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Timing of Delivery for

Women with Stable Placenta Previa


Sean C. Blackwell, MD
Women with placenta previa are at increased risks for complications related to obstetrical
hemorrhage and the need for emergent delivery. Some will remain asymptomatic without
preterm labor or vaginal bleeding, and thus the clinician must decide when to schedule
cesarean delivery in a stable patient. Decision-making for the optimal timing of delivery
across the late preterm and early-term period requires balancing the probability and
severity of maternal hemorrhage at each gestational age versus the probability and severity
of neonatal morbidity. On the basis of the limited available data, in women with uncomplicated complete placenta previa, scheduled delivery between 36 and 37 weeks should be
considered.
Semin Perinatol 35:249-251 2011 Elsevier Inc. All rights reserved.
KEYWORDS placenta previa, hemorrhage, late preterm birth, indicated delivery, early term
birth

lacenta previa, a placenta that overlies or is proximate to


the internal os of the cervix; occurs in approximately
0.3%-0.5% of deliveries.1 If persistent at the time of delivery,
cesarean delivery is indicated because of the risks and consequences of maternal hemorrhage associated with vaginal delivery. Women with placenta previa are at increased risk for
obstetrical hemorrhage, transfusion, hysterectomy, admission to the intensive care unit, and even maternal death.2-5
Placenta previa often requires iatrogenic preterm birth (PTB)
34 weeks because of maternal bleeding or spontaneous
preterm labor.6,7 Women who develop vaginal bleeding after
34 weeks are often promptly delivered because catastrophic
bleeding can occur and is not predictable on the basis of
clinical factors.8 However, many women with placenta previa
remain asymptomatic, and thus the clinician must decide
when to schedule cesarean delivery in a stable patient. This
article summarizes the available literature regarding the potential advantages and disadvantages of scheduled delivery
for placenta previa across the late preterm (LPTB) and earlyterm (ETB) periods.

Larry C. Gilstrap M.D. Center for Perinatal and Womens Health Research,
Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX.
Address reprint requests to Sean C. Blackwell, MD, Larry C. Gilstrap M.D.
Center for Perinatal and Womens Health Research, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas
Health Science Center at Houston, Houston, TX 77030. E-mail:
Sean.blackwell@uth.tmc.edu

0146-0005/11/$-see front matter 2011 Elsevier Inc. All rights reserved.


doi:10.1053/j.semperi.2011.05.004

Placenta previa is associated with PTB. In a U.S. population-based study of live births, approximately 16.9% of
women with placenta previa deliver 34 weeks, 27.5% deliver 34-37 weeks, and 55.6% occur 37 weeks7 Stafford
and colleagues9 found that women with placenta previa and a
midtrimester cervical length 30 mm delivered 34 weeks,
34-37 weeks, and 37 weeks in 45%, 24%, and 31% cases,
respectfully. Interestingly, 76% of these women had an emergent cesarean delivery (emergent delivery occurred in 28% of
women with a cervix 30 mm). Unfortunately, most studies
in which the authors reported outcomes of placenta previa,
they did not clarify what proportion of women who have
LPTB or ETB required emergent care and delivery because of
maternal bleeding vs what proportion were scheduled and
delivery was performed under controlled circumstances.
Table 1 summarizes the potential advantages of scheduled
LPTB in asymptomatic women with placenta previa. The primary advantage of earlier delivery is that it decreases the
probability of a woman presenting with acute hemorrhage
and need for emergent cesarean delivery. In fact, catastrophic
blood loss can rapidly lead to maternal cardiovascular decompensation (shock) and disseminated intravascular coagulopathy. Mobilization of resources (eg, blood bank, anesthesia, surgical) may not be prompt enough to avoid major
maternal and/or neonatal morbidities. However, if delivery is
performed under optimal circumstances (eg, in asymptomatic state with ready availability of resources), the risk of
complications may be lower. The benefits of lower surgical
complication rates with scheduled compared with emergent
249

