarelyrequired.Maybeappropriatewhenmassivebleedingrequirestransfusion
ofmorethan5to7unitsofRBCs.
Redbloodcells(RBCs)in
additivesolution,alsocalled
packedRBCs(1unit=350
mL)
RBCs
Anemia,bleeding.Oneunitincreasesthehemoglobinbyapproximately1g/dL
andthehematocritbyapproximately3percentagepoints.
FreshFrozenPlasma(FFP)*
(1unit=200to300mL)
Allsolubleplasma
proteinsandclotting
factors
Bleedingorexpectedbleeding(eg,emergencysurgery)inindividualswith
deficienciesofmultiplecoagulationfactors(eg,DIC,liverdisease,massive
transfusion,anticoagulationwithwarfarinorothervitaminKantagonist,warfarin
overdose)therapeuticplasmaexchangeinTTP.OneunitofFFPincreasesthe
plasmafibrinogenby7to10mg/dL.Ausualdoseis10to15mL/kg.Mayalsobe
usedinindividualswithisolatedfactordeficienciesifafactorconcentrateor
recombinantfactorisunavailable.
Cryoprecipitate,also
called"cryo"(1unit=10to
20mL)
FibrinogenfactorsVIII
andXIIIVWF
Bleedingorexpectedbleedingwithlowfibrinogen:oneunitofcryoprecipitateper
10kgbodyweightwillraisetheplasmafibrinogenbyapproximately50mg/dL.
BleedingorexpectedbleedinginindividualswithdeficienciesoffactorXIIIor
factorVIII(hemophiliaA)ifarecombinantproductorfactorconcentrateis
unavailable.
BleedingorexpectedbleedinginindividualswithVWDifDDAVPisineffectiveand
recombinantVWForaVWFconcentrateisunavailable.
Cryoprecipitateisgenerallyprovidedinpoolscontaining5unitsandmost
patientsreceivetwopools.
Platelets(derivedfrom
wholebloodorapheresis)
(1unit=200to300mL)
Platelets
Sixunitsofwholebloodderivedplateletsoroneunitofapheresisderived
plateletswillraisetheplateletcountbyapproximately30,000/microLinan
averagesizedadult.
RefertoUpToDatetopicsontheseproductsandonspecificconditionsfordetailsofuse.Frozenbloodproducts(FFP,Cryoprecipitate)take
10to30minutestothaw.Itmaytakethesameamountoftimetoperformanuncomplicatedcrossmatch.
*Otherplasmaproductsmaybesubstituted,includingPlasmaFrozenWithin24HoursAfterPhlebotomy(PF24)orThawedPlasma.
DIC:disseminatedintravascularcoagulationFFP:freshfrozenplasmakg:kilogramsTTP:thromboticthrombocytopenicpurpuraVWD:von
WillebranddiseaseVWF:vonWillebrandfactor.
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Samplemassivetransfusionalgorithm
TexasChildren'sPavilionforWomenmassivetransfusionprotocol.
MTP:massivetransfusionprotocolPRBC:packedredbloodcellsPCA:patientcontrolledanalgesia
RRT:rapidresponseteamBB:bloodbankHg:hemoglobinHct:hematocritDIC:disseminated
intravascularcoagulationPT:prothrombintimeINR:internationalnormalizedratioPTT:partial
thromboplastintimeABG:arterialbloodgasRBC:redbloodcellsFFP:freshfrozenplasmaOB:
ObstetricsAnes:AnesthesiaOR:operatingroomCRNA:certifiedregisterednurseanesthetistChrg:
chargeRN:registerednurseLab:laboratoryTech:technicianMD:medicaldoctorL&D:laborand
deliveryiCa:ionizedcalciumK:potassiumGlu:glucosePCA:patientcareassistant.
*Everytwopackagesorbasedonlabresults.
Reproducedwithpermission.AccessedonFebruary19,2013.CopyrightEvidenceBasedOutcomes
Center,2013.QualityandOutcomesCenter,TexasChildren'sHospital.Thisguidelinewaspreparedbythe
EvidenceBasedOutcomesCenter(EBOC)teamincollaborationwithcontentexpertsatTexasChildren's
HospitalPavilionforWomen.DevelopmentofthisguidelinesupportstheTCHQualityandPatientSafety
Programinitiativetopromoteclinicalguidelinesandoutcomesthatbuildacultureofqualityandsafety
withintheorganization.Guidelinerecommendationsaremadefromthebestevidence,clinicalexpertise
andconsensus,inadditiontothoughtfulconsiderationforthepatientsandfamiliescaredforwithinthe
IntegratedDeliverySystem.Whenevidencewaslackingorinconclusive,contentexpertsmadeconsensus
recommendations.Expertconsensusisimpliedwhenareferenceisnototherwiseindicated.Theguideline
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isnotintendedtoimposestandardsofcarepreventingselectivevariationinpracticethatisnecessaryto
meettheuniqueneedsofindividualpatients.Thephysicianmustconsidereachpatientandfamily's
circumstancetomaketheultimatejudgmentregardingbestcare.
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ContributorDisclosures
CharlesJLockwood,MD,MHCM Consultant/AdvisoryBoards:Celula[Aneuploidyscreening(Nocurrentproductsordrugsinthe
US)]. KarenRussoStieglitz,MD Nothingtodisclose DeborahLevine,MD Nothingtodisclose SusanMRamin,MD Nothingto
disclose VanessaABarss,MD,FACOG Nothingtodisclose
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvetting
throughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriately
referencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy
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