S.C. Blackwell

250
Table 1 Potential Benefits of Iatrogenic LPTB in Women with
Placenta Previa: Advantages of Earlier Delivery
Decrease probability of cesarean delivery with an unstable
patient
Avoid presentation with hemorrhage (anemia, shock),
labor, fetal compromise
Avoid unexpected presentation at a nontertiary care
hospital
Avoid cesarean delivery under emergent circumstances
Optimize availability of hospital resources
OR resources (surgeons, surgical assistants, anesthesia)
Blood bank and blood products
Consultants
Reduce potential conflict of responsibilities from other
patient care activities
Other laboring patients
Other surgical procedures
LPTB, late preterm birth; OR, operating room.

delivery remain theoretic and on the basis of expert opinion,


because the existing literature does not address this question.
The benefits of avoiding emergent delivery with earlier
delivery must be weighed against the neonatal risks of iatrogenic prematurity. Although the absolute risk of death or
long-term complications of prematurity with LPTB are extremely low, softer morbidities are common and may be
clinically significant.10,11 In addition, the neonatal risks associated with LPTB are significantly increased when compared
with delivery at term. Thus, decision-making for the timing
of delivery across the LPTB and ETB period requires balancing the probability and severity of maternal hemorrhage at
each gestational age versus the probability and severity of
neonatal morbidity with delivery (Fig. 1). Because there are
no clinical trials in which the investigators compare strategies
regarding the optimal timing of delivery in women with pla-

centa previa, clinicians have relied on combining data from


observational studies that summarize the average probability of adverse maternal and neonatal outcomes across gestational age ranges. As an example, Table 2 describes the relationships between the probability of maternal hemorrhage
(increases) and neonatal morbidities (decreases) with advancing gestational age. Data regarding the probability of
emergent maternal bleeding are derived from 230 cases of
placenta previa delivered at a single institution between 1980
and 2001.6,12 Data regarding neonatal morbidities and mortality are summarized from the Safe Labor Consortium and
include LPTB and ETB for any indication.13 At what specific
gestational age threshold the maternal and neonatal risks
trade-off is a matter of clinical judgment based on assessment
of clinical factors (eg, number of prior cesarean deliveries,
maternal comorbidities, practice setting, and patient risk tolerance).14
Zlatnik and colleagues6 have recently performed a decision
analysis aimed to address this question. They evaluated delivery between 34 and 38 weeks and compared maternal and
neonatal quality-adjusted life years. They compared 4 strategies at each week: (A) immediate delivery; (B) delivery 48
hours after antenatal corticosteroids (ACS); (C) amniocentesis with delivery if () fetal lung maturity (FLM) or retesting
in 1 week if immature; (D) amniocentesis with delivery if ()
FLM or administration of ACS. Maternal outcomes evaluated
were hysterectomy, transfusion, and maternal death. Fetal/
neonatal outcomes were stillbirth, neonatal death, respiratory distress syndrome, and cerebral palsy. In this model,
ACS administration at 35 weeks, 5 days and delivery at 36
weeks was the optimal strategy. The benefit of this strategy
was predicated on the assumption that there is fetal/neonatal
benefit of ACS at this gestational age. Immediate delivery at
36 weeks without ACS was the second best strategy and
preferred if ACS were already given before 34 weeks or assumed to have absent or minimal efficacy. Other than this
decision analysis study, recommendations for the timing of

Figure 1 Conceptual diagram that presents the trade-off of maternal and neonatal risks and benefits related to the timing
of delivery for women with stable placenta previa.

Timing of delivery for women with stable placenta previa

251

Table 2 Estimation of Risks of Maternal and Fetal/Neonatal Complications


Outcome
bleed1,12

Maternal emergent
Fetal/neonatal13
NICU admission
Need for mechanical ventilation
Neonatal mortality

34 weeks

35 weeks

36 weeks

37 weeks

38 weeks

39 weeks

4.7%

15.0%

29.9%

58.6%

87.2%

67.4%
6.6%
0.8%

42.4%
4.5%
0.4%

22.1%
3%
0.3%

11.8%
1.1%
0.2%

7.2%
0.5%
0.1%

6.1%
0.3%
0.1%

NICU, neonatal intensive care unit.

delivery are limited to expert opinion. In a recent review from


the clinical expert series of obstetrics and gynecology, Oyelese and Smulian1 stated In a stable patient, it is reasonable
to perform a cesarean delivery at 36-37 weeks of gestation,
after documentation of fetal lung maturity by amniocentesis.
If the amniocentesis does not demonstrate lung maturity, we
deliver the women by elective cesarean at 38 weeks, without
repeating the amniocentesis, if they remain stable, or earlier if
bleeding occurs or the patient goes into labor.
Further investigations are warranted to evaluate several
unanswered questions related to the timing of delivery:

What proportion of women with placenta previa require


emergent delivery between 34 and 37 weeks?
To what degree are complications increased with emergent delivery because of maternal hemorrhage vs scheduled delivery under controlled conditions?
Should the type of placenta previa (partial vs total) or
other comorbidities (previous cesarean delivery, maternal obesity) affect the timing of delivery?
Is there any role for FLM assessment with amniocentesis?

In summary, available data suggest the following management recommendations:

In women with uncomplicated complete placenta previa, scheduled delivery between 36 and 37 weeks
should be considered.
In women with a placenta previa with additional comorbidities (eg, high body mass index, multiple previous
cesarean deliveries) or complicated clinical course (eg,
episode[s] of vaginal bleeding), earlier delivery may be
necessary and should be individualized.

References
1. Oyelese Y, Smulian JC: Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 107:927-941, 2006
2. Choi SJ, Song SE, Jung KL, et al: Antepartum risk factors associated
with peripartum cesarean hysterectomy in women with placenta previa. Am J Perinatol 25:37-41, 2008
3. Grobman WA, Gersnoviez R, Landon MB, et al: Pregnancy outcomes
for women with placenta previa in relation to the number of prior
cesarean deliveries. Obstet Gynecol 110:1249-1255, 2007
4. Crane JM, Van den Hof MC, Dodds L, et al: Maternal complications
with placenta previa. Am J Perinatol 17:101-105, 2000
5. Iyasu S, Saftlas AK, Rowley DL, et al: The epidemiology of placenta
previa in the United States, 1979 through 1987. Am J Obstet Gynecol
168:1424-1429, 1993
6. Zlatnik MG, Little SE, Kohli P, et al: When should women with placenta
previa be delivered? A decision analysis. J Reprod Med 55:373-381,
2010
7. Ananth CV, Smulian JC, Vintzileos AM: The effect of placenta previa on
neonatal mortality: A population-based study in the United States,
1989 through 1997. Am J Obstet Gynecol 188:1299-1304, 2003
8. Wing DA, Paul RH, Millar LK: Management of the symptomatic placenta previa: A randomized, controlled trial of inpatient versus outpatient expectant management. Am J Obstet Gynecol 175:806-811, 1996
9. Stafford IA, Dashe JS, Shivvers SA, et al: Ultrasonographic cervical
length and risk of hemorrhage in pregnancies with placenta previa.
Obstet Gynecol 116:595-600, 2010
10. Seubert DE, Stetzer BP, Wolfe HM, et al: Delivery of the marginally
preterm infant: What are the minor morbidities? Am J Obstet Gynecol
181:1087-1091, 1999
11. McIntire DD, Leveno KJ: Neonatal mortality and morbidity rates in late
preterm births compared with births at term. Obstet Gynecol 111:3541, 2008
12. Zlatnik MG, Cheng YW, Norton ME, et al: Placenta previa and the risk
of preterm delivery. J Matern Fetal Neonat Med 20:719-723, 2007
13. Hibbard JU, Wilkins I, Sun L, et al: Respiratory morbidity in late preterm births. JAMA 304:419-425, 2010
14. Joseph KS: Theory of obstetrics: An epidemiologic framework for justifying medically indicated early delivery. BMC Pregnancy Childbirth
7:4, 2007